Search

The introduction of transradial access for percutaneous coronary diagnostic and interventional procedures has led to a decrease in access site complications. The aim of this paper is to propose a combined stepwise technical approach where real time ultrasound ("echo-first" approach) can be used to select the best vascular access and, together with angiography, to manage the potential obstacles that may occur during transradial procedures. In each section, we summarize some tips and tricks based on both our experience and current literature that can be easily implemented in daily practice to increase the success of transradial procedures., (© 2024 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Objectives: To describe and report the results of an original technique for trans-femoral (TF) transcatheter-aortic-valve-replacement (TAVR)., Background: TF approach represents the commonest TAVR technique. The best technique for TF-TAVR is not recognized., Methods: We developed a less-invasive totally-endovascular (LITE) technique for TF-TAVR. The key aspects are: precise TAVR access puncture using angiographic-guidewire-ultrasound guidance radial approach as the "secondary access" (to guide valve positioning, to check femoral-access hemostasis and to manage eventual access-site complications) non-invasive pacing (by retrograde left ventricle stimulation or by definitive pace-maker external programmer) The LITE technique has been systematically adopted at our Institution. Procedure details, complications and clinical events occurring during hospitalization were prospectively recorded. Major vascular complications and life-threatening or major bleedings were the primary study end-points., Results: A total of 153 consecutive patients referred for TF-TAVR were approached using the LITE technique. Mean predicted surgical operative mortality was 4.9% and mean TAVR predicted mortality was 3.9%. In 132 (86.3%) patients, TAVR was completed without the need for additional femoral artery access or transvenous temporary pace-maker implantation. Major vascular complications occurred in 2 (1.3%), life-threatening or major bleedings occurred in 4 (2.6%) patients. All-cause death occurred in 3 patients (2.0%)., Conclusions: TF-TAVR according to LITE technique is feasible and is associated with very low rates of vascular or bleeding complications., (© 2020 Wiley Periodicals, Inc.)

This article summarizes the current research on the benefits of using the transradial approach for percutaneous procedures and the radial artery as a conduit for coronary artery bypass surgery. Based on the available evidence, the authors provide recommendations for the use of the radial artery in patients undergoing percutaneous or surgical coronary procedures., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: to understand the role of a transradial (TR) secondary approach during complex percutaneous interventions., Background: The value of the TR route for ancillary vascular approach has not been adequately validated in this setting, and there is scant data on its role in reducing bleeding complications., Methods: In the present study we retrospectively included patients undergoing the following interventions requiring two vascular approaches at nine high-volume centers in Italy: structural cardiac interventions, complex PCI, endovascular aortic repair (EVAR) and complex lower limb angioplasty. We compared procedural outcomes according to the type of ancillary vascular approach selected, namely TR or transfemoral/transbrachial (TF/TB). Primary endpoints of the study were procedural success and in-hospital BARC grade 3-5 bleedings., Results: We included 906 patients, 433 receiving TR and 473 TF/TB ancillary approaches. Baseline characteristics did not differ significantly. Patients underwent the following types of intervention: structural 50%, complex coronary PCI 37%, EVAR 11%, peripheral angioplasty 2%. Procedural success was similar (90% in TR and 92% TF/TB, P = NS). In-hospital BARC 3/5 bleedings were more common in TF/TB group as compared to TR group (19.7% vs. 6.7%,P < 0.001). In TF/TB group we also observed a higher postprocedural hemoglobin drop (1.92 vs 1.13 g/dl, P = 0.008) and longer hospital stay as compared to TR group. Similar results were observed in a propensity score-matched population of 450 patients., Conclusions: In our study TR ancillary approach was associated with a significant reduction in the risk of major bleedings, without jeopardizing the success of complex structural, coronary, and peripheral percutaneous interventions. The value of the transradial route for ancillary vascular approach during percutaneous interventions has not been adequately validated yet. We retrospectively included 906 patients, 433 receiving TR and 473 TF/TB ancillary approach at nine high-volume centers for the following interventions: structural cardiac interventions, complex PCI, EVAR and complex peripheral angioplasty. Procedural success was similar, whereas in-hospital BARC bleedings were more common in the transfemoral/brachial group. Similar results were observed in a propensity score-matched population. In our study TR ancillary approach was associated with a significant reduction in the risk of major bleedings, without jeopardizing the success of complex interventions. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Background: Consistent evidence of benefit exists for radial access (RA) in ST-elevation acute myocardial infarction (STEMI). Patients with non ST-elevation acute coronary syndrome (NSTE-ACS) have a more varied ischemic and bleeding profile. No randomized trial of vascular access ever focused on NSTE-ACS and landmark studies did not provide conclusive results in this heterogeneous subset of patients., Methods: We assessed in a meta-analysis whether RA is associated with improved outcomes in NSTE-ACS patients. Included studies had to meet the following criteria: 1) enrolling patients with NSTE-ACS undergoing invasive management; 2) reporting outcomes with respect to RA as compared with femoral access (FA); 3) reporting short-term (procedural, in-hospital and up to 30-day) or long-term clinical outcomes. Studies were pooled with fixed and random effects models and heterogeneity was investigated by weighted meta-regression., Results: Eleven studies were included encompassing 131.339 patients, 46.451 receiving RA and 84.888 receiving FA. Thirty-day mortality and MACE were lower with RA (p<0.001 with fixed effects, p=NS with random effects model), but these results depended on one large observational database. Major bleeding was consistently reduced by RA (p<0.001), albeit an inverse relationship with the proportion of patients in each study receiving FA and experiencing major bleeding was evident. The association of RA with reduced long-term mortality was of borderline significance (p=0.054 with random-effects, p=0.001 with fixed-effect model) and also depended on major bleeding in FA patients., Conclusions: RA is associated with better outcomes as compared with FA in NSTE-ACS, although this observation is influenced by nonrandomized comparisons. Large heterogeneity exists among studies., Registration: This study is registered in the PROSPERO database (CRD42015029459)., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Transradial approach (TRA), when compared with transfemoral, improves the safety of percutaneous coronary procedures. Arterial axis variants are known to hinder the performance of transradial approach percutaneous coronary procedures. Data on the occurrence of arterial axis variants in the right and left arm arterial axes of individual patients are lacking., Methods and Results: From a single-center prospective registry, we selected all patients in whom bilateral upper limb arterial anatomy was assessed based on the performance of left and right radial catheterization obtained during the same or during repeat coronary diagnostic or interventional procedure(s). The occurrence of upper right and left limb arterial axis variants was classified according to the previously described operative ABC classification. A total of 610 patients were identified. An ABC upper limb arterial axis variant was detected in 156 (25.6%) patients. Variants were right-sided only in 65 (11.0%), left-sided only in 40 (6.6%), and bilateral in 46 (7.5%) patients. Thus, arterial axis variants were significantly more common in the right side (P=0.02). Bilateral arterial variants were significantly associated with age, female sex, and valvulopathy. Both A (radial/brachial) and B (axillary/subclavian/innominate) variants exhibited concordance across the 2 sides (odds ratio, 7.2; 95% confidence interval, 4.1-12.7 and 8.0; 95% confidence interval, 2.1-30.9, respectively)., Conclusions: The occurrence of an anatomic variant potentially hindering transradial approach coronary diagnostic or interventional procedures is bilateral in <8% of cases and is more common in the right arm. Such information may guide, during the clinical practice, the access selection in the case of repeat procedures or need for additional accesses., (© 2015 American Heart Association, Inc.)

