RadiaL and fEmoral Access foR iNterventional fellows performing
diagnostic coronary angiographies: the LEARN-Cardiogroup II, a
prospective multicenter study.
Pierluigi Omedè MD, Maurizio Bertaina MD, Enrico Cerrato MD, Lolo Rubio MD, Ivan Nuñez-Gil MD, Sebastiano Nuñez-Gili MD, Salma Taha MD, Carlos Macaya MD, Javier Escaned Prof, Fabrizio D’Ascenzo MD.
Division of Cardiology, Città della Salute e della Scienza, Turin (PO; FDA; SG; MB); Division of Cardiology, Infermi Hospital, Rivoli, Turin, Italy (EC)
Division of Cardiology, Assiut University Hospital, Egypt (ST)
Division of Cardiology, Division of Cardiology, Hospital Clinico San Carlos, Madrid (JLR; ING; CM; JE).
Corresponding author: Maurizio Bertaina, MD, Division of Cardiology, University of Turin.
ABSTRACT.
Background. Safety and efficacy of radial and femoral access for coronary
angiography (CA) performed by cardiology fellows remain to be evaluated.
Methods. In this multicenter prospective study, cardiology fellows selected the
access-site (among femoral, right and left radial artery) for CA. Bleedings (all cause, major and minor) were the primary endpoint, while artery occlusion rate, success for access site, time of procedure and of X-ray the secondary ones.
Results. Overall, 201 patients were enrolled. Fellows choose right radial, left radial or femoral access in 164 (82%), 20 (10%) and 17 (8%) cases respectively. Bleedings were less frequent for radial access (18% vs. 30%, p 0.03), mainly driven by less minor bleedings (4% vs. 18%, p 0.04) without any difference in major ones. Radial artery occlusion did not differ among right vs. left approach (4% vs. 5%, p 0.76). Procedural time (minutes) was similar between radial and femoral site (23±9 vs. 22±10, p 0.91), as well as time of X-ray exposure (6±3 vs. 4±2, p 0.11), DAP (Gy/cm2: 17±11 vs 18±12, 0.74) and amount of contrast medium (106±81 vs. 84±43, p 0.89). Success for access was significantly higher with radial artery (89% vs. 71%, p= 0.004).
Conclusion. Radial artery is the most exploited access by cardiologist fellows, leading
to reduction in minor bleedings and higher success compared to femoral one. No differences in procedural time and radiation exposures were recorded.
INTRODUCTION.
Transmission of knowledge in medicine represents an important aspect for physicians and fellows working in a university setting, particularly for interventional and surgical procedures (1,2). Interventional cardiology is one of the most rapidly developing branches in medicine, with constant increase in number and quality of procedures performed in last years (3-6). The need for standardization of training procedures, in this setting, has been advocated as a pivotal step to improve the learning process of young interventional cardiologists (7-8).
In recent years, the shift from femoral to radial access has become largely accepted, due to evidence of potential survival benefit in acute coronary syndromes (ACS) and reduction of access site complications (9-12). On the other side, doubts still remain for a described higher X-ray exposure with radial versus femoral approach, probably due to a more relevant technical challenges offered by radial access (tortuosity of the epiaortic vessels, small arterial lumen and vasospasm) and need for adequate learning curve for operators (13,14). Furthermore, a reduction in radiation dose and consequent patient and cardiologist exposition has been reported for left over right radial access (15-18).
Few data, moreover, were reported about the learning process of cardiology fellows under the mentorship of a trained Interventional cardiologist. A recent work by Balwanz et al (19) showed longer fluoroscopic and procedural times with radial approach when compared to femoral one during a training period in diagnostic angiography. This report can probably be justified by the before-mentioned anatomical issue and an easier improvement of transfemoral techniques with training.
present study to investigate the success, complication rates and the amount of X-ray exposure relating to the choice of the artery access site for a CA by cardiology fellows.
METHODS. Study Design.
In the present prospective multicenter study, cardiology fellows having already performed at least 50 CA were required to select the access site according to his/her experience (femoral or right/left radial) under the supervision of a trained interventional cardiologist.
Study population.
