JACC: Transradial approach gains traction, but practice variances abound
A 5-F introducer sheath was inserted into the radial artery, and a guide wire and a 5-F Simon II catheter were introduced into the ascending aorta.
Image source: Korean J Radiol 2006;7(1):7–13.
Although the use of the transradial approach (TRA) is growing, there is much variation among practice regarding the specifics of TRA, and it is suggested that more data are needed to outline the most optimal strategies for performing the approach, according to a survey published in the October issue of the Journal of the American College of Cardiology: Interventions.

“The direct impact of peri-procedural bleeding and access-site complications on outcomes and costs to health systems has initiated an increasing awareness of the potential benefits for TRA as a default technique instead of the FA [femoral approach],” the authors wrote. “Even in the U.S., a recent study has found a significant increase in the use of TRA for percutaneous coronary interventions (PCI); however, its use remains low (less than 5 percent).”

To better evaluate practice of the transradial approach to treatment, Olivier F. Bertrand, MD, PhD, of the Quebec Heart-Lung Institute, in Quebec City, Quebec, and colleagues surveyed 1,107 interventional cardiologists in 75 countries between August 2009 and January 2010—79 percent responded.

The survey included 39 questions ranging on topics such as respondent characteristics, patient selection, technical aspects of access site puncture and hemostasis, technical aspects of diagnostic angiography and interventions, antithrombotic regimens used during elective PCI, radial access occlusion and hospital discharge.

Survey respondents who used TRA for diagnostic catheterizations were either low-volume (less than 5 percent) or very high-volume (more than 90 percent) TRA operators, 15.4 percent versus 42.4 percent, respectively. Results showed, however, that high-volume TRA operators used the approach less frequently for PCI compared with diagnostic purposes, 32.1 percent versus 42.4 percent, respectively.

Results showed that 89.4 percent of operators used the right radial artery as the initial side; however, 16.8 percent of the operators in Japan preferred the left. The researchers reported that 31.3 percent of operators choose to cross over to the contralateral radial artery after initial radial access failure, while 54.5 percent revert back to standard femoral access.

The survey results also showed that 41.7 percent of operators prescribe anxiety relievers, 10.2 percent prescribe anti-histaminic drugs and 12.5 percent use local Xylocaine spray prior to the procedure; however, 45.7 percent do not prescribe any medication to patients. To prevent radial artery occlusion, 75.8 percent said they use heparin while 5 percent do not administer heparin.

The results showed that 13.3 percent of operators discharged patients on the same-day home day after uncomplicated PCI compared to 24.3 percent of operators who performed a same-day transfer to referring hospitals after uncomplicated PCI. However, 52.2 percent of operators said they never discharge patients on the same day, while 45.5 percent said they would not transfer patients to a referring hospital.

The researchers said limitations stem from the fact that operators with interest in TRA were more likely to respond, which could have increased the percentage of procedures performed via TRA.

“Today, TRA is used in a large number of countries for diagnostic and PCI. Few technical points need to be learned to practice TRA. Most TRA operators use standard diagnostic and guiding catheters initially designed for FA [femoral approach],” the authors concluded.

“Therefore, we believe that most PCI programs should involve specific TRA training and exposure. With current devices and practice, TRA could become rapidly the default technique for diagnostic angiography and interventions, instead of being reserved for patients at high risk of bleeding.”

"Though some might bemoan the need to learn a slightly different technique, it [transradial approach] will preserve the femoral artery integrity for the growing potential need for access with large devices used in valve implantation or aortic stent grafts," wrote Ian C. Gilchrist, MD, Penn State University in Hershey, Pa., in an accompanying editorial.

"With transradial procedures being done for coronary disease, one may see the day when patients survive longer only to get vascular and valvular disease that requires healthy femoral arteries to be treated percutaneously. Not a bad legacy for the early grass root transradialists who were at one time viewed with suspicion or otherwise just ignored."