We describe our solution to the unusual situation of an inflated, large coronary stent (3.5 mm diameter) which became dislodged from the ostium of the right coronary artery after deployment during a transradial procedure. We discussed tips for retrieval from the radial artery while preserving the access for completion of the procedure., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Percutaneous angioplasty of lower limb disease is commonly performed with a transfemoral access. In the coronary field, a transradial approach has shown to reduce access-site bleeding and adverse clinical events. This route has not yet been well studied for the majority of peripheral interventions, like those involving the iliac arteries. In this study we sought to evaluate the feasibility and safety of this approach for iliac interventions., Methods: Multicenter study was performed at high-volume centers with experience in transradial percutaneous interventions. Primary endpoint of the study was procedural success; secondary endpoints included in-hospital bleeding, 1-month freedom from adverse events and the rate of radial occlusion. Feasibility of this technique was evaluated by recording procedural and fluoroscopy time and contrast load., Results: A total of 149 patients from 5 centers were enrolled. The population had a medium risk profile, with 48% of patients having TASC 2 or 3 lesions. Procedural success was achieved in 98.7% of the population, and we did not register in-hospital complications, including both vascular access site and procedural-related complications. An ancillary transfemoral approach was used in 13% of patients. One-month freedom from symptoms was achieved in 97.3% of patients, and the rate of radial occlusion was 2.7%. Major determinants of an unsuccessful procedure were the use of normal 6 or 7-Fr introducer with guiding catheter, TASC D lesion attempt, lesion length>30 mm and total occlusion., Conclusions: A transradial approach for iliac disease may be a feasible and safe alternative to the transfemoral route in experienced hands, in the light of significant technical improvements and dedicated devices., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

This study was performed to analyze the impact of transradial intervention (TRI), performed by long (25-cm) hydrophilic-coated radial introducer sheath (HRS), on radial artery (RA). Both acute damages and chronic intimal modifications, occurring in RA, were assessed using frequency domain-optical coherence tomography (FD-OCT). FD-OCT evaluation of RA was performed in 51 consecutive patients, undergoing TRI by long (25-cm) HRS. FD-OCT was performed from RA ostium to the puncture site. Acute damages such as intimal tears and medial dissections together with chronic intimal modifications, assessed as intimal hyperplasia indexes, were observed and compared between proximal and distal RA segments. Intimal tears were detected in 37% of patients, especially located in proximal RA segment (p = 0.09). Medial dissections were imaged in 9.8% of patients with no significant difference between proximal and distal RA segments. Intimal hyperplasia indexes were higher in distal RA segment, with no significant association with a previous history of TRI. In the setting of TRI, performed by long HRS, intimal tears represented the main RA injury occurring in about one-third of patients, while medial dissections only occurred in a small proportion of patients. Distal RA segment was more prone to intimal thickening, although this phenomenon was not associated with repeated transradial procedures.

