I have read with great interest the review “Strategies to increase the use of forearm approach during coronary angiography and interventions” written by Rigatou et al. [ ]. The authors have nicely covered all aspects of transradial approach (TRA) in different subset of population and in different clinical conditions. But not to forget about the female population where TRA is relatively less common and technically more challenging. Also with the strategies to increase the forearm approach, the issue of increased radiation exposure should always be kept in mind with the availability of latest literature. Therefore, it is important to include both these aspects in the present review.
1
TRA and female population
Females with ischemic heart disease (IHD) managed either medically or by percutaneous coronary intervention (PCI) is at increased risk of bleeding as compared to males [ ]. Post PCI bleeding is one of the important contributors to the increased short-term and long-term morbidity and mortality [ ]. With the increase in TRA for diagnostic and therapeutic coronary interventions, the access site bleeding complications has been reduced significantly. Most of these studies have been conducted in males and very few studies of TRA in females are available in literature. TRA in females is relatively technically more challenging because of small size radial artery and increased frequency of spasms during procedure [ ]. Sunil V Rao and colleagues were the first to address the effect of TRA on outcomes in females undergoing PCI in the SAFE PCI registry [ ]. The study which was terminated early concluded that radial access did not significantly reduce bleeding or vascular complications among women undergoing PCI but there was a trend towards benefit. The SAFE PCI was negative trial but later studies including the post hoc analysis of RIVAL (RadIal Vs femorAL access for coronary intervention) and MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX) found the significant benefit of TRA in females. In a RIVAL post hoc analysis, there was significant 50% reduction in major vascular complication and bleeding in females undergoing coronary angiography and intervention by TRA [ ]. Similarly, another subgroup analysis from the large MATRIX research program has shown that TRA should be preferred without the gender bias in patients undergoing coronary intervention for ACS [ ]. As the risk of bleeding complication is more in females, TRA approach may be more beneficial in females. Although there is significant benefit of TRA approach in females but still there is significantly high crossover rate in females as compared to males mainly due to radial artery spasm. In SAFE PCI, the cross over rate was 6.7%, in RIVAL subgroup analysis 11.1% and in MATRIX substudy it was 7.6%. These technical difficulties during PCI by TRA in females may be minimized by clean radial artery puncture in first attempt, use of spasmolytics cocktails and small size catheter and devices during the procedure. To conclude, the TRA approach should be the default choice in females undergoing coronary intervention for IHD and the benefit may be more as compared to males.
2
TRA and radiation exposure
Interventional cardiologists are always at higher radiation exposure as compared to other medical staff dealing with X rays. With the adoption of TRA, the fear of more radiation exposure as compared to transfemoral (TFA) has increased specially among the low volume operators [ ]. The available literature for radiation exposure among the interventional cardiologist using TRA is showing mixed results with minimal to significant radiation exposure with TRA. Some earlier studies suggested significant increase in fluoroscopy time, X-ray dose and total procedure time [ ]. But with increase in experience of the operators and dedicated hardware for TRA, later studies did not confirm that results by means of patient radiation dose. The REVERE trial randomized patients to TFA, right Radial and left Radial access in 1:1:1 fashion, has shown patient’s exposure similar for all groups [ ]. Similarly, the FERARI study has shown that mean fluoroscopy time, median DAP, procedural duration and the amount of contrast agent used were not significantly different in TRA versus TFA groups [ ]. But the latest and biggest radiation study RAD-MATRIX trial which is a sub study of the MATRIX trial has shown increased radiation exposure for transradial operators even if they are experienced operators [ ]. There was significantly higher radiation exposure at the chest level as compared to arm and forehead level. Since the patient subset in MATRIX trial was acute coronary syndrome and average fluoroscopy was approx. 10 min, the chances of having high radiation exposure might be possible as more complex cases are being performed by TRA. Simple preventive measures by keeping the right arm besides the right leg and utilizing longer radiation shield might help in reducing the radiation exposure.
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