Journal of Invasive Cardiology

“That which we persist in doing becomes easier, not that the task itself has become easier, but that our ability to perform it has improved.”
– Ralph Waldo Emerson (1803–1882)

After Campeau and Kiemeneij published their successful series on diagnostic coronary angiographies and percutaneous coronary intervention (PCI), the radial artery has become the preferred vascular access site, especially in Europe, Japan, Canada and other regions.^1,2 In the United States, transradial access has gained renewed momentum due to the recognition of access-site bleeding as a predictor of adverse outcomes after PCI, and the inception of dedicated micropuncture needles, hydrophilic-coated sheaths and hemostasic radial devices. Trans-radial access is associated with a significant reduction in access-related bleeding, improved patient comfort and lower costs in comparison with transfemoral access. Moreover, observational data suggest that transradial access is associated with a survival benefit among patients undergoing PCI.^3–5 The recent RAPTOR trial demonstrated how operators can easily and safely shift their practice to routine transradial access with a minimal increase in procedure duration and radiation exposure in diagnostic, but not in interventional, catheterization procedures.⁶ However, transradial access demands a specific skill set that is usually acquired after a learning curve of approximately 100 cases and is associated with increased radiation exposure to the operator.^7,8 An additional concern is the increased access failure rate of approximately 5–7% of cases, with the need for crossover to transfemoral access.^9,10

When the initial attempt to puncture the radial artery fails, the usual practice is to switch to transfemoral access, as most operators intuitively assume that the anatomical factors present in one arm would be present in the other. In addition, the uncomfortable position, leaning over the patient to reach the left wrist to manipulate catheters, and the additional radiation exposure may discourage many operators from attempting left radial access after failed right radial access. In general, left radial access is reserved for patients with previous coronary bypass surgery to facilitate imaging of the left internal mammary artery.