1. Radial Access: Lots of Publicity, But What is the Reality?
KENNETH A. GORSKI, RN, RCIS, FSICP
Cleveland Clinic Heart and Vascular Institute
Sones Cardiovascular Laboratories
Cleveland, Ohio

2. I have no real or apparent conflicts of interest to report.
Kenneth A. Gorski, RN, RCIS, RCSA
I have no real or apparent conflicts of interest to report.

3. Reality: There are Real Advantages to Transradial
Patient Comfort
Little/No Bedrest
Less Pain
Less Bruising
Decreased Access site Complications

4. Roadblocks to Transradial
Cath Lab Team Learning Curve
New Patient Prep/Set Up
New Technique = Increased Procedure Time
Resistance to change
Operator Learning Curve
Unfamiliarity with Catheter Curves
Fear of Failure
Limited Ability To Use Larger Equipment

5. United States Transradial Adoption
Of nearly 600,000 first PCI procedures performed , 1.32% were done through the radial artery
2010 data 4.2% of stent procedures were performed via the radial artery
National Cardiovascular Data Registry (NCDR)

6. Dr Olivier Bertrand, Laval University, Quebec, Canada
“Many European countries, including France, Italy, and Spain, the radial route plays a more dominant role, while nearly 50% of cases are done radially in Canada. In Norway, almost 90% of cases are transradial interventions, while in China roughly 80% of interventional procedures are done through the wrist.
The only people still reluctant to change are the US guys; I can tell you that there is momentum for change, and the timing is right.“
Dr Olivier Bertrand, Laval University, Quebec, Canada
theHeart.org , August 20, 2009

7. Cleveland Clinic Transradial Experience
January 2011
Femoral Cases = 580
Radial Cases = 51
8% of Angiographic Cases were Transradial
January 2012
Femoral Cases = 578
Radial Cases = 101
15% of Angiographic Cases were Transradial

8. Retrieved from http://ipo.totfarm.com/pics/pic_12274608241355.jpg

9. Reality: High Success, Reduced Bleeding Complications
Trends in the Prevalence and Outcomes of Radial and Femoral Approaches to Percutaneous Coronary Intervention
- 593,094 procedures
- procedural success: R F-94.68
- vascular complication: R F-0.70
- Bleeding complications: R F-1.83
Rao, S.V., Ou, F.-S., Wang, T.Y., Roe, M.T., Brindis, R., Rumsfeld, J.S., Peterson, E.D. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the national cardiovascular data registry J Am Coll Cardiol Intv (2008) (1) doi: /j.jcin

10. Vascular Complications: Radial vs. Femoral
Chart Source: Terumo Interventional Systems

11. No Hype: Reduced Bleeding
Meta-analysis by Jolly and colleagues (McMaster University, Hamilton, ON) presented at the Canadian Cardiovascular Congress and and published in the American Heart Journal, showed that radial-access PCI reduced the risk of major bleeding 73% compared with the femoral approach
Jolly SS, Amlani S, Hamon M, et al. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: A systematic review and meta-analysis of randomized trials Am Heart J 2009; 157:

12. RIVAL TRIAL
Radial vs. Femoral Access for Coronary Intervention (RIVAL) trial was a head-to-head comparison of radial vs femoral access for the treatment of patients with acute coronary syndromes (ACS)
7021 patients from 158 hospitals in 32 countries (Largest comparison of the transradial and transfemoral approaches to date)
Patients included had ACS with and without ST- Elevation segment elevation
Interventional cardiologists involved in trial performed a minimum of 50 radial angiography/PCI procedures in the last year
Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography in patients with acute coronary syndromes (RIVAL): A randomized, parallel group, multicenter trial. Lancet 2011; DOI: /S (11) Available at:

13. RIVAL TRIAL
30 days Primary outcome composite of death, MI, stroke, or non-CABG-related major bleeding
3.7% of patients randomized to Radial Access
4.0% of patients randomized to Femoral Access
Statistically a nonsignificant difference.

14. RIVAL TRIAL
Post hoc exploratory analysis using the definition of bleeding from the ACUITY Trial revealed a higher rate of major bleeding among patients treated via the femoral artery
1.4% among patients with radial access
3.7% among patients with femoral approach.

