• Total wrist access for angiography and interventions: Procedural success and access site crossover in a high volume transradial center

    Abstract

    Objective

    To assess the crossover rate from primarily chosen transradial access (TRA) in a high volume transradial center.

    Methods

    All consecutive 30,848 patients, that underwent diagnostic angiography and/or intervention in the period from 2010 until 2015 were examined. Preprocedural radial artery angiography was performed in all patients since 2011. Clinical and procedure characteristics, reason for crossover and its direction were analyzed. Primary end-point of the study was the occurrence of TRA failure and need to crossover to another approach to finish the procedure.

    Results

    Procedural success of primarily chosen TRA was 94% (n = 28,988). Crossover to other access sites was 6% (n = 1860). Most common reason for crossover was inability to puncture the right radial artery in 4,1%, presence of radial artery anomalies (0,3%), high grade spasm (0,1%), or radial artery occlusion (1,2%). Crossover direction was primarily through the ipsilateral transulnar access (TUA) 3,8%, left radial access (LRA) 1,5% and in only 0,6% (n = 189) of patients to transfemoral access (TFA). Access site bleeding complications were present in 5,1% (n 1579).

    Conclusion

    Total wrist access is feasible and safe with low rate of access site complications and crossovers, especially when performed in experienced high volume transradial center.

    Highlights

     

    •  

      Total wrist access can be implemented safely in experienced transradial centers.

    •  

      This is an observational study with a large patient cohort.

    •  

      Failure of transradial access is caused by failure to puncture, presence of RA anomalies, high grade spasm or RA occlusion.

    •  

      Pre-procedural radial artery angiography provides a roadmap for successful arterial access.

    •  

      Total wrist access is feasible and safe with low percentage of access site complications

     

    Introduction

    Trans Radial Access (TRA) is now the preferred access site for percutaneous cardiovascular interventions in experienced radial centers [  ,  ,  ]. Considerable evidence supports conversion to radial access for all angiographic diagnostic and interventional procedures with an emphasis on decreasing access site bleeding and vascular complications without sacrificing procedural success [  ,  ]. The radial approach improves patient comfort and satisfaction, allows rapid ambulation and is associated with reduced cost and hospital stay.

    TRA is of particular benefit in patients with increased risk of bleeding and vascular complications: acute coronary syndrome patients, female patients, the elderly, obese, hypertensive and low weight patients, with renal failure, low platelet count and anemia [  ].

    Anatomic variations in the radial artery can influence the success of the selected access site for angiographic procedures [  ] and pose problems in achieving adequate catheter placement and support. It is important that physicians learning the radial technique become familiar with common anatomic variations and learn how to navigate through them. According to our experience as a high volume transradial center with over 6000 transradial procedures per year, pre-procedural radial artery angiography can facilitate the correct strategy for timely completion of the intervention [  ,  ].

    In this study we evaluated the reasons for transradial access site failure in a large series of patients in the period of 6 years.

    Materials and methods

    Patient population

    This was a single center study including all patients from a 6 year period (January 2010 to December 2015) referred for Cardiovascular angiography and intervention, at a large volume tertiary referral center. All procedures were performed by experienced transradial operators (>500 diagnostic TRA procedures and >300 PCI procedures per year). Study was approved by local ethics committee and patients had a regular in hospital follow-up.

    Radial artery puncture was performed using counter puncture technique with a 20 G plastic iv cannula and 0.025 inch mini guide-wire of 45 cm and followed by 5Fr or 6Fr hydrophilic introducer sheath (Terumo, Japan) placement. Spasmolytic cocktail (5 mg verapamil) was given intra-arterially through the radial sheath.

    Preprocedural retrograde radial angiography was performed to define the radial artery anatomy from mid forearm to ulnobrachial anastomosis and to delineate ulnar artery anatomy as well, thus generating the access roadmap. A solution of 3 ml of contrast diluted with 7 ml of blood was injected through the cannula or through the side arm of the sheath under fluoroscopy in PA projection. All patients since 2011 underwent RA (radial artery) angiography and if there was some variation or tortuosity/spasm it was negotiated under fluoroscopy control.

