1. Radial Access Just another artery? Keith G Oldroyd Department of Cardiology Western Infirmary Glasgow

2. Brachial access Not just another artery!

3. Femoral access Not just another artery! C Ilsley; personal communication

4. Femoral access Not just another artery! 45 year old women –Moderate obesity –Elective catheterisation – RFV/RFA Major retroperitoneal haemorrhage –CT scan; 6 unit transfusion –Discharged on day 6 Readmitted on day 9 –RCFA false aneurysm –Doppler, CT, thrombin injections Discharged day 13

5. Radial access: just another artery? History of transradial catheterisation 1964 –Campeau, Montreal Heart Institute –Cut-down on proximal RRA 1970/80’s –Percutaneous approach –Axillary > Femoral > Brachial 1989 –Percutaneous transradial coronary angiography/PTCA

7. Radial access: just another artery? Why bother? Pre-Colombian –Aspirin –Persantin –Warfarin –Dextran –8-9F sheaths –1 week in hospital –No closure devices –10% bleeding –5-10% SAT Post-Colombian –Aspirin –Clopidogrel –6F(5F) sheaths –day case/23 hours –Closure devices –<1% bleeding –<1% SAT

8. Radial access: just another artery? ACCESS Study Randomised comparison of different access sites Experienced operators No difference in procedural or fluoroscopy times RadialBrachialFemoral PCI’s (n)300 Coronary cannulation93%95.7%99.7% Procedural success91.7%90.7% Length of stay (days)1.5(2.5)1.8(3.8)1.8(4.2) Major access site complications02.32.0 JACC 1997; 29: 1269-75. Amsterdam, NL

9. Radial access: just another artery? Carafe Study Randomised Two experienced operators ~50% follow-on PCI with closure devices for femoral cases Radial groups –Reduced pain –Earlier ambulation and discharge –Lower costs RRA (n=70) LRA (n=70) Fem (n=70) X-overs1-LRA00 Caths1.4*2.1 Time12.414.2*11.2 X-rays3.84.23.1* Quality?LCAOK Vasc. Complns 002 CCVI 2001; 52:181-7. Massy, France

10. Radial access: just another artery? Multiple procedures 812 patients 1438 procedures 6F – 45% 5F – 55% Failed procedures (%) 5 th 3 rd 2 nd 30103.5 Men 50207.9 Women CCVI 2001;54: 204-8. Fukuoka, Japan

11. Radial access: just another artery?

12. Radial access: just another artery? Difficult radial anatomy – small vessels (1) Randomised trial of 5Fr vs 6Fr transradial PCI in 171 patients with a +ve Allen test 5Fr6Fr Procedural success95.4%92.9% Failed coronary cannulation1.1%4.8% Minor haematoma1.1%4.8% Radial occlusion1.1%5.9% CCVI 2002; 57: 172-6. Greifswa, FRG

13. Radial access: just another artery? Difficult radial anatomy – small vessels (2) 90 patients Randomised to hydrophilic sheath vs conventional sheath Automatic pullback with an electronic traction guage CCVI 2001; 54: 289-94. Quebec Can

14. Radial access: just another artery?

18. Radial access: just another artery? Difficult radial anatomy Preprocedural ultrasound in 115 patients Anatomic variations in 11 (9.6%) –Tortuosity6 - proceed –Stenoses2 - proceed –Hypoplasia2 - femoral –Radioulnar loop1 - femoral Success111 (97.4%) CCVI 2000; 49: 357-62 Tokyo, Japan

19. Radial access: just another artery?

20. Radial access: just another artery? Difficult subclavian anatomy Retro-oesophageal right subclavian artery 11 patients in 3730 attempted transradial procedures Increased failure rate (7%) CCVI 2001; 54: 202-3. Massy, France

21. Radial access: just another artery? Difficult coronary anatomy LIMA –LRA is access site of choice –Specific catheters to approach from RRA RIMA –RRA is access site of choice Anomalous origin of RCA from L sinus of valsalva –Series of case reports –RRA appears to be access site of choice Saphenous vein grafts –Avoid during initial experience

23. Radial access: just another artery? Comparison with closure devices (1) Two groups of 109 consecutive PCI’s Not randomised but matched for usual demographic parameters Experienced operators RadialPerclose Device not usedN/A20 (18%) Failed haemostasis09 (10%) Procedural time44 (22) mins57 (22) mins* Ambulated same day95%56% CCVI 2000; 49: 157-9. Raleigh, NC, USA

24. Radial access: just another artery? Comparison with closure devices (2) 6 high volume operators in a high volume centre Prospective non-randomised registry RadialProstar PCI’s (n)376580 Device not usedN/A3% Failed haemostasis09.6% Infection requiring a/b’s02 patients Transfusion01 patient CCVI 2000; 51: 417-21. Massy, Fr

25. Radial access: just another artery? GP IIb/IIIa inhibitors 150 consecutive patients treated with GPIIb/IIIa inhibitors RadialFemoral PCI’s (n)8367 Event free @ 1/1294% Length of stay (days)5.04.9 Major access site bleeding 05 (7.4%) Eur Heart J 2000; 21: 662-7. Toulouse, Fr.

26. Radial access: just another artery? Acute myocardial infarction Two centre registry of 1224 patients with AMI treated by primary PCI RadialFemoral Closure Femoral No closure PCI’s (n)277947 Success95% TimeNo difference Major access site bleeding 02%7% CCVI 2002; 55: 206-11. Massy, Fr

27. Radial access: just another artery? Non-coronary intervention Carotid - Case report –Castriota F et al. J Endovasc Surg 1999; 6: 385-6 Vertebral - Case report –Fessler RD et al (Buffalo, NY) Neurosurg 2000; 46: 1527-8 Renal - 25 patients; 27 arteries; 100% success –Galli Met al (Como, It) J Inv Cardiol 2002; 14:386-90

28. Radial access: just another artery? Potential effect on interventional activity Elective day case PCI –Reduced costs compared to groin closure –No failed haemostasis –Convert beds to reclining chairs In-patient PCI programme –Reduced bed utilisation –Fewer complications –Reduced LOS

30. Radial access: just another artery? The only artery!

31. Normal arterial anatomy in forearm

32. Brachial tortuosity