Inclusion criteria for patients were presence of patent right and left radial and femoral accesses deemed exploitable for Seldinger technique and execution of diagnostic-only CA. Radial artery patency was assessed using Allen test. Femoral artery has been considered an eligible access in absence of data (echodoppler or other imaging) of critical stenosis or of peripheral stenting or graft in site of access. Patients presenting with STEMI (ST Segment Elevation Myocardial Infarction) or undergoing staged PCI (percutaneous coronary intervention) were excluded.
Procedures.
Independently from the chosen access, the procedure was performed using the Seldinger technique, with introduction of sheaths of appropriate caliber according to the target artery. Intraradial nitrates or calcium channel blockers were used according to operator’s preferences, while 5000 UI of enoxaparine was routinely administered for both radial and femoral access.
CAs were performed using Judkins catheters; use of any other catheter type was recorded.
All patients underwent CA according to the following projections. For the right coronary artery, default projections were 30° LAO (left anterior oblique), 30° cranial, 30° RAO (Right anterior oblique), and, if deemed necessary, lateral view (90° LAO). For the left coronary artery, default projections were 20° Caudal, 20° RAO/20° Caudal, 30° Cranial, 30° Cranial/30° LAO, 30° Cranial/30° RAO, 30° caudal /45° LAO (“spider view”) and, if deemed necessary, lateral view (90° LAO).
Techniques exploited for access-site closure (manual vs. device) were recorded.
Data recorded.
Age, gender, burden of cardiovascular risk factor, renal function and indication for coronary angiography were recorded, as the type and caliber of the sheaths and catheters used. Radial and femoral artery patency were routinely evaluated by pulse palpation and auscultation before discharge. Arterial echo color-Doppler was requested when needed. All these baseline features, as well as the study end-points were analyzed and compared according to the use of radial vs. femoral access and of right vs. left radial access.
Study end-points and definitions.
All bleeding events relating to the access-site (a composite end point of major and minor bleedings) were the primary safety end-points.
All complications, that is all bleedings (major and minor) along with radial occlusion were the co-primary safety end-points.
Major bleedings, defined as loss of hemoglobin greater than 3 g /dl or need for transfusion or surgery, were the secondary safety end-points (that is BARC definition type 3 events, 14). The latter, along with minor bleedings (defined as any clinically overt sign of hemorrhage that does not fulfill criteria for major bleeding; BARC definition type 2 events) were secondary co-end points. Moreover, artery patency was evaluated by each cardiology fellow before patient’s discharge, and incidence of vascular complications was recorded.
The X-ray exposure was evaluated by recording DAP (Dose Area Product; μGym2), total procedural time and time of radiation exposure.
Fellow’s performance was tested in terms of access-site success (defined as positioning of the sheath into the true lumen at the chosen access site and the subsequent advancement of the angiographic wire) for primary efficacy endpoint and incannulations of RCA (right coronary artery) and LM (left main) for the secondary end-points.
Statistical analysis
Continuous variables are presented as means ± standard deviation or medians with interquartile ranges (IQR) and categorical variable are presented as frequencies (%). Categorical variables were compared with the Fisher’s exact test. Parametric distribution of continuous variables was tested graphically and with Kolmorogov Smirnov, and the appropriate analyses were used in accordance with the results (15). Logistic regression was performed to identify if experience of the fellow (200 vs. 50 angiographies), femoral access and diabetes mellitus were related to all cause bleedings. All statistical analyses were performed with SPSS 21 and differences were considered significant at α=0.05.
RESULTS.
From January to June 2015, 201 patients were prospectively enrolled. In 184 (92%) of them, fellows chose the radial access (164 right and 20 left one), while for the others 17 (8%) femoral access was exploited. Eight different cardiology fellows performed the procedure, six of them being male with a median age of 30 years.
Baseline features of included patients were recorded in table 1. Mean age did not differ among radial or femoral group (67±5 vs 64±4; p=0.67), as well as the burden of cardiovascular risk factors. CA before cardiac surgery was the main clinical indication in both groups, while stable angina tended to prevail among those approached by radial artery.
Complications.
All cause bleedings were lower in radial cohort (18% vs. 30%, p 0.03) mainly driven by minor bleedings (4% vs. 18%, p 0.012), without difference in major one (0% vs. 1%;p=0.76,
Figure 1 and Table S1, web appendix only). Results were preserved even after stratification for enrolling centers. For patients in which radial access was chosen, rate of arterial occlusion at discharge did not differ between right vs. left side (4% vs. 5%, p 0.76, Table S1, web appendix only). Only one major complication was recorded: an iatrogenic dissection of the proximal left anterior descending artery, which was successfully managed with implantation of a drug eluting stent. Logistic regression analysis revealed that femoral access increased the risk of all cause bleedings, while greater experience of the fellow (200 vs. 50 angiography already performed) was protective (see Figure number 1 Table S2, web appendix only).