    Post procedure management : The sheath was removed immediately after procedure, regardless of level of anticoagulation, and a TR band (Terumo, Japan) was applied to the wrist. In order to decrease the rate of radial artery occlusion (RAO) we applied patent hemostasis by using pulse oximetry to confirm the hemoglobin oxygen saturation on the punctured radial artery (>90%), after hemostasis was obtained (during measurement ulnar artery (UA) was compressed manually). Compression was applied for approximately 3 hour period with gradual deflation of the TR band after the 1st hour.

    Study end-points

    Primary end-point of the study was the occurrence of transradial approach failure and need to crossover to another approach to finish the procedure. We additionally evaluated types of procedures, procedure time and fluoroscopy time and access site bleeding complications. Crude in-hospital mortality and MACE rates were recorded.

    Definitions

    Procedure success was defined as angiography and PCI completed with initial radial artery approach without crossing-over to another route.

    Inability to puncture was defined as inability to puncture the right RA.

    No palpable RA was defined as no present pulsations of the RA where the operator decided to directly puncture other access artery mainly UA without previously puncturing the right RA.

    Crossover due to procedural demand was defined as concomitant use of TFA along with TRA due to procedural demand as in cases of SFA (Superficial femoral artery) PTA (percutaneous transluminal angioplasty) or procedures as TAVI (transcatheter aortic valve implantations), TEVAR or EVAR (thoracic/endovascular aortic repair). In all these procedures ancillary TRA was used for the diagnostic part and when necessary along the course of the procedure.

    Inability to cross spasm was defined as high grade spasm of the RA that caused a failure of TRA and was crossed-over to another access to finish the procedure.

    Inability to cross anomaly was defined as procedure where RA anomaly was present and operator was unsuccessful in crossing the anomaly and was transferred to other access site.

    Procedure time was defined as time from puncture until completion of the procedure.

    Clinical radial artery spasm was classified as grade I: minimal local pain and discomfort; grade II: significant local pain and discomfort, not precluding procedure completion; grade III: severe local pain and discomfort necessitating cross over and grade IV: catheter entrapment with severe local pain and disconfort [  ].

    Vascular access site complications were defined as the occurrence of an aneurysm, fistula, hematoma or radial nerve injury.

    Hematoma was classified into five grades according to EASY score (grade I: local hematoma, superficial <5 cm; grade II: hematoma with moderate muscular infiltration; grade III: forearm hematoma and muscular infiltration, below the elbow; grade IV: hematoma and muscular infiltration extending above the elbow; grade V: ischemic threat - compartment syndrome) [  ].

    Statistical analysis

    Simple descriptive statistics was used. For normally distributed numeric variables, data was expressed as mean ± standard deviation and for continuous variables not fitting a normal distribution as median (minimum-maximum). Percentages were used to express categorical variables. Statistical analysis was performed with SPSS 17.O for Windows (SPSS Inc. Chicago, ILL).

    Results

    From 30,848 consecutive transradial procedures procedural success through primarily chosen transradial access site was achieved in 94% of patients.

    Patient population was predominantly male (68%). Most common risk factors were hypertension (55%), diabetes (18%) and smoking (25%) ( Table 1 ). 

    Table 1
    Baseline characteristics of study population.
    Clinical variablesTotal N patients 
    (N = 30,848)
    Age (years) 62 (18–93)
    Male 21,204 (68%)
    BMI (kg/m ) 25 (19–47)
    CAD risk factor  
    Hypertension 16,978 (55%)
    Diabetes mellitus 5595 (18%)
    Dyslipidemia 6439 (21%)
    Smoking 7703 (25%)
    Positive family history for CAD 3477 (11%)
    Prior TRA 6523 (21%)
    Prior stroke 895 (2,9%)
    CAD (coronary artery disease), TRA (transradial access).

     

    Percutaneous coronary intervention was done in 14,315 (46%) with PPCI in 13,5% (3659). PCI in LMN was done in 284 (0,9%) and CAS in 730 (2,3%) patients. Most common sheath size used was 6F with 96% of all interventions ( Table 2 ). 

