Transradial Angiography and Intervention, An Issue of Interventional Cardiology Clinics, 1e (The Clinics-Internal Medicine) (April 21, 2015)_(0323359779)_(Elsevier; UK ed)

109 Pages·2016·3.09 MB·English

by  Sunil V. Rao MD

EDITOR-IN-CHIEF
Matthew J. Price
EDITOR
Sunil V. Rao
ELSEVIER
Copyrighted material
i
INTERVENTIONAL
CARDIOLOGY CLINICS
www.interventional.theclinics.com
Editor-in-Chief
MATTHEW J. PRICE
Transradial Angiography
and Intervention
(cid:1) (cid:1)
April 2015 Volume 4 Number 2
Editor
SUNIL V. RAO
ii
ELSEVIER
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Transradial Angiography and Intervention iii
CONTRIBUTORS
EDITOR-IN-CHIEF
MATTHEW J. PRICE, MD
Assistant Professor,ScrippsTranslational
ScienceInstitute;DirectoroftheCardiac
Catheterization Laboratory,ScrippsGreen
Hospital;Division ofCardiovascular Diseases,
ScrippsClinic, LaJolla, California
EDITOR
SUNIL V. RAO, MD, FACC, FSCAI
Associate Professorwith Tenure,Duke
UniversityMedicalCenter;SectionChief,
Cardiology, DurhamVAMedicalCenter,
Durham,NorthCarolina
AUTHORS
CARLOS E. ALFONSO, MD IAN C. GILCHRIST, MD, FSCAI
CardiacCatheterization Laboratory, Professor ofMedicine,DivisionofCardiology
CardiovascularDivision;AssistantProfessorof Heart andVascularInstitute,Pennsylvania
Medicine,DepartmentofMedicine,University StateUniversityCollegeofMedicine,Hershey,
ofMiamiHospital,UniversityofMiamiMiller Pennsylvania
SchoolofMedicine,Miami,Florida
RAJIV GULATI, MD, PhD
Associate ProfessorofMedicine,Division of
VINAY ARORA, MD
Cardiovascular Diseases,MayoClinic,
SectionofCardiology, UniversityofIllinois
Rochester,Minnesota
Hospital andHealthSciencesSystem;Section
ofCardiology,JesseBrownVA Medical SASKO KEDEV, MD, PhD, FESC, FACC
Center,Chicago,Illinois MedicalFaculty,Professor ofMedicine
(Cardiology); Director,UniversityClinicof
OLIVIER F. BERTRAND, MD, PhD Cardiology, UniversityofSt.Cyriland
QuebecHeart-LungInstitute,QuebecCity, Methodius,Skopje, Macedonia
Quebec, Canada SAMIR B. PANCHOLY, MD, FACC, FSCAI
Associate ProfessorandProgram Director,
MAURICIO G. COHEN, MD, FACC, FSCAI
DepartmentofCardiology,TheWrightCenter
Director, CardiacCatheterization Laboratory, forGraduateMedicalEducation,The
Cardiovascular Division;Associate Professor CommonwealthMedicalCollege,Scranton,
ofMedicine,DepartmentofMedicine, Pennsylvania
UniversityofMiamiHospital,Universityof
MEET PATEL, MD
MiamiMillerSchool ofMedicine,Miami,
Florida SectionofCardiology, UniversityofIllinois
Hospital andHealthSciences System;Section
JOHN COPPOLA, MD, FACC, FSCAI ofCardiology,JesseBrownVAMedical
Center,Chicago,Illinois
DepartmentofCardiology, NYULangone
MedicalCenter,NewYork,NewYork TEJASM.PATEL,MD,FACC,FSCAI,FESC
Chairman,ApexHeartInstitute;Professorand
OLIVIER COSTEROUSSE, PhD Head,DepartmentofCardiology, ShethV.S.
QuebecHeart-LungInstitute,QuebecCity, GeneralHospital,Smt.N.H.L.Municipal
Quebec, Canada MedicalCollege,Ahmedabad, India
iv Contributors
ALBERTO BARRIA PEREZ, MD ofMedicine,PhiladelphiaCollegeof
QuebecHeart-LungInstitute, QuebecCity, OsteopathicMedicine,Philadelphia,
Quebec, Canada Pennsylvania
GUILLAUME PLOURDE, MS
SAURABH SANON, MD
QuebecHeart-LungInstitute, QuebecCity,
Fellow,Division ofCardiovascularDiseases,
Quebec, Canada
Mayo Clinic,Rochester,Minnesota
YANN POIRIER, MS
SANJAY SHAH, MD
QuebecHeart-LungInstitute, QuebecCity,
DirectorofCardiology, ApexHeart Institute;
Quebec, Canada
Associate Professor,Departmentof
GORAN RIMAC, MS Cardiology,ShethV.S.GeneralHospital,Smt.