Procedural time (minutes) did not differ between radial and femoral (23±9 vs. 22±10, p 0.91), as well as time of X-ray exposure (6±3 vs. 4±2, p 0.11) and DAP (Gy/cm2: 17±11 vs 18±12, 0.74-Figure number 2 and Table S3, web appendix only). Moreover, no significant difference emerged according to right or left radial access (Table S4, web appendix only). Amount of contrast medium did not differ between radial and femoral (106±81 vs. 84±43, p 0.89) and between right and left radial access (110±51 vs. 105±45, p 0.76- Table S3 and S4, web appendix only)
Performance of the fellow.
Success rate was significantly higher for radial access as compared to femoral (89% vs. 71%, p 0.02), while no differences were found for successful incannulation of the RCA (82% vs. 88%, p 0.78) and of the LM (77% vs. 87%, p 0.45). Similar results were found for right vs. left radial access (see Figure 3, web appendix only).
DISCUSSION.
The present paper aims to describe the interaction between choice of the access for coronary angiography by cardiology fellows and the related in-hospital complications, X-Ray exposure, procedural time and success rates.
The major findings are: a) femoral access is rarely chosen by cardiology fellows in every-day clinical practice; b) when obtained by in-training cardiology fellows, femoral access is associated with a higher rate of complications, along with a lower rate of success, as compared to radial one; c) no differences in terms of X-ray exposure were recorded between radial and femoral approaches.
Our experience was focused on diagnostic coronary angiography, since, differently from PCI, it did not radically change over the last 10 years in terms of technical procedures, with a technological improvements regarding radial sheats in terms of reduction of external diameter and change to hydrophilic materials. In our observational study performed in two high volume catheterization laboratories, femoral access was rarely chosen for CA by cardiology fellow during their training period (less than 10% of patients). These data are inevitably related to the specific experience of the involved centers, but clearly reflects the contemporary clinical practice activity and are influenced by strong evidence of a safer profile of radial access in diagnostic as well as acute interventional setting (9-12). On the other hand, our report largely differ from those reported by Balwanz et al (19), in which transradial access was used only in 35% of the cases. These differences may be related to the different enrolling time of the previous study (2010-2011 vs 2015) and to the geographical background in which it was conducted (United States of America), where
the use of radial access was, at least in the beginning, less adopted as compared to Europe laboratories.
The higher rate of complications related to femoral access, along with lower rates of success for the fellows, probably reflect the previously discussed shift to radial access as the default access-site with a consequent lack of confidence with older approach. It is interesting to note that no relevant differences in terms of prevalence of the most common predictors of vascular complications at baseline, such as age, gender and renal function, were observed in our study between the two groups. Consequently, the higher rates of bleedings with femoral access may not refer to a selection bias towards high-risk patients, but to the lower experience of young operators in an unfamiliar setting. Indeed, our data confirm those largely reported in literature (9-12) and strengthen the so called concept of “radial paradox” described in a propensity matched comparison by Azzalini et al. (20), i.e. a more relevant number of vascular bleedings with femoral access that may offset the benefit of radial access, especially with trainee physicians. On the contrary, Hulme et al. (21), demonstrated how, in the United Kingdom context, the widespread of radial access as the favorite one, did not negatively influenced femoral outcome, suggesting how, a well organized and balanced training system, can prevent the before-mentioned paradox. In Balwanz et al paper (19), depending on a very low events incidence, no significant differences in terms of bleedings complications emerged, even if a clear higher numerical trend against femoral access could be seen (5 major bleedings vs 0). On the other side, fellows showed a slower learning curve with radial approach compared to femoral one during the training. This observation appears in contrast with our results, but can probably be justified by an opposite interventional setting of the cited study: a sensible smaller sample size of radial access compared to ours, that probably did not
allow fellows to gain the minimum needed number of cases to improve their technique particularly in the more challenging cases (e.g. vessel tortuosity).