Objective: To overview the scientific data and the technical details regarding percutaneous coronary interventions (PCI) on chronic total occlusions (CTO) by radial approach., Background: Trans-femoral approach is commonly regarded as the standard for PCI on CTO., Methods: A systematic search in Medline and in the main international websites was realized. Key data were extracted and analyzed using standard meta-analytic techniques. Bench test assessment of compatibility between different combinations of interventional devices (required for CTO recanalization techniques) and the following guiding catheters was performed: 5 Fr, Sheathless 6.5 Fr, 6 Fr, Sheathless 7.5 Fr and 8 Fr., Results: No prospective randomized study was found, whereas 13 observational studies on 3,501 CTOs treated by radial approach were identified. Overall, the crossover to femoral access rate ranged between 0 and 5.8%. Access site complications were noted in <1% of cases and in-hospital major adverse events were reported in 0-3.8% of patients. PCI success was significantly influenced by the learning curve: In the five studies comparing the success rates between a first and a later period of practice, a significant improvement was observed (OR, 95% CI: 0.30, 0.39-0.51; P < 0.001). The technical details relevant to approach a CTO by transradial access are discussed, and the original results of bench tests provide details regarding the compatibility of various CTO recanalization techniques with specific guiding catheter sizes., Conclusions: The transradial access represents a promising alternative to trans-femoral access to treat patients undergoing CTO PCI in high-volume transradial centres. The presented data may be useful to plan transradial PCI attempts on CTO lesions., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: The role of intraaortic balloon pump (IABP) during percutaneous coronary intervention (PCI) in high-risk acute patients remains debated. Device-related complications and the more complex patient management could explain such lack of clinical benefit. We aimed to assess the impact of transradial versus transfemoral access for PCI requiring IABP support on vascular complications and clinical outcome., Methods: We retrospectively analyzed 321 consecutive patients receiving IABP support during transfemoral (n = 209) or transradial (n = 112) PCI. Thirty-day net adverse clinical events (NACEs) (composite of postprocedural bleeding, cardiac death, myocardial infarction, target lesion revascularization, and stroke) were the primary end point, with access-related bleeding and hospital stay as secondary end points., Results: Cardiogenic shock and hemodynamic instability were the most common indications for IABP support. Cumulative 30-day NACE rate was 50.2%, whereas an access site-related bleeding occurred in 14.3%. Patients undergoing transfemoral PCI had a higher unadjusted rate of NACEs when compared with the transradial group (57.4% vs 36.6%, P < .01), mainly due more access-related bleedings (18.7% vs 6.3%, P < .01). Such increased risk of NACEs was confirmed after propensity score adjustment (hazard ratio 0.57 [0.4-0.9], P = .007), whereas hospital stay appeared comparable in the 2 groups., Conclusions: In this observational registry, high-risk patients undergoing PCI and requiring IABP support appeared to have fewer NACEs if transradial access was used instead of transfemoral, mainly due to fewer access-related bleedings. Given the inherent limitations of this retrospective work, including the inability to adjust for unknown confounders, further controlled studies are warranted to confirm or refute these findings., (© 2013.)

Background: Peripheral arterial disease is a risk factor for cardiac mortality but pathophysiologic mechanisms linking atherosclerosis of peripheral arteries with coronary events in the single patient have not been established., Method and Results: We evaluated by frequency-domain optical coherence tomography (FD-OCT) the possible association between culprit coronary plaque characteristics and proximal radial artery features in a cohort of 51 patients symptomatic coronary artery disease undergoing coronary procedures by transradial route. FD-OCT coronary artery analysis included assessment of TCFA and thrombus. FD-OCT radial artery analysis included intimal thickness index (ITI: intimal area/medial area), intima-media ratio (IMR: the maximum intimal thickness/medial thickness), and percentage of luminal narrowing [%LN: (intimal area+medial area)/external elastic membrane area × 100]. Coronary TCFA and thrombus were detected in 19 (37%) and 7 (14%) patients, respectively. TCFA was significantly associated with higher values of radial artery ITI (0.35 vs. 0.26, p=0.02) and IMR (0.45 vs. 0.32, p=0.03), but not with %LN. In contrast, coronary thrombus was only associated with higher %LN (26.7 vs. 22.8, p=0.02). Multivariate logistic regression analysis identified proximal radial artery IMR (OR 16.3, 95% CI 1.1 to 245.1) as an independent predictor of TCFA., Conclusions: In patients with symptomatic coronary atherosclerosis, vessel wall modifications at the level of the proximal radial artery are associated with adverse coronary features like TCFA and thrombus., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

The transradial approach (TRA) is emerging as a promising strategy to improve the safety of percutaneous coronary diagnostic or interventional procedures. Nevertheless, a series of specific complications related to the radial access have been described so that their prevention and optimal management is clinically relevant. In this article, the types of access-related vascular complications potentially occurring after TRA and their possible management are described. In particular, the vascular complications have been classified in three groups according to the main pathogenetic mechanism: thrombotic, hemorrhagic and nonthrombotic nonhemorrhagic. Moreover, a practical operative protocol for prompt diagnosis and treatment has been proposed.

Background: Access-site vascular complications (ASVC) in patients undergoing trans-radial coronary procedures are rare but may have relevant clinical consequences. Data regarding the optimal management of radial-access-related ASVC are lacking., Methods: During a period of 6 years we prospectively collected ASVC. ASVC were defined as any complication requiring ultrasound examination or upper limb angiography. ASVC were categorized according to the timing of diagnosis: "very early" (in the cath lab), "early" (after cath lab discharge, but during the hospital stay) and "late" (after hospital discharge). The need of surgery (primary end-point) and the development of neurological hand deficit (secondary end-point) were assessed., Results: Fifty-seven radial-artery related ASVC were collected. ASVC diagnosis was obtained by upper limb angiography in 25 patients (44%) and by Doppler in 32 patients (56%). Surgery was required in 6 cases (11%), the remaining patients receiving successful conservative management (which included prolonged local compression). Three patients (who received surgery) exhibited a mild neurological hand deficit in the follow-up. Need for surgery differed significantly according to timing of diagnosis as it occurred in 1 of 26 patients (3.8%) with "very early" diagnosis, in 1 of 21 patients (4.8%) with "early" diagnosis, and in 4 of 10 patients (40%) with "late" diagnosis (p=0.026)., Conclusions: ASVC are diagnosed with different timing after trans-radial procedures. Conservative management including local compression allows successful management in the majority of ASVC. Prompt recognition is pivotal as late diagnosis is associated to the need for surgery., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: The efficacy of trans-radial approach (TRA) in chronic total occlusions (CTO) percutaneous coronary interventions (PCI) is not well established. Thus, we sought to review the feasibility and long-term results of TRA for CTO PCI performed by dedicated TRA operatorsof our center., Methods: CTO PCI performed by dedicated radialists were considered. Primary end-points were "PCI success" (stent implantation with residual stenosis < 20% and TIMI 3) and "patient success" (PCI success in a first or second attempt). Vascular complications and major adverse cardiac events (MACE) were also assessed. Procedures were divided into: Period 1 - no systematic adoption of TRA nor systematic wire selection, and Period 2 - systematic TRA with stepwise wire selection. The starting guidewire was initially an intermediate wire (Period 2a), and, thereafter, a tapered soft polymeric guidewire (Period 2b)., Results: Two operators performed 167 TRA PCI on CTO in 158 patients. PCI success rate was 74.3% and patient success rate was 78.5%. Drug-eluting stents were implanted in 95.1% of successful procedures. One (0.6%) patient had a (minor) vascular complication. After a mean follow-up of 580 days, 93.7% of patients were free from MACE. PCI success (57.1% in Period 1 vs. 76.5% in Period 2a vs. 80.5% in Period 2b, p = 0.029) and patient success (62.5% in Period 1 vs. 77.8% in Period 2a vs. 86.1% in Period 2b, p = 0.025) significantly improved during the study., Conclusions: CTO PCI by TRA is safe and feasible. Its efficacy seems to be strongly dependenton operator experience with CTO techniques and may be influenced by the strategy of guidewire selection.

