Commentary

Safety of the Radial Artery Approach in the Elderly

Shahid Aziz, MBChB, BSc, MRCP and David R. Ramsdale MD, FRCP
Shahid Aziz, MBChB, BSc, MRCP and David R. Ramsdale MD, FRCP
Since the first description of transradial coronary stent implantation in 1993,1 there has been a rapid increase in the number of coronary diagnostic and interventional procedures using this approach. The radial artery (RA) technique has potential advantages over the procedure done from the femoral artery (FA). These may include a low risk of bleeding complications from the access site, patient comfort, and early mobilization and discharge from the hospital.2 It is ideal for obese patients, for patients who are unable to lie flat for more than a short period and for those who require prolonged heparinization or the administration of glycoprotein IIb/IIIa inhibitors. Although the use of femoral artery closure devices has diminished the incidence of problems after FA procedures, bleeding complications still appear to be higher in FA than in RA procedures.3,4 Potential disadvantages include a significant learning curve for the operator, RA spasm and RA occlusion, preventing repeat catheterization and the use of the RA as a conduit for coronary artery bypass graft surgery. Other limitations include the need for a satisfactory Allen’s test, difficulty in negotiating tortuous brachiocephalic/subclavian arteries, problems reaching the contralateral internal mammary artery (IMA), manipulation in a dilated/aneurysmal ascending aorta, perhaps an increased risk of transient ischemic attacks and stroke, and the limitations of this approach in percutaneous coronary intervention (PCI). The study in this issue of the Journal by Molinari et al. reports the satisfactory outcome of patients 5 Unfortunately, the study is retrospective and it is not clear whether the patients were consecutive, whether they were all elective, and exactly how many cases the single operator had performed prior to the study period. It is also not stated how many patients were considered for a RA approach but were rejected because of contraindications such as an abnormal Allen’s test or an absent radial pulse, or who required emergent treatment using the FA approach. Whether patients with valvular heart disease, congenital heart disease, or IMAs were excluded, and whether a recent history of transient ischemic attack or stroke was considered a contraindication, remains unclear. Nor is it evident how many patients underwent an abandoned procedure due to RA spasm, dissection or tortuosity of the brachiocephalic/subclavian arteries, making coronary access impossible. In a report of 594 transradial procedures by Barbeau, the incidence of RA loops and extreme vessel tortuosity was 2.4% — the mean age for tortuous anatomical problems being 72 years.6 The authors do not provide any data to support that the RA procedure in the elderly was more cost-effective, more comfortable or associated with more early mobilization and hospital discharge than after a FA procedure, although this topic is alluded to in the discussion. For many elderly patients who live alone or who live a long distance from the cardiac center, “early” or “same-day” discharge is not considered to be a priority, thus weakening the cost-effectiveness argument in favor of the RA technique. With regard to those patients who went on to ad hoc PCI after RA coronary angiography, no data are provided to indicate the type of procedures performed, which cases were abandoned and done via the FA instead, and why. Moreover, it is hard to believe that the procedure times for patients undergoing combined angiography and ad hoc PCI were as short as indicated in Table 2. Finally, although the numbers are small, there is a trend towards a greater incidence of cerebrovascular events in those patients greater than or equal to 70 years of age. The authors suggest that this may be due to an increased incidence of one of the recognized independent risk factors for stroke — advanced age!
References
1. Kiemeneij F, Laarman GJ. Percutaneous transradial artery approach for coronary stent implantation. Cathet Cardiovasc Diagn 1993; 30:173–178. 2. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;44:349–356. 3. Mann T, Cowper PA, Peterson ED, et al. Transradial coronary stenting: Comparison with femoral access closed with an arterial suture device. Catheter Cardiovasc Interv 2000;49:150–156. 4. Morice MC, Dumas P, Lefevre T, et al. Systematic use of transradial approach or suture of the femoral artery after angioplasty: Attempt at achieving zero access site complications. Catheter Cardiovasc Interv 2000; 51:417–421. 5. Molinari G, Nicoletti I, de Benedictis M, et al. Safety and efficacy of the percutaneous radial artery approach for coronary angiography and angioplasty in the elderly. J Invasive Cardiol 2005;17:651–654. 6. Barbeau GR. Radial loop and extreme vessel tortuosity in the transradial approach: Advantage of hydrophilic-coated guidewires and catheters. Catheter Cardiovasc Interv 2003;59:442–450.