Transradial Approach [LEft vs right]

aNd procedural Times during

percutaneous coronary

procedures: TALENT study

ALESSANDRO SCIAHBASI, MD

UO Cardiologia, Policlinico Casilino – ASL RM B,

Rome, Italy

Background

Coronary transradial procedures may be performed through right or left radial artery approach (RRA and LRA respectively)

Most of studies assessing feasibility of the transradial approach have been performed through RRA, but the LRA may have some important anatomical advantages.

Aim of this study was to evaluate safety and efficacy of RRA versus LRA approach in coronary diagnostic and interventional procedures.

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MethodsFrom January 2009 to December 2009 all

patients who underwent percutaneous coronary procedures (diagnostic or PCI)

Exclusion criteria: previous CABG, acute STEMI,

haemodynamic instability, ischemic Allen test.

Right Radial Approach

Left Radial Approach

Policlinico Casilino

Policlinico Gemelli

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Primary end point: fluoroscopy time and the Dose Area Product (DAP) adsorbed by the patients.

Secondary end-points: contrast amount, cannulation time, access shift rate, number of catheters employed, major complications.

A sub-analysis regarding patient’s age and operator’s

skillness (senior compared to fellow) was also pre-specified

Methods

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1540 consecutive patients were randomized to LRA (770) or RRA (770)

1467 patients

735 LRA 732 RRA

Diagnostic Group (coronary angiography)

688 patients

344 LRA 344 RRA

PCI Group (PCI post angiography or stand alone)

Methods

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Results

Right Radial

(n=770)

Left Radial

(n=770)P

Age (years) 65.7 ± 11.2 66.4 ± 10.9 0.27

Sex (Male) 526 (68%) 527 (68%) 0.95

Height (cm) 168 ± 8 168 ± 9 0.94

Weight (Kg) 77 ± 14 77 ± 14 0.95

BMI 27 ± 4 28 ± 4 0.82

Diabetes (%) 208 (27%) 238 (31%) 0.09

Hypertension (%) 539 (70%) 520 (68%) 0.30

Creatinine (mg/dl) 1.05 ± 0.6 1.04 ± 0.5 0.80

GFR (ml/min) 90 ± 36 89 ± 35 0.58

Hemoglobin (g/dl) 13.5 ± 1.7 13.4 ± 1.7 0.88

Mean ± standard deviation; BMI: body mass index, GFR: glomerular filtration rate

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Results

RRA (n= 732)

LRA (n= 735)

168

149

se

co

nd

s

Fluoroscopy time

0

150

170

(32-1238)

(31-1290)

P= 0.0025

12.1

10.7

0

11

13

Dose Area Product (Fluoroscopy)

Gy

/cm

2

(0.9-229)

(0.8-378)

P= 0.004 23.3 23.5

Dose Area Product (Fluorography)

0

20

25

Gy

/cm

2

(6.4-172) (1.9-328)

P= 0.40

Results are expressed as median with range in brackets

Diagnostic Group (n= 1467)

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695

614

Fluoroscopy time

0

600

700

se

co

nd

s

(54-5087)

(62-5653)

P= 0.087

63.1

53.7

Dose Area Product (Fluoroscopy)

0

55

65

Gy

/cm

2

(2.4-1058)

(4.1-784)

P= 0.17

Results are expressed as median with range in brackets

PCI Group (n= 688)

RRA (n= 344)

LRA (n= 344)

37.8 41.5

Dose Area Product (Fluorography)

0

30

50

Gy

/cm

2

(1.8-285) (5.7-307)

P= 0.60

Results

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Right Radial

(n=770)

Left Radial

(n=770)P

Cannulation Time (min)† 5 (2-85) 5 (2-60) 0.27

Cross over to femoral 6 (0.8%) 9 (1.2%) 0.43

Stroke/TIA 1 (0.1%) 0 (0%) 0.31

Subclavian Tortuosity 125 (16%) 65 (8%) <0.001

Coronay angiography

Contrast medium (ml)* 68 ± 35 65 ± 32 0.098

>2 Catheters 84 (11%) 84 (11%) 0.98

Coronary intervention

Contrast medium (ml)* 165 ± 91 160 ± 92 0.44

>1 Catheter 43 (13%) 42 (12%) 0.91

* Mean ± standard deviation; † Median with ranges

Results

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Cross-over to femoral:Incidence and classification

RRA (n= 770)

LRA (n= 770)

Overall 14 puncture and radial failure vs 1 epi-aortic failure, p= 0.0008

Puncture Failure

Lack of radialcanalization

0

1

2

3

4

5

Cas

es

P= 0.41

Radial Failure

Radialtortuosity/anomalies

Severe spasm

P= 0.70

P= 0.31

Epi-Aortic Failure

Subclavian-aortictortuosity

P= 0.31

Results

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0.01 0.1 1 5 10 50

Radial tortuosity

OR=18.5; 95%CI, 6.4-54, p< 0.001

Multivariate analysis

Predictors of cross over to femoral

OR=2.6; 95%CI, 1.8-3.7, p< 0.001

Age >70 years

0.1 0.5 1 2 5 10

Predictors of subclavian tortuosity

OR=2.7; 95%CI, 1.9- 4, p< 0.001

Right radial approach

Results

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Results are expressed as median with range in brackets

Diagnostic Group (n= 1467)

9.39

Dose Area Product (Fluoroscopy)0

5

10

Gy

/cm

2

(0.9-201)

(0.8-197)

P= 0.26

140

132

se

co

nd

s

Fluoroscopy time

0

130

150

(32-1238)

(31-1282)

P= 0.11

SENIOR

RRA (n= 487)

LRA (n= 478)

FELLOW

256

208

0

200

260

se

co

nd

s

(58-1170)

(35-1290)

P= 0.001

Fluoroscopy time

RRA (n= 245)

LRA (n= 257)

22.4

17.3

0

15

30

Gy

/cm

2

(2.2-229)

(1.3-378)

P= 0.002

Dose Area Product (Fluoroscopy)

Results

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Results are expressed as median with range in brackets

Diagnostic Group (n= 1467)

11.1

10.2

Gy

/cm

2

0

10

12

(0.9-193)

(0.8-305)

P= 0.11

158

138

Fluoroscopy time

0

130

160

se

co

nd

s

(32-990)

(32-1282)

P= 0.048

Age <70 years

RRA (n= 430)

LRA (n= 425)

Dose Area Product (Fluoroscopy)

199

171

Fluoroscopy time

0

170

200

se

co

nd

s

(56-1238)

(31-1290)

P= 0.01

14.2

11.2

0

10

15

(1.7-229)

(0.9-378)

P= 0.001

Age ≥70 years

RRA (n= 302)

LRA (n= 310)

Dose Area Product (Fluoroscopy)

Gy

/cm

2

Results

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Conclusions

LRA for coronary angiography and interventions is

associated with slight but significant lower

fluoroscopy time and radiation dose compared to

RRA

The LRA advantage seems to be confined to operators

at the beginning of learning curve (fellows) and to

be more pronounced in older patients

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