15. RIVAL TRIAL STEMIs
Among PCI centers performing the highest volume of Radial procedures, data from RIVAL showed
40% relative reduction in the risk of death, MI, stroke, or non-CABG-related major bleeding
61% relative reduction in the risk of death among STEMI patients treated via the radial artery. They also reported a
51% significant reduction in the risk of the primary outcome

16. RIVAL TRIAL Summary
Radial vs. Femoral Access for Coronary Intervention (RIVAL) trial was a head-to-head comparison of radial vs femoral access for the treatment of patients with acute coronary syndromes (ACS)
Presented during the late-breaking clinical-trials session at the American College of Cardiology 2011 Scientific Sessions
63% reduction in the risk of large vascular-access complications
Radial artery access did not reduce the rate of death, MI, stroke, or non-coronary artery bypass graft (CABG)-related major bleeding at 30 days
Benefit to radial approach in patients with ST-segment-elevation MI (STEMI), and in centers that perform high volume transradial procedures
Source:

17. SCAAR registry: Transradial PCI cuts mortality in STEMI
Transradial PCI in the treatment of STEMI associated with a 22% reduction in mortality and lower rates of bleeding and rehospitalizations
25,374 STEMI cases in Sweden
30-day and one-year mortality lower

18. Key findings: SCAAR radial analysis
End point
Transfemoral
Transradial
Adjusted OR p
30-day mortality (%)
4.4
3.2
0.57
<0.001
One-year mortality (%)
7.3
6.2
0.78
0.018
Serious bleeding (%)
2.2 1
0.43
Hospital stay (days)
5.2
4.8 —

19. Conflicting Data on Fluoro Times and Radiation Doses
Transradial diagnostic catheterization is associated with an increase in radiation exposure when compared with access via the femoral artery
In 5954 procedures, Radial access was associated with a 23% increase in measured Air Kerma
Variations radiation exposure between different operators correlating to clinical practice
Mercuri M, Mehta S, Xie C, et al. Radial artery access as a predictor of increased radiation exposure during a diagnostic cardiac catheterization procedure. JACC Cardiovasc Interv 2011; 4:

20. The “No-Go” Transradial:
Absolute contraindications:
Absent Radial Pulse
Ischemic Allen’s test
Arteriovenous Fistula (Use Opposite)
Relative contraindications:
Small Radial Artery
Known disease (subclavian stenosis)
Raynaud’s Syndrome

21. PATIENTS FIRST
“There is little justification to ignore one of the main developments in interventional cardiology and stubbornly refuse to embrace a technique likely to reduce minor adverse events and improve patients' comfort“ (Drs Carlo Di Mario and Nicola Viceconte, Royal Brompton Hospital, London, UK)
Di Mario C, Viceconte N. Radial angioplasty: Worthy RIVAL, not undisputed winner. Lancet 2011; DOI: /S (11) Available at:

22. So Why the Reluctance? SCAI: A 12-step program for ‘Femoral-aholics'
January 18, 2011 | Volume 5, Number 5
So Why the Reluctance?
January 18, 2011 | Volume 5, Number 5
SCAI: A 12-step program for ‘Femoral-aholics'
PHILADELPHIA--There are a variety of excuses why people won't adopt the radial approach to PCI. "If you are using any of them, you may be a femoral-aholic, and just like with any addiction, there is a 12-step program to help," said Pinak B. Shah, MD, at the Transradial Interventional Program sponsored by the Society for Cardiovascular Angiography and Interventions (SCAI) Jan. 15., 2011

23. femoral

24. SCAI 12-STEP PROGRAM FOR FEMORAL-AHOLICS
Accept Shortcomings of Femoral Access
Recognize Benefits of Radial access
(Physician) Educate yourself
Educate Cath Lab Staff
Take a Field Trip (observation, proctoring)
Have the Right Equipment (BEFORE you start)
Retrieved from

25. SCAI 12-STEP PROGRAM FOR FEMORAL-AHOLICS
7. Pick First Cases Carefully
8. Avoid Cases Where Inexperience Has Potential to Lead to Harm/Complications
9. Start Slow / Ramp Up
Get Colleagues on Board (Physicians and CVL Staff)
Talk to Patients With Previous Femoral Experience
Stay Committed
Retrieved from

27. JUST SAY NO!
GO RADIAL!