N.H.L.MunicipalMedicalCollege,
QuebecHeart-LungInstitute, QuebecCity,
Ahmedabad, India
Quebec, Canada
KINTUR SANGHVI, MD, FACC, FSCAI ADHIR R. SHROFF, MD, MPH
DirectorofTransradialProgram,Departmentof SectionofCardiology,UniversityofIllinois
InterventionalCardiologyandEndovascular Hospital andHealthSciencesSystem;Section
Medicine,DeborahHeartandLungCenter, ofCardiology, JesseBrownVA Medical
BrownsMills,NewJersey;AssociateProfessor Center,Chicago,Illinois
Transradial Angiography and Intervention v
CONTENTS
Preface: Radial Approach: Fundamental Techniques and Evidence ix
Sunil V. Rao
Radial Artery Access, Hemostasis, and Radial Artery Occlusion 121
Samir B. Pancholy, Sanjay Shah, and Tejas M. Patel
Radial artery access is usually achieved using a micropuncture system. Hydro-
philic introducers are used to improve comfort, probably by reducing spasm.
A vasodilator cocktail should be administered to prevent severe spasm and
anticoagulation;usually,unfractionatedheparinisadministeredtopreventsub-
sequentradialarteryocclusion(RAO).Hemostasisattheradialarterypuncture
siteiseasilyachievablebylocalcompression.Applicationoflocalcompression
frequentlyleadstointerruptionofradialarteryflowandsubsequentocclusion.
Careful attention to maintenance of radial artery patency during hemostatic
compression has been shown to decrease the risk of RAO without increasing
access-related bleeding complications.
Strategies to Traverse the Arm and Chest Vasculature 127
Tejas M. Patel, Sanjay Shah, and Samir B. Pancholy
This article discusses different methods of working through arm and chest
vasculature to increase the success rate of the transradial approach (TRA).
Despite lower rates of bleeding and vascular complications as compared
with the transfemoral approach, adoption of the TRA has been slow, particu-
larly because of higher failure rates. Anatomic complexities of arm and chest
vasculatureplayanimportantroleincasesofTRAfailure.Usingasimpleframe-
work to classify the anatomic or functional problem and approaching these
challenges in a logical sequence should facilitate management and increase
the success rate for TRA.
Diagnostic and Guide Catheter Selection and Manipulation for Radial Approach 145
Carlos E. Alfonso and Mauricio G. Cohen
Transradialcatheterizationandpercutaneouscoronaryinterventionshavemul-
tipleadvantages,includingreducedbleedingrisk,reducedlengthofstayand
costs,andincreasedpatientcomfort.Transradialcatheterizationandinterven-
tions requires the acquisition of various additional skill sets including radial
arterial puncture, the ability to navigate the upper extremity vasculature,
and understanding catheter selection and coronary engagement technique.
Although standard femoral catheter shapes perform adequately from the
leftorrightradialapproachforcoronaryangiography,forpercutaneouscoro-
nary intervention guide catheter support is critical. This article summarizes
some practical learning points pertaining to navigating the upper extremity
vasculature, and understanding catheter selection and coronary engagement
technique.
viii Transradial Angiography and Intervention
TRANSRADIAL ANGIOGRAPHY AND
INTERVENTION
FORTHCOMING ISSUES RECENT ISSUES
July2015 January2015
Intravascular Imaging: OCT and IVUS Transcatheter Aortic Valve Replacement
MatthewJ.Price,Editor Susheel K.Kodali, Editor
October2015 October2014
Intravascular Physiology Peripheral Vascular Disease
AllenJeremias,Editor PrakashKrishnanandTyroneCollins,Editors
January2016 July 2014
Transcatheter Mitral Valve Intervention Renal Complications in the Catheterization
JasonRogers,Editor Laboratory
Hitinder S.GurmandJudithKooiman,Editors
ISSUEOFRELATEDINTEREST
Cardiology Clinics, August2014 (Vol. 32, No. 3)
CoronaryArtery Disease
DavidM.Shavelle,Editor
Availableat:http://www.cardiology.theclinics.com/
THE CLINICS ARE NOW AVAILABLE ONLINE!
