ORIGINAL ARTICLES

Safety and Efficacy of the Percutaneous Radial Artery Approach
for Coronary Angiography and Angioplasty in the Elderly

Gionata Molinari, MD, Ilaria Nicoletti, MD, Marialuisa De Benedictis, MD, Clotilde Terraneo, MD, Giorgio Morando, MD, Marco Turri, MD, Maurizio Anselmi, MD, Piero Zardini, MD Giuliana Menegatti, MD, Corrado Vassanelli, MD
Gionata Molinari, MD, Ilaria Nicoletti, MD, Marialuisa De Benedictis, MD, Clotilde Terraneo, MD, Giorgio Morando, MD, Marco Turri, MD, Maurizio Anselmi, MD, Piero Zardini, MD Giuliana Menegatti, MD, Corrado Vassanelli, MD
Percutaneous coronary catheterization and revascularization are commonly performed all over the world. Among various access sites for coronary interventions, most cardiologists favor the femoral approach, while the procedure via the radial artery is only performed by a limited number of operators (less than 2% in the United States), probably because of the steep learning curve the radial procedure requires.1,2 However, it has been shown that the transradial approach to coronary interventions presents a series of advantages that make it an attractive alternative to the brachial or femoral approaches.3 Campeau first reported the feasibility of the transradial approach to coronary angiography in 1989.4 Subsequently, further studies confirmed the efficacy and the safety of coronary angioplasty and stent implantation by the transradial approach.5–8 Moreover, in the ACCESS study, Kiemeneij et al. compared the radial approach to the brachial and femoral approaches in patients undergoing PTCA (percutaneous transluminal coronary angioplasty), demonstrating that there were no significant differences between the three approaches in terms of the success of coronary angiography or angioplasty or the duration of the procedures.6 However, the radial approach is associated with fewer vascular complications,7 shorter hospital stays, lower hospital costs and earlier patient mobilization compared with the transfemoral approach.8–10 Therefore, the transradial procedure may be routinely attempted, with some exceptions, and is to be preferred in those patients at high risk of local vascular complications (such as the elderly, the obese, patients with aorto-iliac disease or those receiving antithrombotic and antiplatelet drugs). In the elderly the transfemoral catheterization can be more complicated. Older patient’s arteries are more calcified and their walls contain less elastic fibers. Consequently, this can increase the risk of injury which could result in hematomas or aneurysm. Moreover, the elderly are frequently affected by prostatic hypertrophy or backache, thus a site approach for catheterization which shortens bedrest time, is necessary to improve their comfort. With the increasing age of the population and of patients requiring cardiac revascularization, this technique should be taken into account as a useful strategy for reducing vascular complications and for improving patient comfort. So far the results of the radial approach have been studied in groups with an average age 8 The purpose of our study was to assess the efficacy and safety of the transradial approach for angiography and/or angioplasty in patients > 70 years of age, and to evaluate the procedural results and clinical course in the elderly as compared to younger patients. Methods Study population. This study is a retrospective analysis of data on transradial procedures that were collected over a 5-year period. From 1999 to 2003, transradial catheterization was attempted in 850 patients. A single cardiologist experienced in the transradial approach to coronary interventions performed all procedures, mostly via the right radial approach (680 patients; 80%). Patients were divided into two groups according to age: the first group (600 patients; 70.5%) consisted of patients 8,9 or the need to use intra-aortic balloon pump or 8 Fr catheters (such as in directional or rotational atherectomy). The Allen’s test was considered positive when, after compression of both ulnar and radial arteries, a return of normal hand color occurred within 10 seconds after release of the ulnar artery. Procedure Arterial cannulation. After a local subcutaneous anesthesia (1–2 cc of lidocaine 2%), the radial artery was punctured with a 20 gauge needle and a guidewire was passed directly through the needle. A 23 cm long 6 Fr sheath was advanced on the guidewire. In order to prevent arterial vasospasm, 1–2 cc nitroglycerine and a bolus of heparin (5,000 IU) were administered intra-arterially.10 Diagnostic angiography was performed using 6 Fr catheters (Judkins Left and Right, Amplatz Left and Right or Multipurpose type), and PTCA was performed using 6 Fr catheters (Judkins Left and Right, Amplatz Left and Right, XB 3.5 or Multipurpose type). Sheath management. At the end of the procedure, the arterial sheath was immediately removed and hemostasis was achieved by applying gauze and a compressive elastic bandage for about 4 hours. This dressing was then replaced by another, less compressive bandage that was removed after 24 hours. All patients were allowed to move immediately after the procedure. In the population study, we evaluated clinical characteristics, procedure duration (from patient arrival in the catheterization laboratory to completion of the procedure), X-ray exposure, number of catheters used per patient and complications during the in-hospital follow-up (death, acute myocardial infarction, local hematomas, radial occlusion, transient ischemic attack or stroke). Statistical analysis. Comparisons between groups were made using the unpaired Student’s t-test, Chi-square test or Fisher’s exact test, as appropriate. A p-value 11 reported a stroke event rate of 0.38%. A similar stroke rate was observed in the reports from Emory University (0.05–0.38%)12 and the Cleveland Clinic (0.3%).13 It was also noticed that the elderly population is at increased risk of stroke due to more extensive carotid and cerebral vascular disease and associated comorbid conditions.14,18 In particular, a recent analysis by De Servi et al.15 on short-term outcomes in a population of patients admitted to Coronary Care Units for acute