Background: Single center studies using serial cerebral diffusion-weighted magnetic resonance imaging in patients having cardiac catheterization have suggested that cerebral microembolism might be responsible for silent cerebral infarct (SCI) as high as 15% to 22%. We evaluated in a multicenter trial the incidence of SCIs after cardiac catheterization and whether or not the choice of the arterial access site might impact this phenomenon., Methods and Results: Patients were randomized to have cardiac catheterization either by Radial (n = 83) or Femoral (n = 77) arterial approaches by experimented operators. The main outcome measure was the occurrence of new cerebral infarct on serial diffusion-weighted magnetic resonance imaging. Patient and catheterization characteristics, including duration of catheterization, were similar in both groups. The risk of SCI did not differ significantly between the Femoral and Radial groups (incidence of 11.7% versus 17.5%; OR, 0.85; 95% CI, 0.62-1.16; P = .31). At multivariable analysis, the independent predictors of SCI were the patient's higher height and lower transvalvular gradient., Conclusions: The high rate of SCI after cardiac catheterization of patients with aortic stenosis was confirmed, but its occurrence was not affected by the selection of Radial and Femoral access., (Copyright © 2012 Mosby, Inc. All rights reserved.)

It remains undefined if transradial coronary angiography from a right or left radial arterial approach differs in real-world practice. To address this issue, we performed a subanalysis of the PREVAIL study. The PREVAIL study was a prospective, multicenter, observational survey of unselected consecutive patients undergoing invasive cardiovascular procedures over a 1-month observation period, specifically aimed at assessing the outcomes of radial approach in the contemporary real world. The choice of arterial approach was left to the discretion of the operator. Prespecified end points of this subanalysis were procedural characteristics. Of 1,052 patients consecutively enrolled, 509 patients underwent transradial catheterization, 304 with a right radial and 205 with a left radial approach. Procedural success rates were similar between the 2 groups. Compared to the left radial group, the right radial group had longer procedure duration (46 ± 29 vs 33 ± 24 minutes, p <0.0001) and fluoroscopy time (765 ± 787 vs 533 ± 502, p <0.0001). At multivariate analysis, including a parsimonious propensity score for the choice of left radial approach, duration of procedure (beta coefficient 11.38, p <0.001) and total dose-area product (beta coefficient 11.38, p <0.001) were independently associated with the choice of the left radial artery approach. The operator's proficiency in right/left radial approach did not influence study results. In conclusion, right and left radial approaches are feasible and effective to perform percutaneous procedures. In the contemporary real world, however, the left radial route is associated with shorter procedures and lower radiologic exposure than the right radial approach, independently of an operator's proficiency., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: To assess the impact of an "operative" classification of vascular anatomic variants on the feasibility of trans-radial approach., Background: Vascular anatomic variants located from the wrist to the aorta may influence the feasibility of trans-radial procedures. Recently, a new "operative" classification of these variants was proposed., Methods: Consecutive trans-radial diagnostic or interventional catheterizations were considered. Vascular anatomic variants were classified according to 10 categories and sub-grouped according to the ABC classification (A: radial-brachial arterial axis; B: axillary-subclavian-anonymous axis; C: aortic arch). Primary study end-point was failure of trans-radial approach (necessity to cross-over to another approach to complete the procedure)., Results: Three thousand four hundred seventy-seven consecutive radial procedures were considered. Anatomic variants were diagnosed in 308 procedures (8.8%): A variants: 7.2%, B variants: 1.9%; C variants: 0.3%. Failure occurred in 2.0% of procedures. Failure rate was 0.7% in the absence of variants vs.15.2% in the presence of any variant (P < 0.0001, OR 27.7, 95%CI 16.3-46.9). Each of the 10 variants was significantly associated with increased failure rate. Each of the three level-subgroups of variants was significantly associated to the risk of failure (failure 14.7% in A level, 13.9% in B level, 33.3% in C level; P < 0.0001 vs. absence of variants)., Conclusions: Failure of trans-radial procedures is associated to anatomic variants located from the wrist to the aorta. The "operative" ABC classification of anatomic variants is useful not only to categorize these anatomic variants, but also to predict the risk of failure of trans-radial approach., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: Trans-radial approach (TRA) reduces vascular access-site complications but has some technical limitations. Usually, TRA procedures are performed using 5 Fr or 6 Fr sheaths, whereas complex interventions requiring larger sheaths are approached by trans-femoral access., Methods: During 4 years, at two Institutions with high TRA use, we have attempted to perform selected complex coronary or peripheral interventions by TRA using sheaths larger than 6 Fr. Clinical and procedural data were prospectively collected. Attempt to place a 7 Fr or 8 Fr sheath (according to the planned strategy of the procedure) was performed after 5-6 Fr sheath insertion, administration of intra-arterial nitrates and radial artery angiography. Late (>3 months) patency of the radial artery was checked (by angiography in the case of repeated procedures or by palpation + reverse Allen test)., Results: We collected 60 patients in which TRA large sheath insertion was attempted. The large sheath (87% 7 Fr, 13% 8 Fr) was successfully placed in all cases. Most of the procedures were complex coronary interventions (bifurcated or highly thrombotic or calcific chronic total occlusive lesions), whereas 8.3% were carotid interventions. Procedural success rate was 98.3% (1 failure to reopen a chronic total occlusion). No access-site related complication occurred. In 57 (95%) patients, late radial artery patency was assessed and showed patency in 90% of the cases, the remaining patients having asymptomatic collateralized occlusion., Conclusions: In selected patients, complex percutaneous interventions requiring 7-8 Fr sheaths can be successfully performed by RA approach without access-site clinical consequences., (Copyright © 2011 Wiley Periodicals, Inc.)

