Radial artery (RA) access has been increasingly utilized for coronary procedures because of lower rates of access-site complications and improved patient satisfaction. However, limited data are available for RA access for peripheral vascular intervention (PVI). We performed a retrospective review of 143 patients who underwent PVI through RA access from February 2020 to September 2022 at a single institution. Baseline characteristics and follow-up data were ascertained from a prospectively maintained institutional database. Of 491 PVI, 156 (31.8%) were performed through the RA. Anatomical locations for intervention were the femoral (44.8%), iliac (31.1%), popliteal (9.6%) peroneal (2.7%), tibial (9.9%), and subclavian (1.9%) arteries. Procedural access was obtained through the right RA (92.9%), left RA (4.5%), or right ulnar artery (2.6%) using the 6 French R2P Destination Slender sheath in 85, 105, and 119 cm lengths. Atherectomy was used in 34.7%. Mean contrast volume was 105.5 ml and the average fluoroscopy time was 18.5 minutes. Conversion to femoral access occurred in 3 cases (1.9%) because of arterial spasm and noncrossable lesions. Concomitant pedal access occurred in 2 cases (1.3%). Periprocedural complication rate was 3.84%, of which access-site hematoma was most common (3.2%); none required blood transfusion, surgical intervention, or additional hospital stay. There was 1 case (0.64%) of in-hospital stroke. The mortality rate at 30-day, 6-month, and 1-year was 1.4%, 2.8%, and 4.2%, respectively. In conclusion, RA access is feasible for diverse PVI, and future studies are needed to assess safety and benefit compared with femoral artery access.
Percutaneous peripheral vascular interventions (PVIs), such as angioplasty and stenting, are the standard of care for patients with peripheral arterial disease (PAD). Traditionally, these procedures have been performed through the common femoral artery (CFA). Although the femoral approach is generally safe, it has been associated with access site complications, including groin infection, groin hematoma, pseudoaneurysm, retroperitoneal hematoma, and arterial thrombosis. In recent years, the radial artery (RA) has emerged as an alternative access site for PVI. In fact, RA access provides an additional access site for PVI in patients with unfavorable CFA access. The management of access-site complications, including wrist hematoma, is also easier to detect and control compared with retroperitoneal hematoma after CFA access, which may require surgical intervention. , Furthermore, RA access allows for simultaneous bilateral and multilevel intervention, which can be particularly useful in patients with extensive disease. Additionally, it facilitates early ambulation, contributes to a more comfortable recuperation phase, and offers a shorter length of stay. Despite these benefits, RA access for PVI is still not widely adopted in clinical practice and scant data are available regarding its feasibility and outcomes after PVI. , We report one of the largest single-center experiences of RA access for endovascular interventions of lower extremities and subclavian artery disease.
Methods
We retrospectively reviewed all consecutive endovascular interventions for lower extremity and subclavian artery disease performed with documented RA access from February 2020 to September 2022 at a single healthcare center. Diagnostic angiograms, renal and mesenteric artery interventions, and transcatheter aortic valve replacement-associated radial access interventions were excluded. All procedures were performed using the 6-French R2P Destination Slender sheaths (Terumo) in lengths of 85, 105, and 119 cm. The “cocktail” that was administered included 400 mcg of nitroglycerin and 5 mg of verapamil. Heparin protocol consisted of 50 units per kg during the diagnostic part and then 80 to 100 units per kg when proceeding with intervention with an activated clotting time of >250. Demographic data of the patients, anatomic location of arterial intervention, procedural characteristics (access laterality, intra-op ultrasound use for access guidance, stent, and atherectomy use, and contrast volume), procedural outcomes, and access-site complications were analyzed and reported for all patients. Rutherford classification was used to assess lower extremity claudication severity. In all included patients, RA patency and adequacy were assessed by physical examination including Allen’s test and duplex examination before the procedure. Immediately after the procedure, all patients were clinically evaluated for RA patency and potential complications such as access-site hematoma and hand ischemic symptoms including pain or pallor. All patients were again evaluated by physical examination at 30 days, 6 months, and 1 year after the procedure during the follow-up visit.
The primary end point (efficacy) of this study was procedure success rate, defined as the successful completion of the intended procedure without conversion to femoral access. Secondary end points (safety) included the composite of access-site complication (pseudoaneurysms and access-site hematoma) and postoperative stroke.
Our institutional review board and ethics committee approved this study. Given the retrospective nature of the study, informed consent was waived.