    Table 2
    Procedural characteristics of study population.
    Procedural variablesN = 30,848 (2010–2015)
    Procedure
    Diagnostic coronary angiography 16,533 (53%)
    PCI 14,315 (46,4%)
    PPCI 3659 (13,5%)
    PCI in LM 284 (0,9%)
    CAS 730 (2,3%)
    ILIAC/SFA artery PTA 167 (0,5%)
    Subclavian artery PTA 62 (0,2%)
    RAO (on RA angiography) 608 (2%)
    Sheath size
    5F 917 (3%)
    6F 24,730 (96%)
    7F 96 (0, 3%)
    7.5F Asahi Sheathless 79 (0,25%)
    8F 52 (0,17%)
    Fluoroscopy time (minute) 12 (1–98)
    Procedural time (minute) 32 ± 20
    Access site bleeding complications 1579 (5,1%)
    Hematoma grade 4/5 23 (0,007%)
    Clinical RA spasm 1197 (3,9%)
    RA anomalies 2220 (7,2%)
    High take off RA 1554 (5%)
    RA 360 degree loop 291 (1%)
    Tortuous RA 338 (1,1%)
    Small “hypoplastic” RA 37 (0,1%)
    Length of stay <2 days 20,387 (66%)
    Same day discharged 8990 (29%)
    PCI (percutaneous coronary intervention), LM (left main), CAS (carotid artery stenting), SFA (superficial femoral artery), RAO (radial artery occlusion), RA (radial artery).

     

    Crossover was done in 1860 (6%) of patients. Most common reason for crossover was inability to puncture the right radial artery in 4,1% and direct TUA crossover due to lack of RA pulsations in 1,2%. Operators decided to crossover due to RA angiogram alone in certain cases with presence of complex 360 degree RA loop (n = 65), small RA (n = 7) or other RA anomalies as very tortuous RA (n = 11) and high take off RA with high degree spasm (n = 21) ( Fig. 1 ). 

    Fig. 1
    Reasons for crossover.
    Abbreviations: TRA (transradial access), TFA (transfemoral access), RA (radial artery).

     

    The analysis of crossover rate (from 6.9% in 2010 to 5% in 2015 and in STEMI patients from 4.6% to 2.1%) showed a trend toward lower crossover rate after implementing routine RA angiography ( Fig. 2 ). 

    Fig. 2
    RA crossover rate 2010–2015.

     

    Crossover direction was primarily done to ipsilateral TUA 3,8%, left radial access 1,5% with only 0,6% of patients transferred to TFA.

    Separately we accessed the reasons for crossover to all other access sites. Main cause for TUA transfer was inability to puncture the RA with 63% (746 patients) and direct transfer in 32% due to lack of RA pulsations (operator decision). Crossover to TFA was made mainly due to inability to puncture in 62% (n 117) (presence of AV fistula in chronic kidney disease, occluded UA) and procedural demand 34% (n 65) in SFA PTA and procedures as TAVI, TEVAR or EVAR (that require TFA access). Crossover to LRA was made mainly due to inability to puncture the RRA in 82% (n 383) of cases ( Fig. 3 ). 

    Fig. 3
    Crossover direction.
    Abbreviations: TUA (transulnar access), LRA (left radial access), TFA (transfemoral access), TBA (transbrachial access), RRA (right radial artery), SA (subclavian artery).

     

    Some crossovers due to inability to puncture can be related to the presence of chronic RAO (with palpable RA distal to the occlusion). Consequently, numbers of detected chronic RAO on RA angiography (2%) might be underestimated.

    Procedure time was 32 ± 20 (10−300) min, and fluoroscopy time was 12 (1–98) min.

    Significant number of patients were discharged the same day (29%, n = 8990) and most of them had a length of stay under 2 days (66%, n = 20,387).

    Clinical radial artery spasm was present in 3,9% of patients. Access site bleeding complications (EASY score for hematoma type 1 to 5) were present in 5,1% (n 1579) of patients [  ]. Hematoma type 4 was present in 21 patients (0,006%). Two patients (0,0006%) needed vascular repair of the forearm due to compartment syndrome (hematoma type 5), without further clinical consequences. There were no signs of hand ischemia at discharge or follow up in any patient ( Table 3 ). 