Regarding X-ray exposure, no differences have been registered between radial and femoral access (6±3 vs. 4±2, p 0.11). Our X-ray exposure times were similar or slightly lower when compared to those by Balwanz et al. (19) in which radial approach requested higher fluoroscopic time in the second half of the training [11.0 ± 8.9 and 6.7±6.8; p<0.001]. This report as other previously reported in literature (13) was not confirmed by our results, suggesting that with growing experience of high volume center, fluoroscopic times can be reduced even approaching by more challenging radial side.
Choice between right (81%) and left (11%) radial access represents another important point of interest. The first one is usually preferred because catheter manipulation is easier than on other side. Although not significantly, success rate of fellows appeared to be lower with left radial access, even if with a similar rate of complications, probably reflecting, one time more, the lower experience with this access site. Another interesting topic is related to X-ray exposure. Previous publications on this topic suggested a lower X-Ray exposure, both for patients and operators, with left side radial approach (16-18). This report was more solid in training context, while it became less evident with senior operator and can be justified also by anatomical consideration such as less subclavian tortuosity on left side (17). Our data, although being limited by the non-randomized design and the small sample size did not confirm this finding.
The present study has several practical repercussions. First of all, radial access should be taught as a first line technique for inexperienced operators, as it does not represent a
procedural success, despite the more difficult technical challenges as compared to femoral (lower caliber of the artery, risk of dissection and spasm, difficulty to advance wires and catheters in case of tortuosity of epiaortic vessels). This is of utmost importance in terms of patients’ safety, as radial access has been shown to be safer as compared to femoral, particularly in the acute coronary syndromes setting (9,10). Moreover, given the concerning reports of increasing access-site complication rates when femoral access is used, teaching of this latter technique should remain a pivotal part of training program of cardiology fellows. In fact, it is well known the importance of this type of approach in many critical clinical condition, such as cardiogenic shock, requiring ventilation or with a known complex coronary anatomy . Based on our study, interventional fellows could start their training from radial access; later on in the process, after they have gained more confidence with the Seldinger technique and the manipulation of diagnostic devices, they should be instructed to approach the femoral access. This would limit the access site complications at the femoral site (large hematomas, artero-venous fistulas, pseudo-aneurysms, retro-peritoneal hemorrhages), which are known to have a relevant prognostic effect, as opposed to radial access-site ones (mainly, radial thrombosis or dissection, vasospasm). Furthermore, choice of radial access in the early stages of interventional training does not imply a significant increase in radiation and contrast medium exposure, thus warranting patients’ safety. The present data may help physicians working in a university setting to develop a stepwise program for fellows in the cath lab in order to progressively guide fellows to the femoral access.
LIMITATIONS
Our paper shares some limitations, due to its observational and not randomized design. The low number of patients deemed suitable to femoral or left radial access from one
side limits our conclusions, from the other mirrors a “real life” situation. Involved fellows were at very early stage of their training, so that they did not yet developed into “radialist” or “femoralist” operators. However, as their previous training mainly took place in the centers involved in the study, an imbalance towards a more frequent use of radial access in their early phases of their training may biased the present results.
Conclusion. Radial access results the most exploited choice for cardiology fellows,
with reductions in minor bleeding rates and higher success rates when compared to femoral. No differences in procedural time and radiation exposures were recorded.
REFERENCES.
1- Phillips DP, Kanter EJ, Bednarczyk B, Tastad PL. Importance of the lay press in the transmission of medical knowledge to the scientific community. N Engl J Med. 1991 Oct 17;325(16):1180-3.
2- Kassutto SM, Dine CJ, Kreider M, Shah RJ. Changing the Ambulatory Training Paradigm: The Design and Implementation of an Outpatient Pulmonology Fellowship Curriculum. Ann Am Thorac Soc. 2016 Feb 10.
3- Golwala H, Pant S, Raheja P. The Changing Face of Interventional Cardiology Training: A Fellow's Perspective. J Am Coll Cardiol. 2015 Jul 28;66(4):484-5.
4- D'Ascenzo F, Chieffo A, Cerrato E, Ugo F, Pavani M, Kawamoto H, di Summa R, Varbella F, Boccuzzi G, Omedè P, Rettegno S, Garbo R, Conrotto F, Montefusco A, Biondi-Zoccai G, D'Amico M, Moretti C, Escaned J, Gaita F, Colombo A. Incidence and Management of Restenosis After Treatment of Unprotected Left Main Disease With Second-Generation Drug-Eluting Stents (from Failure in Left Main Study With 2nd Generation Stents-Cardiogroup III Study). Am J Cardiol. 2017 Apr 1;119(7):978-98 5- Lüscher TF. Interventional cardiology: in search of the balance between ischaemia and bleeding Eur
Heart J. 2015 May 21;36(20):1197-9.
