Previous studies have shown that the right radial approach encounters more tortuosity than the left radial approach during transradial coronary angiography. The objective of this study was to compare the procedural difficulty of the right and left radial approaches in the modern era with dedicated transradial catheters. One hundred ninety-three patients scheduled for transradial coronary angiography with normal Allen test results and without histories of coronary artery bypass grafting were randomized to the right or left radial approach. The choice of catheter was left to the discretion of the operator, with the preferred catheter being a dedicated transradial Optitorque catheter. The primary end point was procedural difficulty, defined as (1) hydrophilic or coronary wire use for tortuosity, (2) stiff wire use for the coronary engagement, (3) multiple catheters used, or (4) nonselective injection. The clinical characteristics were similar between the 2 groups. Procedural success was achieved in 98 of 101 (98%) in the right radial group and 91 of 92 (99%) in the left radial group. Procedural difficulty, fluoroscopy time, and contrast use were similar between the 2 groups. The use of a single catheter was more common in the right radial group (73% vs 18%, p <0.001). In conclusion, procedural success and difficulty were similar in the comparison groups. The right and left radial approaches are feasible and effective to perform coronary angiography and intervention.
Transradial cardiac catheterization has become increasingly popular because of its lower incidence of access-site complications, earlier patient ambulation, decreased patient discomfort, and decreased length of stay. With the increased use of the transradial approach, several dedicated transradial catheters have been developed. The aim of this study was to compare the right radial and left radial artery approaches for cardiac catheterization in the modern era with dedicated transradial catheters in our diverse patient population.
Methods
From June 2009 to August 2009, 193 patients who were scheduled for diagnostic transradial cardiac catheterization were prospectively randomized to the right radial or left radial artery approach. Patients with acute coronary syndromes, histories of coronary artery bypass graft surgery, or abnormal Allen test results were excluded. After informed consent, patients were randomized to the right radial or left radial approach on the basis of medical record number. The study protocol was approved by the institutional review board of Beth Israel Medical Center.
In the right radial approach, the patient’s right arm was secured to an arm board on the right side of the catheterization table. In the left radial approach, access was obtained from the left side, and the patient’s left forearm was pulled to the right side and secured to the catheterization table using a sling ( Figure 1 ). In the 2 approaches, the procedure was performed on the right side of the patient.
Transradial coronary angiography was performed by experienced operators. Access was obtained using a modified Seldinger technique with a 20-gauge SURFLO needle (Terumo, Tokyo, Japan), and a 5Fr radial glide sheath (Terumo) was inserted for diagnostic coronary angiography. The combination of nitroglycerin 200 μg, verapamil 2.5 mg, and heparin 2,500 U was administered intra-arterially after sheath insertion. The catheter choice was left to the discretion of the operator. Standard 0.035-inch J-tip wires (Cordis Corporation, Miami Lakes, Florida) were used to bring the catheter to the aortic cusp. The Optitorque catheter (Terumo), which allows selective cannulation of the right and left coronary arteries with 1 catheter, was the preferred catheter for the right radial approach among most operators. Ad hoc percutaneous coronary intervention was performed on the basis of the clinical judgment of the operators with or without upsizing to a 6Fr system.
After completion of coronary angiography with or without intervention, the sheath was immediately removed, and a compression device (TR Band; Terumo) was applied for hemostasis. Patients were carefully monitored for access-site complications. The formation of a hematoma that required additional compression or adjustment of the compression device was documented as an access-site complication.
The primary end point was procedural difficulty, defined as (1) hydrophilic or coronary wire use for tortuosity, (2) stiff wire use for tortuosity to engage the coronary arteries, (3) multiple catheter use, defined as ≥3 catheters used for each ostium, and (4) inability to selectively engage the coronary ostia. The secondary end points were fluoroscopy time, procedure time, room time, and the volume of contrast used.
Continuous variables are expressed as mean ± SD, and discrete variables are presented as percentages. Patient characteristics, procedural characteristics, and the outcomes for the right and left radial approaches were compared. Student’s t test was used to compare the continuous variables, and chi-square analysis or Fisher’s exact test was used to compare the categorical variables. A p value <0.05 was considered statistically significant.
Results
One hundred one patients were randomized to the right radial approach and 92 patients to the left radial approach. Patient characteristics were similar, with the exception of lower body mass indexes in the left radial group ( Table 1 ).
| Variable | Right (n = 101) | Left (n = 92) | p Value |
|---|---|---|---|
| Age (years) | 64 ± 10 | 66 ± 11 | 0.187 |
| Men | 47 (46%) | 54 (59%) | 0.122 |
| Black | 30 (30%) | 18 (20%) | 0.213 |
| Asian | 42 (42%) | 45 (49%) | |
| Hispanic | 20 (20%) | 15 (16%) | |
| White | 9 (8%) | 14 (15%) | |
| Height (cm) | 165 ± 10 | 166 ± 9 | 0.468 |
| Weight (kg) | 82 ± 22 | 77 ± 22 | 0.117 |
| Body mass index (kg/m 2 ) | 30 ± 7 | 28 ± 7 | 0.049 |
| Hypertension ⁎ | 82 (82%) | 73 (79%) | 0.889 |
| Diabetes mellitus ⁎ | 34 (34%) | 38 (41%) | 0.151 |
| Dyslipidemia ⁎ | 62 (62%) | 62 (67%) | 0.472 |
| Smoker | 16 (16%) | 13 (14%) | 0.896 |
| Previous percutaneous coronary intervention | 17 (17%) | 25 (27%) | 0.118 |
| Creatinine (mg/dl) | 0.9 ± 0.3 | 1.0 ± 0.4 | 0.050 |
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