Are Radial Artery Anomalies a Major Cause of Transradial Procedure Failure?

1
Are Radial Artery Anomalies a Major Cause of
Transradial Procedure Failure?

• Ted S N Lo1, E Fountzopoulos1, R Butler1, S L
  Hetherington2, A Zaman2, James Nolan1, David
  Hildick-Smith3
• 1. University Hospital of North Staffordshire,
  Stoke-on-Trent UK
• 2. Freeman Hospital, Newcastle-upon-Tyne, UK
• 3. Brighton and Sussex University Hospital,
  Brighton, UK

2
Background 1

• The radial artery (RA) is increasingly used as a
  preferred access route for percutaneous coronary
  procedures.
• It has minimal vascular complications, immediate
  ambulation and better post procedure comfort but
  is associated with a significant learning curve
  than femoral procedures.

3
Background 2

• Anecdotal evidence suggests that once the
  learning curve is passed, most transradial
  procedure failures are due to anatomical
  anomalies but there are currently limited data on
  such information.
• This study aims to systematically establish the
  incidence and significance of RA anomalies in
  patients undergoing transradial coronary
  procedures.

4
Methods 1

• A multicentre prospective study University
  Hospital of North Staffordshire, Brighton
  Sussex University Hospital and Freeman Hospital.
• From December 2005 to March 2007.
• Retrograde radial arteriography using a short
  introducing sheath was performed in all patients
  presenting for a first-time radial procedure.

5
Methods 2

• Patient characteristics, procedural data, radial
  artery anatomy and local vascular complications
  were analysed.
• Procedure success is defined as completion of the
  intended procedure via the radial access route.
• Procedural duration is defined as time elapsed
  from patient entering the lab to leaving the lab.

6
Methods 3

• Minor vascular complications are defined as
  haematoma lt5cm, vessel dissection localised
  infection.
• Major vascular complications are defined as
  haematoma gt5cm, pseudoaneurysm, any access site
  complications that required surgical or
  radiological intervention, gt3gm Hb drop due to
  access site bleeding, bleeding requiring
  transfusion, limb ischaemia and compartment
  syndrome.

7
Results 1 Patients and procedural characteristics
No. of patients (n1026)
Male Female 731 295 71.2 28.8
Age in years (range) 6411 (24-90)
Risk factors 697 67.9
Type of procedures
Diagnostic angiography 317 30.9
Ad hoc PCI 423 41.2
PCI 286 27.9
Initial access attempted
Right radial Left radial 961 65 93.7 6.3
Access approach changed to
Left radial Right femoral 12 37 1.2 3.6
Sheath gauge
5F 6F 7F 683 332 8 66.7 32.5 0.8
Data in number, meanSD and percentage.
hypertension, diabetes, peripheral vascular
disease, previous CABG.
8
Results 2 RA anatomy and procedural outcome
No.0f patients (n1026)
RA anatomy findings
Normal 871 84.9
Anomaly 155 15.1
Procedural success via RA only 989 96.4
Procedure duration (min)
Diagnostic angiography 25.712.1 NA
Ad hoc PCI 49.420.1 NA
PCI 48.722.6 NA
Fluoroscopy time (min)
Diagnostic angiography 3.54.5 NA
Ad hoc PCI 11.76.8 NA
PCI 12.48.7 NA
Vascular complications
Minor 11 1.1
Major 2 0.2
9
Results 3 Breakdown of anatomy and procedural
outcome
Anatomical Findings No. of Patients (n1026) No. of failure () P value
Normal 871 84.9 8 (0.9) NA
Types of anomaly
High RA bifurcation 80 7.8 4 (5.0) 0.415
RA loop 22 2.1 9 (40.1) lt0.0001
RA tortuosity 25 2.4 6 (24.0) lt0.001
UA anomaly 7 0.7 0 NA
Others 21 2.1 5 (23.8) lt0.001
Total aomalies 155 15.1 24 (15.5) lt0.0001
Percentage of failure to RA anatomical findings
10
Normal Anatomy
BA
BA
RA
RA
UA
UA
Interosseous Median artery
Interosseous artery
11
High Bifurcating RA
High bifurcating RA
BA
High bifurcating RA
12
RA Loop Recurrent RA
2 Remnant recurrent RA
Large recurrent RA
Complex large RA loop
Small RA loop
13
Tortuous RA
Tortuous RA
UA
UA
Tortuous RA
14
Conclusions 1

• Anomalous RA anatomy is common and is the major
  cause of transradial procedural failures.
• The commonest variation is high bifurcating
  radial origin which is normally of smaller
  calibre necessitating the use of 5F equipment.

15
Conclusions 2

• Retrograde radial arteriography before the
  intended radial procedure helps to delineate the
  anatomy and identify patients with potentially
  unfavourable RA anatomy, and procedural technique
  can then be modified to facilitate successful
  catheterisation.
• It should be incorporated into routine practice
  for transradial procedures.