Abstract
Background
Transradial approach (TRA) for percutaneous coronary procedures is associated with improved patient outcome and is being increasingly adopted worldwide. We surveyed Italian interventional cardiologists in order to take a snapshot of the current practice of TRA.
Methods
A web-based questionnaire was emailed to all members of the Italian Society of Interventional Cardiology.
Results
The survey was taken by 508 respondents. Cardiogenic shock and chronic total occlusions represented the principal limitations to TRA. Right TRA was the default approach for 81% of respondents. Both diagnostic and interventional procedures were routinely performed through 6 Fr sheaths (83% and 93%, respectively); dedicated TRA curves were used in 11% of diagnostic and in about 3% of interventional procedures. Almost 70% of the operators did not assess dual hand circulation. In case of crossover, the contralateral radial artery was the preferred site (57%). Radial artery hemostasis was mostly achieved by pneumatic bracelet (64%) and patency of the radial artery during hemostasis was ensured in 60% of cases. Pre-discharge patency of the radial artery was routinely assessed by almost 60% of respondents. For diagnostic procedures, adequate heparin anticoagulation (5000 IU) was only given by 45% of operators. Most respondents believed that TRA is associated with greater radiation exposure for both the patient (82%) and the operator (98%) as compared to transfemoral approach.
Conclusions
This survey provides contemporary data about the adoption of TRA in Italy and gives interesting insights about several technical and clinical issues related to the practice of this vascular approach for coronary procedures.
Highlights
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Transradial approach for coronary procedures is becoming increasingly popular.
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We conducted a survey on the contemporary practice of transradial approach in Italy.
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We appraised several clinical and technical issues related to transradial approach.
1
Introduction
The transradial approach (TRA) for invasive coronary angiography and percutaneous coronary intervention (PCI) is associated with less access-site complications and with improved patient outcome as compared with transfemoral approach (TFA) . Accordingly, in the last decade TRA has been adopted by a growing number of interventionalists in many countries . In Italy, the prevalence of TRA has increased from 39% in 2010 to 73% in 2015 ( Fig. 1 ) . In spite of its diffusion, many technical aspects of TRA are far from being standardized and there are several issues, such as patient selection, post-procedural management and radioprotection, which deserve consideration from the interventional community for both clinical and research purposes. Relevant insights about this topic were reported by an international survey published in 2010 ; however, the results of this study showed significant heterogeneity among different Countries and, at that time, the overall prevalence of TRA was lower as compared to nowadays. Therefore, the Italian Radial Club, an association of physicians and nurses established in 2008 and devoted to the development of TRA through educational courses and scientific meetings, with the endorsement and support of the Italian Society of Interventional Cardiology (SICI-GISE), ideated and conducted a survey among Italian interventional cardiologist in order to take an updated picture of the current practice of TRA in Italy.
2
Methods
This survey was collegially developed by all authors and included 35 questions covering the following aspects of TRA: 1) patient selection; 2) technique and side of TRA and peri-procedural medications; 3) selection of diagnostic and guiding catheters; 4) radial artery hemostasis and occlusion; 5) radiation exposure; 6) post-procedural management. Data about center-level and operator-level procedural volumes were also collected. A web-based software (SurveyMonkey, Palo Alto, CA, USA) was used to perform the survey. The link to the survey was e-mailed to all Italian interventional cardiologist being members of the Italian Society of Interventional Cardiology (SICI-GISE). To be member of SICI-GISE a physician must be actively working in a cath lab and must be aged at least 30 years (younger physicians can apply provided that they have already completed the Residency in Cardiology). The survey was launched on July 14th and was closed on September 30th, 2016. Every participant was allowed to take the survey only once in anonymous way. Data were downloaded in a spreadsheet from the Survey Monkey website and were analyzed in a descriptive fashion, reporting values as percentages of the total number of responses.
2
Methods
This survey was collegially developed by all authors and included 35 questions covering the following aspects of TRA: 1) patient selection; 2) technique and side of TRA and peri-procedural medications; 3) selection of diagnostic and guiding catheters; 4) radial artery hemostasis and occlusion; 5) radiation exposure; 6) post-procedural management. Data about center-level and operator-level procedural volumes were also collected. A web-based software (SurveyMonkey, Palo Alto, CA, USA) was used to perform the survey. The link to the survey was e-mailed to all Italian interventional cardiologist being members of the Italian Society of Interventional Cardiology (SICI-GISE). To be member of SICI-GISE a physician must be actively working in a cath lab and must be aged at least 30 years (younger physicians can apply provided that they have already completed the Residency in Cardiology). The survey was launched on July 14th and was closed on September 30th, 2016. Every participant was allowed to take the survey only once in anonymous way. Data were downloaded in a spreadsheet from the Survey Monkey website and were analyzed in a descriptive fashion, reporting values as percentages of the total number of responses.