    Table 3
    Access site complications.
    Access site complicationsN
    Clinical radial artery spasm 1197 (3,9%)
    Grade I 961 (3,1%)
    Grade II 188 (0,6%)
    Grade III 47 (0,1%)
    Grade IV 1 (0%)
    Access site bleeding complications 1579 (5,1%)
    Hematoma grade 1 1015 (3,2%)
    Hematoma grade 2 466 (1,5%)
    Hematoma grade 3 75 (0,2%)
    Hematoma grade 4 21 (0,006%)
    Hematoma grade 5 2 (0,0006%)
    Major vascular complications 2 (0,0006%)
    Sign of hand ischemia 0 (0%)

     

    In-hospital MACE and mortality rates were 856 (2,7%) and 368 (1,1%) accordingly.

    Discussion

    In this observational study, we report our results as an experienced transradial center with implementation of total wrist access (with low crossover to TFA) in majority of interventions. Overall, procedural success was high with low percentages of bleeding or vascular complications, likely due to the wrist approach.

    Considering the last STEMI (ST segment elevation myocardial infarction) [  ] and NSTEMI [  ] guidelines and the recognition given by the European cardiology panel consensus document [  ] that the Transradial approach should be the default approach for PCI in experienced transradial centers, class I, level of evidence A. However, it is important to understand any issues that could influence the success of TRA percutaneous interventions.

    The reported overall failure in transradial procedures is between 1% and 10% [  ,  ]. One published study has evaluated the reasons for TRA site failure in primary PCI and developed multivariate risk factors that influence the success of transradial access [  ]. Most probably same factors will apply in all PCI patients.

    Prior studies have also reported that arterial anomalies found from wrist to aorta influence the success of transradial access and are cause for access crossover from TRA to other access sites [  ].

    Our center did a complete transitioning from TFA to TR approach from 2007 to 2010 [  ]. Since then 94% of all cardiovascular interventions have been performed by TRA. However, femoral access expertise was preserved despite adopting the default radial-first approach.

    The British Cardiovascular Intervention Society (BCIS) Registry results showed reassuringly that high-volume TRA PCI centers do not lose femoral skills overtime [  ].

    Considering that our center is highly experienced radial center with >99% wrist access, we experienced lower rate of TRA failure and access site bleeding and vascular complications compared to other published studies [  ].

    According to our experience, routine pre-procedural radial artery angiography provides a roadmap for successful arterial access and decreases crossover rate and bleeding complications [  ,  ].

    Most of the cases with no palpable RA (occluded RA) were directly transferred to TUA depending on operator decision. In the cases where there was inability to puncture the right RA, most were transferred to TUA or left TRA (88% of transferred cases). There was no single case of hand ischemia registered postprocedurally or at follow up.

    Thus, total wrist access might be safely achieved in most patients. Nonetheless, procedural time and success should not be sacrificed by forcing wrist access and assessment should be done individually.

    With the extensive complex arterial circulation available in the upper extremity and the emerging data on ulnar access, we may be approaching the post-femoral era for coronary angiography and intervention [  ,  ].

    Study limitations

    This study was conducted in an experienced high-volume transradial center, thus our opinion is that cross-over rate could be higher if performed by less experienced operators and during the learning period.

    The definition of clinical radial artery spasm was subjective made by presence of clinical signs.

    Conclusion

    Failure of transradial access is caused by failure to puncture, presence of radial artery anomalies, high grade spasm or RA occlusion.

    Pre-procedural radial artery angiography provides a roadmap for successful arterial access.

    Total wrist access is feasible and safe with low percentage of access site complications especially when performed in experienced transradial centers.

    Conflict of interest

    Authors have no conflicts of interest

    Author bio

    Cardiovascular Revascularization Medicine, 2018-07-01, Volume 19, Issue 5, Pages 570-574, Copyright © 2017 Elsevier Inc.

    Source:

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