Brief Reports

Comparison of Radial Versus Brachial Approaches for Diagnostic Coronary Angiography When the Femoral Approach Is Contraindicated

Diagnostic catheter angiography remains the gold standard for evaluation of vascular lesions of the brain, head and neck, and spine. It is often combined with cross-sectional and functional imaging to provide a complete anatomic and physiologic workup of patients. Such data are combined with clinical information to help make treatment decisions. This chapter describes the specific techniques for arterial access and catheter navigation of the cerebrospinal vasculature. Discussion of patient positioning, injection rates, and basic anatomy of arterial and venous systems is included. Finally, important safety issues related to contrast allergy, renal failure, and complications are considered.

We investigated the incidence of radial anomalies (RA) in patients undergoing transradial (TR) coronary procedure and their impact on procedural outcome in the Egyptian population.

Radial anomalies (RA) are considered an important factor for procedural failure. Information about anatomical variation is limited in our Egyptian population.

We performed a multicentre prospective study in Egypt. A total of 650 consecutive patients undergoing their first TR coronary procedure were recruited from January 2013 till January 2015. By retrograde radial arteriography we assessed the frequency of RA and their impact on procedural outcome.

650 consecutive patients were studied, 74% male, mean (SD) age 55 (10) years. The overall incidence of radial artery anomaly was 12.6% (n = 82). 40 (6.2%) patients had a high-bifurcating radial origin, 8 (1.2%) had a full radial loop, 14 (2.1%) had extreme radial artery tortuosity and 20 (3%) had other anomalies such as persistent left subclavian artery and extreme subclavian tortuosity. Overall transradial procedural success was 95%. Procedural failure was more common in patients with anomalous anatomy (39%) than in patients with normal anatomy (0.2%). Procedural failure was highest in patients with radial loop (87.5%), followed by those with subclavian tortuosity (45%), then high radial bifurcation (30%), and severe radial tortuosity (28.5%). 14 (2.1%) vascular complications occurred, all of which were treated conservatively.

There is a relatively significant presence of radial anomalies, with different degrees of impact on procedural failure rate, in our Egyptian population. Further collaborative studies are recommended to increase our success rates.

One of the major criticisms of the radial approach is that it takes longer overall procedure and fluoroscopy time, which means not only more staff will be exposed during the procedures, but they will also stand close to the patient where rates of radiation scattered by the patient are higher. The aim of this study was to evaluate the safety of the radial versus femoral artery approach in our institution’s routine coronary angiography practice.

All cases of diagnostic coronary angiography (CA) over a 23 month period at a tertiary care hospital were reviewed for this analysis. Procedure duration was calculated as a total in laboratory catheter time. Contrast volume and fluoroscopy time were recorded, as it is correlated to catheter manipulation.

Eight hundred patients who underwent a diagnostic CA were included in this study. The radial approach was used in 586 patients (73.25%) and the femoral approach in 214 patients (26.75%). Comparing the radial and femoral approaches, fluoroscopy and procedure times were not significantly different (3.43 ± 1.19 vs 3.86 ± 1.49 min, P = 0.215 and 31.87 ± 9.61 vs 33.24 ± 10.33 min, P = 0.170, respectively). While contrast utilization during the procedure was significantly lower in the radial than the femoral approach (67.63 ± 25.49 vs 81.53 ± 24.80 mL respectively, P = 0.03).

Transradial coronary angiography can be safely performed for the patient and the professional staff members as the transfemoral approach.

Although the transbrachial artery approach has been well described as an alternative for percutaneous coronary interventions and diagnostic cerebral arteriography, little has been reported regarding the use of this technique for therapeutic neuroendovascular procedures. We highlight the technical applications of this technique during 5 procedures. Three women (age 68, 69, and 83 years) and 1 man (age 79 years) were treated using brachial artery access. Two of the women with complex posterior circulation aneurysms were treated with stent-assisted coil embolization. The third woman presented with a symptomatic occlusion of the basilar artery and underwent intra-arterial thrombolysis and angioplasty, followed at a later date by a second intra-arterial thrombolysis procedure. The male patient presented with recurrent, intractable posterior circulation ischemic events and underwent balloon angioplasty and stenting of a high-grade stenosis of the right vertebral artery. All patients had failed treatment via a transfemoral route and demonstrated significant thoracoaortic and/or iliofemoral tortuosity. Appropriate intracranial vascular access was achieved in all patients, and there were no intraprocedural complications. We conclude that a transbrachial approach may be successfully used for a variety of therapeutic neuroendovascular interventions when a transfemoral route is not available.

Transradial approach is known to reduce access-site complications of coronary procedures. However, the diffusion of transradial approach in the interventional cardiology community is limited by its higher failure rate compared to transfemoral. Transradial approach failures are mainly caused by a series of anatomic variants which may be encountered in the upper limb arteries. Such anatomic variants have been variously classified based on postmortem studies or systematic angiographic studies. We propose a simplified “operative” classification of anatomic vascular variants and physiopathologic conditions of the arterial axis, from radial to aortic root, possibly affecting transradial cardiovascular procedures.

The transradial approach is associated with fewer bleeding complications during percutaneous coronary interventions (PCIs) but is more technically challenging and associated with prolonged times during intervention. The aim of this study is to retrospectively compare the results of radial vs. femoral approach in patients ≥80 years old undergoing primary or rescue PCI.

Between January 2002 and December 2007, 354 interventions were performed in our institution with the indication of primary or rescue PCI in patients over 80 years old, without history of previous bypass operation or cardiogenic shock on presentation. Thirteen patients required a change of the approach during the procedure and were not enrolled in the final analysis. Forty (12%) interventions were performed through the transradial approach and 301 (88%) through the femoral approach. In-hospital major adverse cerebral and cardiac events and access site bleeding complications as well as 30- and 365-day mortality, procedural times, and contrast volume were evaluated.

The two groups had similar clinical characteristics, with the exception of serum creatinine that was higher in the transfemoral approach group. There were no differences in procedural times and clinical outcomes, although the transfemoral group had numerically more access site bleeding complications (12/301 vs. 0/40, P=.41). The transradial approach had a higher conversion rate compared with the transfemoral approach (18.3% vs. 1.3%, P<.001).

The transradial approach is feasible and safe in the octogenarians undergoing primary and rescue PCI, but it is associated with a high conversion rate to another approach.