Background: Randomized trials have shown that transradial approach, compared with transfemoral, reduces vascular complications (VCs) of coronary procedures in selected patients. Yet, radial approach is associated to a variety of access-site VC as well as to a higher failure rate compared with femoral access., Methods: At our institution, from May 2005 to May 2010, we prospectively assessed the occurrence and outcome of VC in consecutive patients undergoing transradial percutaneous coronary procedures performed by trained radial operators. The need of access crossover to complete the procedure was also prospectively investigated. Vascular complications were classified as "radial related" or "nonradial related" (in the case of access crossover). Vascular complications were also classified "major" if requiring surgery and/or blood transfusions or causing hemoglobin drop >3 g/dL., Results: Ten thousand six hundred seventy-six procedures were performed using a right radial (87.5%), left radial (12.4%), or ulnar (0.1%) artery as primary access. A total of 53 VCs (0.5%) were observed: 44 (83%) radial related and 9 (17%) nonradial related. Major VCs occurred in 16 patients only (0.2%) and were radial related in 10 (62.5%) and nonradial related in 6 (37.5%) patients. Vascular complications rate was stable during the study and independent of operator's experience. Access crossover rate was 4.9%, differed according to the operator radial experience and significantly decreased over time., Conclusions: The present study, conducted in a center with high volume of radial procedures, shows that transradial approach is associated with a very low rate of VC, which is stable over time. On the contrary, access crossover rate decreased over time and differed according to operator (radial) experience., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Background: Transradial percutaneous coronary procedures may be effectively performed through the right radial approach (RRA) or the left radial approach (LRA), but data on radiation dose absorbed by operators comparing the two approaches are lacking. The aim of the present study was to evaluate radiation dose absorbed by operators during coronary procedures through the RRA and LRA., Methods and Results: Three operators were equipped with 5 different dosimeters (left wrist, shoulder, thorax outside the lead apron, thorax under the lead apron, and thyroid) during RRA or LRA for coronary procedures. Each month, the dosimeters were analyzed to determine the radiation dose absorbed. From February to December 2009, 390 patients were randomly assigned to the RRA (185 patients; age, 66±11 years) or the LRA (185 patients; age, 66±11 years). There were no significant differences in fluoroscopy time (for RRA, 369 seconds; interquartile range, 134 to 857 seconds; for LRA, 362 seconds; interquartile range, 142 to 885 seconds; P=0.58) between the 2 groups. There were no significant differences in monthly radiation dose at the thorax (0.85±0.46 mSv for RRA and 1.12±0.78 mSv for LRA, P=0.33), at the thyroid (0.36±0.2 mSv for RRA and 0.34±0.3 mSv for LRA, P=0.87), and at the shoulder (0.73±0.44 mSv for RRA and 0.94±0.42 mSv for LRA, P=0.27). The dose at the wrist was significantly higher for the RRA (2.44±1.12 mSv) compared with the LRA (1±0.8 mSv, P=0.002). In both radial approaches, the thoracic radiation dose under the lead apron was undetectable., Conclusions: Compared with RRA, LRA for coronary procedures is associated with similar radiation dose for operators at the body, shoulder, or thyroid level, with a possible significant advantage at the wrist. The cumulative radiation dose for both approaches is well under to the annual dose-equivalent limit., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00282646.

Percutaneous revascularization of superficial femoral artery (SFA) is increasingly carried out to treat patients with peripheral vascular disease and either intermittent claudication or critical limb ischemia. Transradial vascular access is increasingly adopted for invasive procedures due to reduced access-site complications and improved patient's comfort, compared with transfemoral. However, compared with coronary interventions, the adoption of transradial access in peripheral procedures is limited. Concerning SFA interventions, transradial access is usually prevented by the distance between the vascular access and the target lesion, which extends over the length of the currently available devices. Thanks to technical improvements, resulting in specifically dedicated low-profile equipment with adequate shaft length availability, transradial access is now feasible for the treatment of selected SFA lesions. We report the first two cases of SFA stenting performed by transradial access with a new specifically developed self-expanding nitinol stent with extended delivery system length. This report suggests that, with proper technique and specifically dedicated equipment, transradial SFA stenting is feasible. Treatment of SFA disease by transradial route, allowing for immediate post-procedure walking and simultaneous bilateral interventions, may represent an alternative for effective treatment of selected patients with SFA lesions.