3
Results
The survey was taken by 508 interventional cardiologists, with an average response rate/question of 97% (range 86% to 100%). Fifty-one percent of respondents were from cath labs located in northern Italy, 22% in central Italy and 27% in southern Italy and islands ( Fig. 2 ). The majority of operators (52%) were from high-volume centers (annual volume of PCI >600), whereas 36% were from moderate-volume centers (annual volume of PCI between 400 and 600) and 12% from low-volume centers (annual volume of PCI <400). In most cath labs (85%) the overall prevalence of TRA was higher than 80%. As far as the operator volume is concerned, 85% of respondents declared to perform more than 100 PCI/year and 89% of them declared to use TRA in more than 80% of procedures. Transulnar approach was unfrequently used (less than 5% of respondents used it in >5% of procedures).
3.1
Patient selection
We asked to identify one or more clinical or procedural settings in which TRA was considered not suitable or contraindicated. The majority of respondents (55%) did not identify any limitation for TRA, whereas cardiogenic shock and hemodynamic instability were perceived as a contraindication for TRA by 33%. Interestingly, patients with end-stage renal disease or on hemodialysis were perceived as a limitation by only 21% of respondents, whereas only a minority of them considered TRA contraindicated in patients with acute coronary syndromes (6.6%) or in frail patients such as the elderly and short-stature, low-weight women (7.6%). As far as procedural complexity is concerned, in the case of complex PCI (including left main, rotational atherectomy, bifurcation lesions needing 2-stent techniques) only 22% of operators shifted to femoral approach; however, in the subset of chronic total occlusions (CTO), only 6.8% felt confident in using bilateral TRA for both antegrade and retrograde procedures (Table). The subset of previous coronary artery bypass grafting (CABG) patients with double in-situ mammary artery grafts was generally managed by TFA (76%). Most operators (68%) did not routinely assess the patency of the palmar arch, whereas the others did this either by the Allen’s test (27%) or by the Barbeau’s test (4.3%).
3.2
Technique and side of TRA and peri-procedural medications
For radial cannulation, the bare needle technique was largely preferred as compared to the sheath-covered needle (77% vs 23%). A 6 Fr sheath was generally used for diagnostic procedures and most operators (68%) preferred hydrophilic, long (>10 cm) sheaths. As far as peri-procedural drugs are concerned, anxiolytics were routinely given by only 16% of operators, spasmolytics were frequently used whereas only 45% of respondents gave the recommended dosage of heparin (5000 IU) for diagnostic procedures (Table). Most operators preferred right TRA as compared to left TRA (89% vs 11%). In the case of access failure, contralateral TRA, followed by TFA, was the preferred route (Table).
3.3
Selection of diagnostic and guiding catheters
For diagnostic coronary angiography, most operators (84%) used standard Judkins catheters, whereas 11% used a single dedicated catheter for TRA. As far as PCI is concerned, extra back up curves were largely preferred for the left coronary system, whereas Judkins right was largely preferred for the right coronary system. Dedicated TRA catheters were unfrequently used ( Fig. 3 ). A 6 Fr guide was selected as default catheter for PCI by most operators ( Table 1 ).
| Percent (%) of respondents | |
|---|---|
| Diagnostic catheter size | |
| 4 Fr | 0.8 |
| 5 Fr | 16.1 |
| 6 Fr | 83.1 |
| Guiding catheter size for PCI | |
| 5 Fr | 6.1 |
| 6 Fr | 93.5 |
| 6.5 Fr sheathless | 0.4 |
| Spasmolytic drugs | |
| None | 41.3 |
| Nitrates | 19.9 |
| Verapamil | 20.7 |
| Cocktails | 18.1 |
| Heparin dosage for diagnostic procedures | |
| 5000 IU | 44.7 |
| 2500 IU | 47.5 |
| None | 7.8 |
| Preferred site of crossover | |
| contralateral TRA | 57.5 |
| TFA | 40.7 |
| ulnar artery | 1.6 |
| brachial artery | 0.2 |
| Use of adjunctive anti-X devices | |
| routine | 18.6 |
| occasional | 15.8 |
| never | 65.6 |
| Preferred access in previous CABG patients with bilateral mammary grafts | |
| TFA | 76.3 |
| Left TRA | 9.1 |
| Right TRA | 6.9 |
| Bilateral TRA | 7.7 |
| Preferred access for complex PCI | |
| TFA | 22.0 |
| TRA with 6 Fr guiding catheter | 25.2 |
| TRA with >6 Fr guiding catheter | 20.4 |
| TRA with 7-in-6 devices | 18.1 |
| TRA with sheathless devices | 14.3 |
| Preferred access for CTO PCI | |
| TFA | 29.5 |
| TFA + TRA for contralateral injection | 38.8 |
| Bilateral TRA only for antegrade procedure | 24.9 |
| Bilateral TRA for both antegrade and retrograde procedures | 6.8 |
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