A Left-handed Complement to PCI

 - Left hand

The transfemoral approach for PCI continues to dominate clinical practice, but among operators who perform transradial PCI, another option has emerged: left radial access. While most operators prefer a right radial approach, left radial access offers some clinical and operational advantages that have begun to win over converts.

Acknowledging TALENT

Two years ago, a team of researchers in Rome published results of a randomized, two-center study designed to evaluate the safety and efficacy of left vs. right radial access for coronary angiography. The study was among the first to coax out differences between the two radial approaches, and it put Italy on the map as a leader in left radial access for cardiac catheterization.

It also helped to nudge the left approach into everyday clinical practice, at least at some centers.

TALENT randomized 1,467 patients into either a right or left radial access group, where all patients received diagnostic coronary angiography (Am Heart J 2011;161:172-179). Additionally, 344 patients in each group underwent PCI. The researchers found that patients in the left radial access diagnostic group had on average a shorter fluoroscopy time and reduced dose absorbed compared with the right access group.

Left’s upper hand was particularly pronounced in elderly patients, largely for anatomical reasons. Right-side subclavian tortuosity is more common in the elderly, which can impair procedural success and prolong the length of the procedure. In TALENT, operators reported two cases of subclavian tortuosity in the right radial access group and none in the left group. TALENT also showed that left access was easier for less experienced operators because catheter handling was similar to the more traditional transfemoral approach.

Preferred Site for Transradial Access
Right Radial % 89.4 92 89.5 93.2 94.6 83.2
Left Radial % 10.6 8 10.5 6.8 5.4 16.8
Source: J Am Coll Cardiol Intv 2010;3:1022–31

In its 2013 consensus document on the radial approach to PCI, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) gave left radial access a nod, noting that operators determine which approach to use (EuroInterventions, online January 2013). But the authors addressed the challenges of tortuosity and urged operators to be cautious when using a right radial approach.

Uptake of transradial has been slow in the U.S., but nonetheless TALENT’s findings have influenced PCI practice. “TALENT identified two groups in whom left radial access is associated with lower procedure times,” says Sunil V. Rao, MD, who was an international reviewer for the EAPCI document. Those groups included not only patients who are 70 years old and older, but also patients under 5 foot 5 inches because shorter people also tend to have more subclavian tortuosity on their right side than on their left side.

As director of the Cardiac Catheterization Laboratories at the Durham Veterans Affairs Medical Center in North Carolina and an interventional cardiologist at Duke University Medical Center, also in Durham, Rao and his colleagues have made a point of integrating TALENT’s lessons into their PCI protocol. Physicians tend to use a left approach on older and shorter patients, if appropriate, as well as all patients who have had a previous left internal mammary artery bypass graft.

Fellows also learn to perform both approaches.  

“Our cardiology fellows train radial from day one, and they train left radial from day one in a patient who has had bypass surgery,” Rao says. He estimates that about 30 percent of their cases involve post-bypass patients, “so we do a fair percentage of our cases [as left radial] and are very comfortable with that.”

Still an underdog

Rao’s center may be the exception, though, for the U.S. and globally. In a survey sent to more than 1,000 interventional cardiologists in 75 countries, Rao and colleagues asked operators about their transradial practice patterns (J Am Coll Cardiol Intv 2010;3:1022–31). The survey showed transradial is gaining traction worldwide for diagnostic and PCI purposes, but right access by far dominates the cath lab today. Overall, operators used the left approach only 10.6 percent of the time. European and Canadian physicians’ preferences hovered near the average at 10.5 percent but the U.S. ranked lower, at 8 percent. Japanese operators had the highest adoption rate for left radial access, at 16.8 percent.     

Many operators cite discomfort as a top reason for the left’s potential disfavor.