Aims: To assess: the reasons behind an operator choosing to perform radial artery catheterisation (RAC) as against femoral arterial catheterisation, and to explore why RAC may fail in the real world., Methods and Results: A pre-determined analysis of PREVAIL study database was performed. Relevant data were collected in a prospective, observational survey of 1,052 consecutive patients undergoing invasive cardiovascular procedures at nine Italian hospitals over a one month observation period. By multivariate analysis, the independent predictors of RAC choice were having the procedure performed: (1) at a high procedural volume centre; and (2) by an operator who performs a high volume of radial procedures; clinical variables played no statistically significant role. RAC failure was predicted independently by (1) a lower operator propensity to use RAC; and (2) the presence of obstructive peripheral artery disease. A 10-fold lower rate of RAC failure was observed among operators who perform RAC for > 85% of their personal caseload than among those who use RAC < 25% of the time (3.8% vs. 33.0%, respectively); by receiver operator characteristic (ROC) analysis, no threshold value for operator RAC volume predicted RAC failure., Conclusions: A routine RAC in all-comers is superior to a selective strategy in terms of feasibility and success rate.

The adoption of transradial approach for percutaneous coronary diagnostic and interventional procedures is known to reduce access-site complications. However, anatomic variants of brachial-radial axis, axillary-subclavian-anonymous axis and aortic arch may obstacle successful completion of transradial procedures. In the present paper, we discuss how to diagnose and manage the possible obstacles occurring at the different steps of transradial diagnostic and interventional procedures.

Transradial vascular access for invasive procedures is gaining increasingly acceptance due to reduced access-site complications and improved patient's comfort compared with transfemoral. However, the adoption of transradial access in peripheral vascular procedures is actually limited by anatomical and technical considerations. Yet, among all the peripheral vascular districts, the renal one seems to be particularly suitable for transradial approach. In this article, we discuss the rationale for preferring the radial approach instead of femoral and review the specific technical issues related to transradial renal artery stenting (RAS)., (Copyright 2009 Wiley-Liss, Inc.)

Background: Transradial access reduces the incidence of access site complications of percutaneous revascularization procedures. However, in patients with peripheral vascular disease, the adoption of transradial approach for superficial femoral artery (SFA) angioplasty is usually prevented by the distance between the vascular access and the target lesions; thus, SFA angioplasty is commonly performed by transfemoral approach. Recently, low-profile balloons with extended shaft length became available, allowing to potentially address SFA lesions by transradial approach. As plain balloon angioplasty represents a valuable option for SFA in-stent restenosis treatment, we evaluated the feasibility of transradial approach in this clinical setting., Methods: Transradial balloon angioplasty of SFA diffuse in-stent restenosis was attempted in 12 patients aged 69.4 +/- 5.1 years. Six-French 125 cm long MP guiding catheters, 300 cm long 0.018'' guidewire, and low-profile 4 Fr compatible 180 cm long shaft balloons (5 and 6 mm in diameter and 80-150 mm in length) were used., Results: The procedural success was 100%, and no complications occurred during the hospital stay. Compared with a matched group of patients in whom angioplasty was performed by trans-femoral approach, main procedural key data resulted similar except for the amount of administered contrast dye, which was slightly but significantly lower in transradial group (170 +/- 59 ml vs. 241 +/- 103, P = 0.03)., Conclusions: In conclusion, with the currently available equipment, the transradial approach is feasible and represents a valuable alternative for treatment of patients with SFA in-stent restenosis., (2009 Wiley-Liss, Inc.)

Proximal embolic protection devices (PPDs) are increasingly used during carotid artery stenting (CAS) due to the theoretical advantage of cerebral protection during the entire procedure. Transradial approach reduces access site vascular complications and can be useful for CAS in patients at high bleeding risk, with contraindications for prolonged bed rest and when a bovine aortic arch is present. Due to the large size of the available equipment, PPDs have only been employed by transfemoral approach. Recently, one PPD (MoMa, Invatec, Roncadelle, Italy) has become available in 8 Fr configuration. Such improved design may theoretically permit its introduction in the radial artery. Here we report three cases of severe internal carotid artery stenosis successfully treated by CAS with 8 Fr MoMa using transradial approach, showing the technical feasibility of such procedure., ((c) 2009 Wiley-Liss, Inc.)

Objective: To obtain a "snapshot" view of access-specific percutaneous cardiovascular procedures outcomes in the real world., Design: Multicentre, prospective study performed over a 30-day period., Setting: Nine hospitals with invasive cardiology facilities, reflecting the contemporary state of healthcare., Patients: Unselected consecutive sample of patients undergoing any percutaneous cardiovascular procedure requiring an arterial access., Interventions: Percutaneous cardiovascular procedures by radial or femoral access, Main Outcome Measures: The primary outcome was the combined incidence of in-hospital (a) major and minor haemorrhages; (b) peri-procedural stroke; and (c) entry-site vascular complications. The secondary outcome was the combined incidence of in-hospital death and myocardial infarction/reinfarction. For analysis purposes, outcomes were allocated to arterial access-determined study arms on an intention-to treat basis. Multivariable analysis adjusted using propensity score was performed to correct for selection bias related to arterial site., Results: A total of 1052 patients were enrolled: 509 underwent radial access and 543 femoral access. In both groups, 40% underwent a coronary angioplasty. Relative to femoral access, radial access was associated with a lower incidence both of primary (4.2% vs 1.96%, p = 0.03, respectively) and secondary endpoints (3.1% vs 0.6%, p = 0.005, respectively). Multivariate analysis, adjusted for procedural and clinical confounders, confirmed that intention-to-access via the radial route was significantly and independently associated with a decreased risk both of primary (OR 0.37, 95% CI 0.16 to 0.84) and secondary endpoints (OR 0.14, 95% CI 0.03 to 0.62)., Conclusions: Our study indicates strikingly better outcomes of percutaneous cardiovascular procedures with radial access versus femoral access in contemporary, real-world clinical settings.