Continuous data were presented as mean ± SD and categorical variables as proportion unless otherwise specified. Comparisons across periods were made using the Student’s t test for numerical outcomes and chi-square test for categorical outcomes. Longitudinal outcomes were modeled using a linear mixed-effects model, which included data from all available time points (baseline, 30 days, 6 months, and 1 year). The analyses included time as a fixed effect and patient as a random effect to adjust for repeated measures within each patient. All analyses were performed at the 0.05 significance level using SAS Enterprise Guide 8.2 with SAS 9.4 (SAS Institute, Cary, North Carolina).
Results
Between February 2020 and September 2022, 447 patients underwent 491 endovascular interventions for lower extremity and subclavian diseases. Of these patients, 143 (32% [143 of 447]) underwent 156 (31.8% [156 of 491]) endovascular interventions through RA access (97.4%) and ulnar artery access (2.6%). Patients who underwent diagnostic procedures (n = 9) through the RA were not included. The remaining patients underwent endovascular interventions through CFA access and were not included in the study population. The baseline demographic and procedural characteristics of the study population are listed in Tables 1 and 2 . The mean patient age was 70.9 ± 8.1 years, and 100 patients (69.9%) were male. One-third of the patients were obese (BMI ≥30 kg/m²). In total, 117 patients (75%) were in Rutherford class III, 25 (16.0%) in Rutherford class IV, and 10 (6.4%) in Rutherford class V at baseline. Access was obtained through the right RA in 92.9% of cases, left RA in 4.5%, and right ulnar artery in 2.6%. Ultrasound was used for access guidance in 32.1% of RA access cases. Of the 261 lesions treated, most (37.5%) were located in the superficial femoral artery, followed by the common iliac artery (19.2%), external iliac artery (11.9%), tibial artery (9.9%), popliteal artery (9.6%), common femoral artery (7.3%), peroneal artery (2.7%), and subclavian artery (1.9%). Balloon angioplasty was performed in all cases, stent deployment in 74.3% of cases, and atherectomy in 34.7%. Most cases (78.2%) involved a single-side intervention. Wrist bands were used in 100% of cases. The mean dose area product was 331.1 ± 540 mGycm² and the mean contrast volume was 105.5 ± 47.8 ml. The mean sedation time was 96.2 ± 16.1 minutes, and the mean fluoroscopy time was 18.5 ± 3.7 minutes. Most patients (96.8%) were discharged on the same procedural day.
| Baseline Characteristics | n = 143 |
|---|---|
| Age (years) | 70.9 ± 8.1 |
| BMI (kg/m²) | 27.8 ± 5.3 |
| BMI ≥30 | 48 (33.6) |
| Male | 100 (69.9) |
| Hypertension | 134 (93.7) |
| Diabetes | 50 (35.0) |
| Hyperlipidemia | 128 (89.5) |
| Coronary artery disease | 97 (67.8) |
| Chronic kidney disease | 29 (20.3) |
| Congestive heart failure | 20 (14.0) |
| Previous PCI | 54 (37.8) |
| Previous CABG | 38 (26.6) |
| Previous CVA | 18 (12.6) |
| Prior smokers | 69 (48.3) |
| Current smokers | 48 (33.6) |
| Rutherford Classification | n = 156 |
| Rutherford Class I | 0 |
| Rutherford Class II | 4 (2.6) |
| Rutherford Class III | 117 (75.0) |
| Rutherford Class IV | 25 (16.0) |
| Rutherford Class V | 10 (6.4) |
| Anatomic location of arterial intervention | n = 261 |
|---|---|
| Common Femoral | 19 (7.3) |
| Superficial Femoral | 98 (37.5) |
| Common Iliac | 50 (19.2) |
| External Iliac | 31 (11.9) |
| Popliteal | 25 (9.6) |
| Peroneal | 7 (2.7) |
| Tibial | 26 (9.9) |
| Subclavian | 5 (1.9) |
| Procedure category | n = 156 |
| Isolated angioplasty | 30 (19.2) |
| Angioplasty and stenting | 72 (46.1) |
| Angioplasty, atherectomy, and stenting | 44 (28.2) |
| Angioplasty and atherectomy | 10 (6.5) |
| Periprocedural characteristics | n = 156 |
| Intervention side | |
| Single-side intervention | 122 (78.2) |
| Bilateral intervention | 34 (21.8) |
| Arterial access | |
| Radial artery | 152 (97.4) |
| Ulnar artery | 4 (2.6) |
| Arterial access side | |
| Right-sided access | 149 (95.5) |
| Left-sided access | 7 (4.5) |
| Ultrasound-guided access | 50 (32.1) |
| Concomitant pedal access | 2 (1.3) |
| Sedation time (min) | 96.2 ± 16.1 |
| Fluoroscopy time (min) | 18.5 ± 3.7 |
| Air Kerma, mGy | 642.2 ±818 |
| DAP (mGycm²) | 331.1 ±540 |
| Contrast volume (mL) | 105.5 ±47.8 |
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