coronary syndrome demonstrated that the elderly population facedapproximately two-fold risk of stroke (1.3% vs. 0.5%) as compared with younger patients, independently of the type of therapeutic strategy employed, aggressive or conservative. Similar results were obtained in a comparison of short- and long-term complications after coronary stenting in patients greater than or equal to 80 years of age versus those 75 years with acute myocardial infarction treated with primary angioplasty, the incidence of stroke was significantly higher as compared to younger patients as reported by Tespili and colleagues (0.5% vs. 2.1%),17 and by the analysis of the PAMI trials (0.8% vs. 2.9%; p = 0.001).18 These findings are consistent with those obtained by Abizaid et al.19 in a large population of patients undergoing coronary stent implantation divided into three groups according to age, and with those of Cohen et al. obtained in PCI-treated patients.20 Discussion At present there is little information about the outcome of cardiac catheterization procedures in the elderly. Since the population of older subjects needing coronary interventions is progressively increasing, knowledge of the results, complications and patient satisfaction after these procedures is fundamental for both physicians and patients. The current study shows that transradial cardiac catheterization is a feasible procedure in both younger and older patients. Of particular note, no statistical difference between the two groups was observed in regard to procedure duration and local vascular complications. The lower rate of access site complications of transradial catheterization compared to the femoral approach is mainly due to the double blood supply to the hand and to the favorable anatomical course of the distal radial artery, which is distant from major nerves or veins and is superficial so that hemostasis can be easily achieved with local compression. These anatomical characteristics confer several advantages to radial artery interventions. The radial approach determines a low risk of vascular complication, reduces procedural costs and allows earlier mobilization and discharge, thereby increasing patient comfort.21 These benefits are especially important in the elderly, in whom immediate ambulation is necessary to obviate age-related problems such as difficulty urinating in bed and backache due to osteoarthritis. All these benefits make this technique safe, effective and attractive, especially in those patients at high risk of vascular complications. It has been widely demonstrated that elderly patients undergoing PCI experience more frequent vascular complications at the femoral puncture site. In the EPIC trial,22 Blankenship et al. studied a large group of patients treated with PCI and abciximab: the logistic regression analysis identified advanced age as an independent predictor of any vascular access site bleed or vascular access site surgery (p = 0.0049). In the NHLBI Dynamic Registry,27 4,620 PCI-treated patients were examined and divided into 3 groups according to age. This analysis demonstrated the incidence of access site complications increased by age categories (2.6% in patients 21,23–27 report similar findings and further confirm that older patients are at particularly high risk of vascular complications; the elderly should thus be treated with an alternative coronary route or with arterial puncture closure devices to reduce vascular complication risks. Recently, new arterial sealing devices allowing earlier mobilization have been introduced. Nevertheless, not all patients selected for the femoral approach can receive these vascular closure devices, and their use is not always successful. The rate of complications using vascular local devices is almost the same as that of manual compression in the femoral approach (2.5%). Moreover, the advanced age in patients who undergo vascular access site closure with the Angio-Seal™ (St. Jude Medical, St. Paul, Minnesota) device is a predictive factor of complications, probably due to the presence of peripheral vascular disease that causes less effective anchoring of the device.26 A recent meta-analysis of 30 randomized trials27 concluded that there is only marginal evidence that arterial closure devices are effective, and they may increase the risk of hematoma and pseudoaneurysm. Whether these devices would allow similar improvement in quality of life observed with transradial catheterization remains to be determined. Certainly, the use of expensive vascular closure devices would make it difficult to achieve cost-savings with the radial access approach.28 In our study population there seems to be a trend towards a higher incidence of cerebrovascular complications in older patients. However, according to our analysis, these events did not differ statistically (p = 0.08). We think further studies involving a larger number of patients are needed to determine if a rare event such as a stroke or a TIA might occur more frequently in the elderly following transradial catheterization. We conclude that cardiac catheterization via the radial artery represents a useful and safe procedure associated with a low risk of vascular complications, and allowing rapid ambulation, which is particularly beneficial for patients of advanced age.
References
1. Louvard Y, Krol M, Pezzano M, Sheers L, et al. Feasibility of routine transradial coronary angiography: A single operator’s experience. J Invasive Cardiol 1999;11:543–548. 2. Hildick-Smith DJR, Lowe MD, Walsh JT, et al. Coronary angiography from the radial artery: Experience, complications and limitations. Int J Cardiol 1998;64:231–239. 3. Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison. Am Heart J 1999;138:430–436. 4. Campeau IG. Percutaneous transradial artery approach for coronary angiography. Cathet Cardiovasc Diagn 1989;16:3–7. 5. Kiemeneij F, Laarman GJ. Percutaneous transradial artery approach for coronary stent implantation. Cathet Cardiovasc Diagn 1993;30:173–178. 6. Kiemeneij F, Laarman GJ, Oderkerken D, et al. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial, and femoral approaches: The ACCESS study. J Am Coll Cardiol 1997;29:1269–1275.