6- D'Ascenzo F, Barbero U, Cerrato E, Lipinski MJ, Omedè P, Montefusco A, Taha , Naganuma T, Reith S, Voros S, Latib A, Gonzalo N, Quadri G, Colombo A, Biondi-Zoccai G2, Escaned J, Moretti C, Gaita F. Accuracy of intravascular ultrasound and optical coherence tomography in identifying functionally significant coronary stenosis according to vessel diameter: A meta-analysis of 2,581 patients and 2,807 lesions. Am Heart J. 2015 May;169(5):663-73.
7- Di Mario C, Di Sciascio G, Dubois-Randé JL, Michels R, Mills P. Curriculum and syllabus for Interventional Cardiology subspecialty training in Europe. EuroIntervention. 2006 May;2(1):31-6
8- Fabris E, Kennedy MW. International Subspecialty Fellowship Training, the Path for Cardiologists of Tomorrow?: A European Perspective. J Am Coll Cardiol. 2017 Mar 7;69(9):1200-1203.
9- Romagnoli E, Biondi-Zoccai G, Sciahbasi A, Politi L, Rigattieri S, Pendenza G, Summaria F, Patrizi R, Borghi A, Di Russo C, Moretti C, Agostoni P, Loschiavo P, Lioy E, Sheiban I, Sangiorgi G. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the
RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol. 2012 Dec 18;60(24):2481-9.
10-Valgimigli M, Gagnor A, Calabró P, Frigoli E, Leonardi S, Zaro T, RubartelliP, Briguori C, Andò G, Repetto A, Limbruno U, Cortese B, Sganzerla P, Lupi A,Galli M, Colangelo S, Ierna S, Ausiello A, Presbitero P, Sardella G, Varbella F, Esposito G, Santarelli A, Tresoldi S, Nazzaro M, Zingarelli A, de Cesare N,Rigattieri S, Tosi P, Palmieri C, Brugaletta S, Rao SV, Heg D, Rothenbühler M,Vranckx P, Jüni P; MATRIX Investigators. Radial versus femoral access in patientswith acute coronary syndromes undergoing invasive management: a randomizedmulticentre trial. Lancet. 2015 Jun 20;385(9986):2465-76.
11-Porto I, Bolognese L, Dudek D, Goldstein P, Hamm C, Tanguay JF, Ten Berg J,Widimský P, Le Gall N, Zagar AJ, LeNarz LA, Miller D, Montalescot G; ACCOAST Investigators. Impact of Access Site on Bleeding and Ischemic Events in Patients With Non-ST-Segment Elevation Myocardial Infarction Treated With Prasugrel: The ACCOAST Access Substudy. JACC Cardiovasc Interv. 2016 May 9;9(9):897-907.
12-Brener MI, Bush A, Miller JM, Hasan RK. Influence of radial versus femoral access site on coronary angiography and intervention outcomes: A systematic review and meta-analysis. Catheter Cardiovasc Interv. 2017 Dec 1;90(7):1093-1104.
13-Sciahbasi A, Frigoli E, Sarandrea A, Rothenbühler M, Calabrò P, Lupi A, Tomassini F, Cortese B, Rigattieri S, Cerrato E, Zavalloni D, Zingarelli A, Calabria P, Rubartelli P, Sardella G, Tebaldi M, Windecker S, Jüni P, Heg D, Valgimigli M. Radiation Exposure and Vascular Access in Acute Coronary Syndromes:The RAD-Matrix Trial. J Am Coll Cardiol. 2017 May 23;69(20):2530-2537.
14- Jolly SS, Cairns J, Niemela K, Steg PG, Natarajan MK, Cheema AN, Rao SV, Cantor WJ, Džavík V, Budaj A, Sheth T, Valentin V, Fung A, Widimsky P, Ferrari E, Gao P, Jedrzejowski B, Mehta SR; RIVAL Investigators. Effect of radial versus femoral access on radiation dose and the importance of procedural volume: a substudy of the multicenter randomized RIVAL trial. JACC Cardiovasc Interv. 2013 Mar;6(3):258-66.
