Best Practices for Transradial Approach in Diagnostic Angiography and Intervention by Bertrand Olivier & Rao Sunil

Author:Bertrand, Olivier & Rao, Sunil
Language: eng
Format: epub
Publisher: LWW
Published: 2014-11-30T16:00:00+00:00

FIGURE 15-4 The initial parts of the curve up to 2 hours were reconstructed on the basis of experimental studies. For the first 15 minutes (15 m) after coronary occlusion, myocardial necrosis is not observed. At 40 minutes (40 m) after coronary occlusion, myocardial cell death develops rapidly, and the myocardial necrosis is confluent. After this point, progression to necrosis is slowed considerably. The other part of the curve showing myocardial salvage from 2 to more than 12 hours from symptom onset is reconstructed on the basis of data from scintigraphic studies in patients with acute myocardial infarction. Efficacy of reperfusion is expressed as follows: (++++), very effective; (+++), effective; (++), moderately effective; (±), uncertainly effective; and (–), not effective. (From Schomig A, Ndrepepa G, Kastrati A. Late myocardial salvage: time to recognize its reality in the reperfusion therapy of acute myocardial infarction. Eur Heart J. 2006;27(16):1900–1907.)

After radial access in patients with STEMI with severe congestive heart failure, patients can sit up immediately and can potentially avoid intubation and nosocomial pulmonary infections. Finally, patients prefer radial to femoral access on the basis of published literature.12

Potential Disadvantages of Radial Access in ST-Elevation Myocardial Infarction

Owing to technical challenges with radial access (e.g., subclavian tortuosity and radial loops), there have been concerns of longer door-to-balloon times with radial access than with femoral access. There have also been concerns that owing to anatomic abnormalities, radial access could be associated with reduced guide support and differential PCI success rates. The rates of PCI success were the same and very high with both radial and femoral accesses in the RIVAL trial (95.4% vs 95.2%, P = 0.83). Similar and very high procedural success rates were also found in RIFLE-STEACS (Radial versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) and STEMI-RADIAL randomized trials.18,19

In smaller, particularly elderly, individuals, the radial artery may only be able to accommodate 5F sheaths. This may be a potential problem if thrombectomy is needed because most available thrombectomy devices are 6F compatible. However, the use of hydrophilic sheathless guiding catheter might be particularly helpful in such complex situations (see Chapter 20).

Finally, another potential disadvantage is radial artery occlusion. Most radial artery occlusions are silent but may preclude future radial access. Radial artery occlusion is discussed in further detail in Chapter 10.

Evidence Regarding the Use of Radial versus Femoral Access in ST-Elevation Myocardial Infarction

There have been at least 11 randomized trials of radial versus femoral access for STEMI PCI. The characteristics and results of these trials are listed in Tables 15-1 and 15-2. But the majority of these trials have been small single-center trials not powered for hard clinical outcomes. However, recently three large randomized trials have been published.

The first was the RIVAL trial, an international multicenter randomized trial of 7,021 patients with acute coronary syndromes that included STEMI (n = 1,958). The overall trial showed no difference in primary outcome of death, MI, stroke, or non-CABG major bleeding (Fig. 15-5). There was no difference in the rate of major bleeding utilizing RIVAL

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