Among patients undergoing coronary procedures, patients with coronary artery bypass grafts represent an important, high risk subgroup. Routine transradial approach may be successfully adopted in these patients to reduce access-site complications. However, transradial cannulation of the grafts may result technically demanding. In this article we discuss the specific technical issues and we present a series of tips and tricks which may facilitate angiography and interventions on both internal mammary and aorto-coronary grafts., ((c) 2008 Wiley-Liss, Inc.)

Objective: Transradial access for coronary angiography may offer some advantages in comparison with conventional transfemoral access in specific subgroups of patients. Therefore, the aim of this study was to compare the transradial and transfemoral approaches in patients with previous coronary artery bypass graft (CABG) surgery using the left internal mammary artery (IMA)., Methods: The time to left IMA cannulation, the time needed for left IMA evaluation, and total procedure time were compared in 60 patients previously submitted to CABG surgery using the left IMA. The homolateral radial access was attempted in 20 consecutive patients (TR group), whereas the transfemoral approach was undertaken in 40 patients (2: 1, TF group), matched for age, sex and number of grafts., Results: In the TR group, the time to left IMA cannulation and the time needed for left IMA evaluation were 39% and 46%, respectively, lower than those in the TF group (P = 0.01 and P = 0.001, respectively), whereas total procedure time was similar. In the subgroup of patients with less than three saphenous vein grafts (n = 36), the time to left IMA cannulation, the time needed for left IMA evaluation as well as total procedure time were significantly reduced (P = 0.01, P = 0.001 and P = 0.004, respectively). The rate of ad-hoc coronary angioplasty procedures was unaffected by the access site (20% in the TR group and 27% in the TF group, P = 0.53)., Conclusions: The present study shows that the homolateral transradial approach facilitates left IMA evaluation in patients with previous CABG surgery undergoing coronary angiography, in particular in patients with a lower number of coronary artery bypass conduits, in the absence of an excess of periprocedural complications.

Background: In patients who develop in-stent restenosis, successful revascularization can be difficult to achieve using percutaneous methods. This study was designed to verify the surgical results in this setting and to evaluate the potential beneficial role of arterial bypass conduits., Methods and Results: Sixty consecutive coronary artery bypass patients with previous in-stent restenosis and 60 control cases were randomly assigned to receive an arterial conduit (either right internal thoracic or radial artery; study group) or a great saphenous vein graft (control group) on the first obtuse marginal artery to complete the surgical revascularization procedure. At a mean follow-up of 52+/-11 months, patients were reassessed clinically and by angiography. Freedom from clinical and instrumental evidence of ischemia recurrence was found in 19 of 60 subjects in the study group versus 45 of 60 in the control series (P=0.01). The results of the arterial grafts were excellent in both the study and control groups (right internal thoracic artery patency rate, 19 of 20 for both, and radial artery patency rate, 20 of 20 versus 19 of 20; P=0.99). Saphenous vein grafts showed lower patency rate than arterial grafts in both series and had extremely high failure rate in the study group (patency rate, 10 of 20 in the study group versus 18 of 20 in the control group; P=0.001). Use of venous graft was an independent predictor of failure in the study group, whereas hypercholesterolemia was associated with graft failure in both series., Conclusions: Venous grafts have an high incidence of failure among cases who previously developed in-stent restenosis, whereas the use of arterial conduits can improve the angiographic and clinical results. Arterial grafts should probably be the first surgical choice in this patient population.

Background: The purpose of this research was to investigate the in vivo morphofunctional changes induced in the radial artery (RA) by its use as coronary artery bypass conduit by comparing the morphological features and vasoreactivity of the native RA versus the coronary RA graft in the same patient., Methods and Results: Ten years after surgery, 10 patients were submitted to intravascular ultrasound examination of the RA graft of the controlateral (in situ) RA and of the internal thoracic artery (ITA) graft and to vasoactive challenges with acetylcholine and serotonin. Quantitative angiographic assessment showed that the mean diameter of the RA coronary grafts was significantly larger than that of the in situ RA and of the ITA (2.89+/-0.40 mm RA grafts, 2.14+/-0.52 mm in situ RA, 2.25+/-0.53 mm ITA grafts; P<0.001). The in situ RA demonstrated a typical muscular architecture, whereas RA coronary grafts showed a clear reduction of the thickness of the medial layer and had a less well-defined muscular component of the media with interposition of elastic tissue. Serotonin endovascular infusion elicited a strong spastic reaction in in situ RAs; the same challenge induced only moderate constriction in RA and ITA coronary grafts., Conclusions: Implantation in the coronary circulation leads to major anatomic and vasoreactive modifications of the RAs that tend to lose the morphofunctional features of a muscular conduit and assume those of an elastomuscular artery, such as the ITA.

Direct stent implantation using radial approach represents to date the less invasive, less traumatic strategy to perform a percutaneous coronary intervention, rendering its adoption an attraction for many interventional cardiologists. A growing series of reports suggests the feasibility of transradial direct stenting in a variety of clinical situations. Here we discuss the main advantages of the adoption of this technique. Moreover, a detailed analysis of the technical issues specifically related with each phase of transradial direct stenting procedures is reported., ((c) 2004 Wiley-Liss, Inc.)

Background: No information is available on the long-term results of radial artery (RA) grafts used as coronary artery bypass conduits., Methods and Results: In this report, we describe the long-term (105+/-9 months) angiographic results of a series of 90 consecutive patients in whom the RA was used as a coronary artery bypass conduit directly anastomosed to the ascending aorta. The long-term patency and perfect patency rates of the RA were 91.6% and 88%, respectively, versus 97.5% and 96.3% for internal thoracic artery grafts. The severity of stenosis of the target vessel clearly influenced long-term RA patency, whereas location of the target vessel and long-term use of calcium channel blockers did not influence angiographic results. Preserved endothelial function and absence of flow-limiting, fibrous, intimal hyperplasia were also documented., Conclusions: Ten years after surgery, RA grafts have excellent patency and perfect patency rates. Appropriate surgical technique and correct indication are the key factors for long-term RA patency.