Region (PREVAIL) Study Group. Comparison of the feasibility and effectiveness of transradial coronary angiography via right versus left radial artery approaches (from the PREVAIL Study). Am J Cardiol. 2012 Sep 15;110(6):771-5.
16- Dominici M, Diletti R, Milici C, Bock C, Placanica A, D'Alessandro G, Arrivi A, Italiani M, Buono E, Boschetti E. Operator exposure to x-ray in left and right radial access during percutaneous coronary procedures: OPERA randomised study Heart. 2013 Apr;99(7):480-4.
17-Sciahbasi A, Romagnoli E, Burzotta F, Trani C, Sarandrea A, Summaria F, Pendenza G, Tommasino A, Patrizi R, Mazzari M, Mongiardo R, Lioy E. Transradial approach (left vs right) and procedural times during percutaneous coronaryprocedures: TALENT study. Am Heart J. 2011 Jan;161(1):172-9.
18-Sciahbasi A, Romagnoli E, Trani C, Burzotta F, Sarandrea A, Summaria F, Patrizi R, Rao S, Lioy E. Operator radiation exposure during percutaneous coronary procedures through the left or right radial approach: the TALENTdosimetric substudy. Circ Cardiovasc Interv. 2011 Jun;4(3):226-31.
19- Balwanz CR Javed U, Singh GD, Armstrong EJ, Southard JA, Wong GB, Yeo KK, Low RI, Laird JR Jr, Rogers JH. Transradial and transfemoral coronary angiography and interventions: 1-year outcomes after initiating the transradial approach in a cardiology training program Am Heart J. 2013 Mar;165(3):310-6. 20-Azzalini L, Tosin K, Chabot-Blanchet M, Avram R, Ly HQ, Gaudet B, Gallo R, Doucet S,
Tanguay JF, Ibrahim R, Grégoire JC, Crépeau J, Bonan R, de Guise P, Nosair M, Dorval JF, Gosselin G, L'Allier PL, Guertin MC, Asgar AW, Jolicœur EM. The Benefits Conferred by Radial Access for Cardiac Catheterization Are Offset by a Paradoxical Increase in the Rate of Vascular Access Site Complications With Femoral Access: The Campeau Radial Paradox. JACC Cardiovasc Interv. 2015 Dec 21;8(14):1854-64.
21-Hulme W, Sperrin M, Kontopantelis E, Ratib K, Ludman P, Sirker A, Kinnaird T, Curzen N, Kwok CS, De Belder M, Nolan J, Mamas MA; British Cardiovascular Intervention Society and the National Institute of Cardiovascular Outcomes Research. Increased Radial Access Is
Not Associated With Worse Femoral Outcomes for Percutaneous Coronary Intervention in the United Kingdom. Circ CardiovascInterv. 2017 Feb;10(2):e004279.
22- Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J, Kaul S, Wiviott SD, Menon V, Nikolsky E, Serebruany V, Valgimigli M, Vranckx P, Taggart D, Sabik JF, Cutlip DE, Krucoff MW, Ohman EM, Steg PG, White H. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation. 2011 Jun 14;123(23):2736-47 23- D'Ascenzo F, Cavallero E, Biondi-Zoccai G, Moretti C, Omede P, Bollati M, Castagno D, Modena MG,
Gaita F, Sheiban I. Use and misuse of multivariable approaches in interventional cardiology studies on drug-eluting stents: a systematic review. J Interv Cardiol 2012;25(6):611-2.
Biblio suggerita:
Valgimigli M, Gagnor A, Calabró P, Frigoli E, Leonardi S, Zaro T, Rubartelli P, Briguori C, Andò G, Repetto A, Limbruno U, Cortese B, Sganzerla P, Lupi A, Galli M, Colangelo S, Ierna S, Ausiello A, Presbitero P, Sardella G, Varbella F, Esposito G, Santarelli A, Tresoldi S, Nazzaro M, Zingarelli A, de Cesare N,
Rigattieri S, Tosi P, Palmieri C, Brugaletta S, Rao SV, Heg D, Rothenbühler M, Vranckx P, Jüni P; MATRIX Investigators. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised
multicentre trial. Lancet. 2015 Jun 20;385(9986):2465-76. doi: 10.1016/S0140-6736(15)60292-6. Epub 2015 Mar 16.
