麻豆传媒

The Society for Cardiovascular Angiography and Interventions has issued a consensus statement detailing best practices for the use of transradial access in the cardiac catheterization lab in response to growing use of the approach in the U.S.

The statement -- published online in -- focuses on three areas: avoidance of radial artery occlusion, minimization of radiation exposure for the operator and the patient, and transitioning to the use of the transradial approach for patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention.

Recent studies have shown that the percentage of diagnostic procedures or interventions performed via the radial artery -- versus the femoral artery -- in the U.S. has increased to about 20%, according to , of Duke University Medical Center, one of the members of the SCAI transradial working group that wrote the statement.

"What we wanted to do ... is to make sure that people who are adopting this approach are also using best practices so that they can get the best outcomes for their patients," Rao said in an interview with 麻豆传媒.

Transradial access has been associated with a reduced risk of bleeding and vascular complications and improved patient satisfaction compared with the transfemoral approach. And there is some evidence that the transradial approach might also improve clinical outcomes in high-risk patients.

Those benefits are offset somewhat, however, by greater radiation exposure while operators gain experience, certain limitations in terms of catheter size, and the possibility of radial artery occlusion.

SCAI issued the consensus statement to address some of these issues.

To monitor for and manage radial artery occlusion, the authors recommend that radial artery patency be evaluated after a transradial procedure both before discharge and at the first post-discharge visit using either ultrasound or the reverse Barbeau test, which is detailed in the paper.

Maintaining patency is important both to avoid hand ischemia and to keep the artery viable if needed for future procedures.

Operators can use various strategies to reduce the risk of artery occlusion, the authors noted, including administration of anticoagulation, use of catheter systems with the lowest possible profile, and use of the patent hemostasis technique to stop bleeding at the access site.

In terms of radiation exposure, Rao and colleagues pointed to studies showing that differences in exposure between transradial and transfemoral procedures were largely eliminated as operators gained more experience and they recommend that "operators should make an effort to maintain a high proportion of transradial procedures in their practice."

The consensus statement also includes a framework for making the transition to transradial access for primary PCI in patients with STEMI. Operators and centers should not do so until they are performing at least 100 elective PCI cases with an initial transradial approach and no more than a 4% rate of crossover to transfemoral access, according to the recommendations.

Patients with STEMI undergoing primary PCI potentially have the most to gain from transradial access because of the need for aggressive use of anticoagulants and antiplatelets, which increase the risk of access-site complications, the authors said.

The RIFLE-STEACS trial showed a significant improvement in clinical outcomes with the transradial versus the transfemoral approach, and the RIVAL trial showed a similar benefit, but only in the subgroups of patients treated at high-volume centers and those with STEMI.

Operators and centers should be cautious when making the transition, however, because of the possibility that the time to reperfusion will increase.

"Operators who are not very proficient with the radial approach, who have not done it in practice frequently may, in fact, experience very prolonged door-to-balloon times, which may offset the benefits of the radial approach when it's practiced by proficient operators," Rao said.

Areas that could not be fully addressed in the consensus statement because of the need for further research included routine pre-procedure testing for dual circulation of the hand, the best anti-thrombotic treatments for transradial procedures, and the elements needed for a successful transradial training program.

From the American Heart Association:

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