Background: The purpose of this study was to elucidate the midterm endothelium-dependent vasodilatory capacity of radial artery grafts anastomosed to the aorta, as well as their morphometric evolution with the time., Methods: Five years after surgery we evaluated the response of aorta-anastomosed radial artery grafts to the endovascular infusion of acetylcholine in 11 of the first 61 patients operated on at our institution, and we compared it to the response with that of internal thoracic artery grafts. Moreover, the first 20 patients who had a perfect radial artery graft on angiography at 1 year were restudied at 5 years and subjected to a comparative analysis of the diameters of the radial artery graft and the grafted coronary arteries., Results: At midterm angiography, dilation of the 2 types of grafts was similar in response to acetylcholine administration (radial artery, from 2.61 +/- 0.39 to 2. 90 +/- 0.34 mm; internal thoracic artery, from 2.68 +/- 0.21 to 2.93 +/- 0.27 mm; P =.01 for both). The diameters of aorta-anastomosed radial artery grafts and grafted coronary arteries increased between both 1 and 5 years according to angiographic studies (radial artery grafts, from 2.08 +/- 0.45 to 2.54 +/- 0.53 mm; grafted coronary arteries, from 1.92 +/- 0.47 to 2.18 +/- 0.41 mm; P <.001 for both), but the increase was greater for the radial artery grafts (P <.001)., Conclusions: Aorta-anastomosed radial artery grafts maintain an appreciable capacity for endothelium-dependent vasodilatation 5 years after implantation and undergo a progressive increase in luminal diameter with time. These observations contradict the presumed tendency for progressive fibrous intimal hyperplasia to develop in radial artery grafts.

Background: The radial artery (RA) is being employed as coronary artery bypass graft with good results, but when it is proximally anastomosed to the ascending aorta, undergoes substantial hemodynamic changes which could lead to significant graft intimal hyperplasia. The aim of this study was to investigate the evolution of RA graft morphology over time., Methods: We studied 20 patients with a perfectly patent RA graft at both 1 and 5 year angiography after coronary artery bypass graft., Results: Both RA graft and grafted coronary artery diameters, assessed by quantitative coronary angiography, significantly increased at 5 years, in comparison to 1 year angiography (2.08 +/- 0.45 vs 2.54 +/- 0.53 mm, +22%, p < 0.001 and 1.92 +/- 0.47 vs 2.18 +/- 0.41 mm, +13.3%, p < 0.001, respectively)., Conclusions: Hemodynamic changes following RA employment for coronary artery bypass graft stimulate a remodeling of RA graft itself and of the grafted coronary arteries. The progressive increase of diameters observed in RA grafts strongly argues against the development of flow-limiting graft intimal hyperplasia when RA is proximally anastomosed to the ascending aorta. Moreover, grafted coronary artery dilation suggests that hemorrheologic changes following coronary artery bypass graft could play a major role in the development of RA remodeling over time.

Objective: To evaluate the mid-term angiographic results of radial artery grafts used for myocardial revascularization., Methods: The first 68 consecutive surviving patients who received a radial artery graft proximally anastomosed to the aorta at our institution were restudied in a five-year follow-up (mean 59 +/- 6.5 months); 48 of these patients had already undergone an early angiographic examination. The response of the radial artery to the endovascular infusion of serotonin was evaluated one and five years after surgery and the mid-term status of the radial artery grafts was correlated with the degree of stenosis of the target vessel and with the Ca(++)-channel-blocker therapy., Results: The patency and perfect patency rates of the radial artery five years after the operation were 91.9 and 87.0% respectively. All radial artery grafts that were patent early after surgery remained patent at mid-term follow-up and in seven patients early parietal irregularities disappeared after five years. The early propensity to graft spasm after serotonin challenge decreased markedly at mid-term follow-up. The continued use of Ca(++)-antagonists after the first postoperative year did not affect the status of the radial artery graft, whereas the severity of target-vessel stenosis markedly influenced the angiographic results., Conclusions: The mid-term angiographic results of RA grafts used for myocardial revascularization are excellent. A correct surgical indication is essential, whereas continued therapy with Ca(++)-antagonists after the first year does not influence the mid-term angiographic results.

Objective: To evaluate the midterm angiographic results of the use of radial artery grafts for myocardial revascularization., Methods: The first 68 consecutive surviving patients who received a radial artery graft proximally anastomosed to the aorta at our institution were studied again at 5 years (mean 59 +/- 6.5 months) of follow-up; 48 of these patients had previously undergone an early angiographic examination. The response of the radial artery to the endovascular infusion of serotonin was evaluated 1 and 5 years after the operation, and the midterm status of the radial artery graft was correlated with the degree of preoperative stenosis of the target vessel and with calcium-channel blocker therapy., Results: The patency and perfect patency rates of the radial artery grafts 5 years after the operation were 91.9% and 87.0%, respectively. All radial artery grafts that were patent early after the operation remained patent at midterm follow-up, and early parietal irregularities in 7 patients were seen to have disappeared after 5 years. The early propensity toward graft spasm after serotonin challenge was markedly decreased at midterm follow-up. The continued use of calcium-channel antagonists after the first postoperative year did not influence the radial artery graft status, whereas the preoperative severity of the target-vessel stenosis markedly influenced the angiographic results., Conclusions: The midterm angiographic results of radial artery grafts used for myocardial revascularization are excellent. The correct surgical indication is essential. Continued therapy with calcium-channel antagonists after the first year does not influence the midterm angiographic results.