Acc radiale in SCA reduce MACE NACE per riduzione major bleeding e morte.
Porto I, Bolognese L, Dudek D, Goldstein P, Hamm C, Tanguay JF, Ten Berg J, Widimský P, Le Gall N, Zagar AJ, LeNarz LA, Miller D, Montalescot G; ACCOAST Investigators. Impact of Access Site on Bleeding and Ischemic Events in Patients With Non-ST-Segment Elevation Myocardial Infarction Treated With Prasugrel: The ACCOAST Access Substudy. JACC Cardiovasc Interv. 2016 May 9;9(9):897-907. doi: 10.1016/j.jcin.2016.01.041.
NSTEMI trattati con Prasugrel. Nell’analisi propensity matched TF non > sang TIMI major. Ma TR riduce sanguinamenti overall. No diff per outcome ischemici
Brener MI, Bush A, Miller JM, Hasan RK. Influence of radial versus femoral access site on coronary angiography and intervention outcomes: A systematic
review and meta-analysis. Catheter Cardiovasc Interv. 2017 Dec 1;90(7):1093-1104. doi: 10.1002/ccd.27043. Epub 2017 May 25.
Hulme W, Sperrin M, Kontopantelis E, Ratib K, Ludman P, Sirker A, Kinnaird T, Curzen N, Kwok CS, De Belder M, Nolan J, Mamas MA; British Cardiovascular Intervention Society and the National Institute of Cardiovascular Outcomes Research. Increased Radial Access Is Not Associated With Worse Femoral Outcomes for Percutaneous Coronary Intervention in the United Kingdom. Circ Cardiovasc Interv. 2017 Feb;10(2):e004279. doi: 10.1161/CIRCINTERVENTIONS.116.004279.
Retrospettivo che dim che l’adozione dell’approccio TR come preferito non ha influito negativamente su outcome (morte a 30 gg) dell’approccio transfemorale.
Sciahbasi A, Frigoli E, Sarandrea A, Rothenbühler M, Calabrò P, Lupi A, Tomassini F, Cortese B, Rigattieri S, Cerrato E, Zavalloni D, Zingarelli A, Calabria P, Rubartelli P, Sardella G, Tebaldi M, Windecker S, Jüni P, Heg D, Valgimigli M. Radiation Exposure and Vascular Access in Acute Coronary Syndromes: The RAD-Matrix Trial. J Am Coll Cardiol. 2017 May 23;69(20):2530-2537. doi:
10.1016/j.jacc.2017.03.018.
Sub del matrix trial. Accesso radiale in SCA associate a maggiore esposizione radiologica degli operatori . (maggiore esposizione toracica degli operatori, maggiori tempi di fluoroscopia e DAP nell’overall population del matrix) non differenze tra radiale dx e sx.
Sciahbasi A, Romagnoli E, Trani C, Burzotta F, Sarandrea A, Summaria F, Patrizi R, Rao S, Lioy E. Operator radiation exposure during percutaneous coronary procedures through the left or right radial approach: the TALENT dosimetric substudy. Circ Cardiovasc Interv. 2011 Jun;4(3):226-31. doi: 10.1161/CIRCINTERVENTIONS.111.961185. Epub 2011 May 17.
Confronto acc radiale dx vs sinistro. Minor esposizione radiologica al polso dell’operatore con accesso radiale sx.
Sciahbasi A, Romagnoli E, Burzotta F, Trani C, Sarandrea A, Summaria F,
Pendenza G, Tommasino A, Patrizi R, Mazzari M, Mongiardo R, Lioy E. Transradial approach (left vs right) and procedural times during percutaneous coronary procedures: TALENT study. Am Heart J. 2011 Jan;161(1):172-9. doi:
10.1016/j.ahj.2010.10.003.
Confronto Acc radiale dx vs sx in coro diagnostiche e PCI. Minori tempi di scopia x il PAZIENTE con accesso radiale sinistro (minore esposizione del paziente); diff evidente soprtt per operatori con poca esperienza; praticamente non visibile in quelli più esperti
Mehta SR, Jolly SS, Cairns J, et al. Effects of radial versus femoral artery access in patients with acute coronary syndromes with or without ST- segment elevation. J Am Coll Cardiol 2012;60: 2490–9.
