Be well-armed: Best practices for radial angiography, PCI

Based on evidence that has emerged with the growing use of transradial interventions, 16 cardiologists have teamed up to define best practices for performing transradial angiography and PCI. Their recommendations focus on reducing occlusion risks, radiation exposure and transitioning to radial primary PCI.

“The motivation behind this is the rapid uptick in the adoption of this particular procedure,” Sunil V. Rao, MD, of Duke Medical Center in Durham, told Cardiovascular Business. Rao was lead author of the paper, which was written by the transradial working group of the Society for Cardiovascular Angiography and Interventions and published online in Oct. 23 in Catheterization and Cardiovascular Interventions. “We wanted to make sure people were aware that there is a solid base of evidence around some of the practices, so let’s make sure that our exuberance for adopting this procedure doesn’t overtake our attention to do it in the right way to see best outcomes.”

Transradial access has gained traction in Europe and Asia and is beginning to pick up steam in the U.S., where radial use grew from 1.2 percent to 16.1 percent between the first quarter of 2007 and the third quarter of 2012, according to an analysis of data from the National Cardiovascular Data Registry’s CathPCI Registry. Research has shown some advantages using the radial approach, including reduced risk for bleeding and vascular complications as well as disadvantages such as increased radiation exposure to operators until they become proficient at the procedure.

“The data are strong to support the use of the radial approach,” Rao said. “The thing that will inhibit the adoption of this approach is lack of good outcomes, not because of the procedure but because people aren’t practicing it the right way.”

The authors recommended monitoring patients for radial artery occlusion and reducing the risk of occlusion. That would include assessing radial artery patency, adequate anticoagulation, choosing lowest-profile systems and using hemostasis techniques. They emphasized that physicians should routinely check for radial artery patency before discharge and monitor of occlusion before discharge and during the post-procedure follow-up.

To reduce radiation exposure to the patient and operator, they called for positioning the access arm near the patient’s torso, applying shielding and distancing strategies and considering the left radial approach, especially in patients who are older than 75 years, are short and who have tortuous vascular anatomy. More experienced operators typically can complete procedures more swiftly, making proficiency an important goal that will also decrease radiation exposure.

They selected 100 elective PCIs using a radial first approach with a crossover rate of 4 percent or less as the minimum number an operator should perform before taking on transradial primary PCI. Rao described the 100 cases as conservative but setting a high threshold would ensure operators had rounded the learning curve. 

Recognizing that the transradial approach may affect door-to-balloon times, the authors suggested that programs transitioning to transradial primary PCI keep track of their door-to-balloon times to identify early any practices that may compromise rapid time to treatment. Door-to-balloon time is a publicly reported quality measure in the U.S. “We called that specific aspect out because it is very relevant to U.S. practice but the underlying recommendation is translatable across all countries,” he said.

The group also identified three areas in need of more research. The role of procedure testing for dual circulation in the hand; optimal antithrombotic strategies; and what constitutes a successful training program.

Given the rapid evolution of technology in interventional procedures and the growing evidence base, the writing group anticipates it will be revising its consensus statement over time. “We will need to revisit these recommendations. The onus is on the working group” to keep the recommendations current, Rao noted.