A 48-year-old male hypertensive smoker with no previous heart disease but a strong family history of coronary artery disease developed epigastric discomfort similar to “indigestion.” After 3 hours of antacids and “waiting it out,” his wife insisted that he call 911. Upon arrival at our emergency department, he had anterior ST-segment elevation on his electrocardiogram (ECG), and a “STEMI (ST-segment elevation myocardial infarction) alert” was called. After assembling the catheterization, or “cath,” lab team, the patient was given 324 mg of aspirin and 600 mg of clopidogrel, his right wrist and groin were prepped per protocol, and the fellow began obtaining radial artery access under our “3-minute rule” protocol (ie, if radial access is not obtained in 3 minutes, operator number 2 is to obtain femoral artery access). The fellow was successful in obtaining radial access, and the left coronary angiogram revealed a 99% stenosis of the proximal left anterior descending (LAD) artery with Thrombolysis in Myocardial Infarction (TIMI) 1 flow (flow did not reach the end of the vessel). Unfractionated heparin had already been given via the radial artery as a part of our pre-transradial cocktail, and an intravenous glycoprotein IIb/IIIa antagonist was given to rapidly achieve maximal platelet inhibition. Next, a hydrophilic guide wire was advanced across the occlusion and into the distal LAD, followed by several passes of a thrombectomy catheter to minimize the thrombotic burden of the lesion. Direct placement of a drug-eluting stent was then performed without complication, and brisk, TIMI 3 flow was restored into the LAD. The patient’s discomfort and ECG changes abated shortly thereafter. The total door-to-balloon time was 17 minutes. Afterward, the patient wanted to see his angiogram (he is a physician) and asked if he could stand to see it better. As he had not been sedated, per his request, he was helped to a standing position and studied the angiographic images. A photograph was taken of this special moment (Figure 7-1). He was ambulating around the nurses’ station 1 hour after myocardial infarction and was discharged on day 3, having had no complications. He has successfully quit smoking.

The most common cause of death in the United States, coronary atherosclerotic heart disease, is most often detected clinically by performing coronary angiography. Over 1 million coronary angiograms and coronary interventions are performed annually, with most performed by puncturing the femoral artery and advancing a catheter retrograde up the aorta to engage the coronary ostia. Alternate arterial access sites for coronary angiography include the brachial, ulnar, and radial arteries. Despite years of data indicating that the radial artery access site offers significant advantages of safety, patient convenience, and a reduction in complications, the majority of coronary angiograms in the United States are still performed via the femoral artery.^1,2 Although technical considerations with the radial approach can frustrate the operator, such as the well-known tendency of the radial artery to spasm when punctured, or tortuosity of the radial, brachial, or subclavian arteries complicating attempts to advance the catheter to the coronaries, simple physician inertia may explain a portion of the continued dominance of the femoral approach in this country. Many currently practicing cardiologists who were trained to perform cardiac catheterization via the femoral approach see no reason to switch if they can complete the procedure safely and efficiently from the femoral artery.³ In this chapter, we will review the benefits and drawbacks of the transradial (TR) approach to coronary angiography/intervention compared with the transfemoral (TF) approach, discuss the utility of the TR approach in treating patients with STEMI, and briefly review the concept of discharging selected patients from the hospital the same day as their coronary intervention procedure, which the TR approach allows. Finally, we will review the technique of radial artery access and our training program and provide our recommendation on the preferred access site for coronary angiography.

Femoral artery access site complications include arteriovenous fistulas, pseudo-aneurysms, large hematomas, bleeding requiring blood transfusions, and retroperitoneal hemorrhage. Overall, these complications occur in anywhere from 0.5% to 5% of TF procedures, with higher risks occurring with percutaneous coronary interventions (PCIs) as opposed to diagnostic procedures.⁴ Although more than half of fistulas and pseudo-aneurysms can be treated nonsurgically, they can prolong hospitalization and increase overall morbidity and occasionally require surgical repair. Recent studies have demonstrated that acute coronary syndrome patients treated with blood transfusions after PCI have increased cardiac events in long-term follow-up.⁵ The most dreaded of all access site complications, retroperitoneal hemorrhage (RPH), is associated with mortality rates of 6% to 75%.⁶

With the exception of RPH, each of the above complications can occur during TR procedures; radial artery pseudo-aneurysms, radial artery-vein fistulas, and hematomas have all been described with radial access procedures, although in the radial position, these are considered relatively minor. Even radial artery occlusion, which can complicate up to 20% or more of TR PCIs is usually asymptomatic if adequate ulnar artery perfusion of the hand is assured prior to the procedure. However, major complications can rarely occur. Forearm hemorrhage with resultant compartment syndrome has been described, as has complete avulsion of the radial artery⁷ (Figure 7-2). Virtually all studies comparing the TR and TF approaches have demonstrated significant reductions in all access site complications with the TR approach. Due to the lower incidence of all access site–related complications, especially those considered serious or life-threatening, the TR approach must be considered superior to the TF approach in terms of safety, at least with respect to the access site.

Femoral artery puncture requires several hours of strict bed rest in the supine position with little or no motion of the affected leg to facilitate hemostasis. While this 2- to 8-hour period is tolerated well by many patients, it can be challenging for patients with dyspnea in the supine position, such as those with decompensated congestive heart failure (CHF) or moderate to severe compensated heart failure or those with chronic lower back pain problems. Patients with these conditions are commonly encountered in catheterization laboratories. In contrast, the patient undergoing TR catheterization or PCI is able to sit up immediately after the procedure. The authors have on occasion halted a TR catheterization on a severely ill CHF patient to sit the patient up at 90 degrees and dangle the patient’s legs over the table to relieve pulmonary edema and avoid emergent intubation, a maneuver obviously not possible with a TF approach. While femoral arterial closure devices are frequently used, most still require at least 2 hours of bed rest after procedure. For these and other reasons, many patients who have had both TF and TR procedures prefer the TR approach.^8,9