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

Failure?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, UK3. Brighton and Sussex University Hospital,

Brighton, UK

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.

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.

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.

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.

Methods 3

Minor vascular complications are defined as: haematoma <5cm, vessel dissection & localised infection.

Major vascular complications are defined as: haematoma >5cm, pseudoaneurysm, any access site complications that required surgical or radiological intervention, >3gm Hb drop due to access site bleeding, bleeding requiring transfusion, limb ischaemia and compartment syndrome.

Results 1: Patients and procedural characteristics

No. of patients (n=1026) %

Male : Female 731 :295 71.2 : 28.8

Age in years (range) 64±11 (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, mean±SD and percentage. *hypertension, diabetes, peripheral vascular disease, previous CABG.

Results 2: RA anatomy and procedural outcome

No.0f patients (n=1026) %

RA anatomy findings

Normal 871 84.9

Anomaly 155 15.1

Procedural success via RA only 989 96.4

Procedure duration (min)

Diagnostic angiography 25.7±12.1 NA

Ad hoc PCI 49.4±20.1 NA

PCI 48.7±22.6 NA

Fluoroscopy time (min)

Diagnostic angiography 3.5±4.5 NA

Ad hoc PCI 11.7±6.8 NA

PCI 12.4±8.7 NA

Vascular complications

Minor 11 1.1

Major 2 0.2

Results 3: Breakdown of anatomy and procedural outcome

Anatomical Findings No. of Patients (n=1026)

% 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) <0.0001

RA tortuosity 25 2.4 6 (24.0) <0.001

UA anomaly 7 0.7 0 NA

Others 21 2.1 5 (23.8) <0.001

Total aomalies 155 15.1 24 (15.5) <0.0001

*Percentage of failure to RA anatomical findings

Normal Anatomy

Interosseous & Median arteryInterosseous artery

RA

UA

BA

RA

UA

BA

High Bifurcating RA

High bifurcating RA

High bifurcating RA

BA

RA Loop & Recurrent RA

Complex large RA loop

2 Remnant recurrent RALarge recurrent RA

Small RA loop

Tortuous RA

Tortuous RA

UATortuous RA

UA

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.

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.