Access your subscription at:
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vi Contents
Slender Approach and Sheathless Techniques 161
Saurabh Sanon and Rajiv Gulati
Most radial arteries cannot accommodate 7- and 8-French introducer sheaths
forlarge-borepercutaneouscoronaryinterventionwithoutoverstretch.Inaddi-
tiontobeinguncomfortable,radialarteryoverstretchisassociatedwithspasm
andhigherratesofprocedure-relatedradialarteryocclusion.Methodsforthe
transradial interventionist to overcome the limitation of radial artery–sheath
size mismatch include both sheath-based and sheathless approaches. In this
article we discuss a variety of techniques that can be used to minimize radial
artery stretch for straightforward and complex coronary procedures.
Transradial Primary Percutaneous Coronary Intervention 167
Sasko Kedev
Videosofrightforearmangiogramdemonstratingsignificantradialarterytortuosity
andtortuositynegotiatedwith0.014-inchguidewireaccompanythisarticle
Despiteadvancesinantithromboticandantiplatelettherapy,bleedingcompli-
cations remain an important cause of morbidity and mortality in patients with
acuteSTsegmentelevationmyocardialinfarction(STEMI)undergoingprimary
percutaneous coronary intervention (PPCI). Many bleeding events are related
to the access site. Transradial access (TRA) PPCI is associated with significant
reductioninbleedingandvascularcomplicationsandreducedcardiacmortal-
ity compared with the transfemoral approach (TFA). High-risk patients might
particularlybenefitfromTRA.Radialskillsprovidingproceduraltimesandsuc-
cessratescomparablewiththoseoftheTFAarestronglyrecommendedbefore
using this technique in the STEMI PPCI setting.
Transradial Peripheral Arterial Procedures 179
Kintur Sanghvi and John Coppola
Videosoftransradialperipheralarterialproceduresaccompanythisarticle
Increasedunderstandingandincreasedadoptionoftransradialcatheterization
acrosstheworldhaveledtofurtherexploringofradialarteryaccessfortrans-
radialendovascularinterventionsinperipheralarterydisease(PAD).Thisarticle
discussestheadvantagesandlimitationsofthetransradialapproachforendo-
vascularmedicinebyusingcaseexamples,illustrations,andvideos.Thedetails
about how to use a radial approach for PAD intervention, including tips and
tricks, are discussed.
Complications of Transradial Cardiac Catheterization and Management 193
Vinay Arora, Meet Patel, and Adhir R. Shroff
Thetransradialapproachforcoronaryangiographyhasbecomeanincreasingly
usedalternativetotheconventionaltransfemoralapproach.Decreasedaccess
sitecomplicationsandbleeding,reducedhospitalstaysandhealthcarecosts,
and increased patient satisfaction contribute to the attractiveness of this
approach.However,operatorsmustbefamiliarwiththedistinctcomplications
associatedwiththetransradialapproach.Inthisarticle,wediscussthecommon
andlesscommoncomplicationsoftransradialcatheterization,preventionstra-
tegies, and management options.
Contents vii
The Transradial Learning Curve and Volume-Outcome Relationship 203
Ian C. Gilchrist
Thisarticlediscusseshowlearningcurvescorrelatewithlearningintransradial
catheterization.Althoughlearningcurvesexistintheconversiontotransradial
approaches, current percutaneous coronary intervention (PCI) procedures are
sosafethatonlysurrogateendpointssuchascontrastusageandx-rayexpo-
sureshowlearningeffects.Usingthesesurrogates,alearningcurveof30to50
patientsseemstypical to transition cardiologists from transfemoral totransra-
dialPCI.Thistransitionoccurswiththeimmediatebenefitofreducedvascular
complications and bleeding and without loss of overall procedural success.
Thesemeasuresofsafetyduringlearningexistdespitedifferenceofprocedural
volumes.
TheTransradialApproachandAntithromboticTherapy:RationaleandOutcomes 213
Alberto Barria Perez, Goran Rimac, Guillaume Plourde, Yann Poirier,
Olivier Costerousse, and Olivier F. Bertrand
This article reviews antithrombotic strategies for percutaneous coronary inter-
ventions according to the access site and the current evidence with the aim
of limiting ischemic complications and preventing radial artery occlusion
(RAO). Prevention of RAO should be part of the quality control of any radial
program. The incidence of RAO postcatheterization and interventions should
be determined initially using the echo-duplex and then frequently assessed
usingthemorecost-effectivepulseoximetrytechnique.Anyevidenceofhigher
risk of RAO should prompt internal analysis and multidisciplinary mechanisms
to be put in place.
Transradial Angiography and Intervention
PREFACE
Radial Approach: Fundamental
Techniques and Evidence
SunilV.Rao,MD,FACC,FSCAI
Editor
Bleeding is the most common complication of radialtopicswrittenbyinternationalexpertsforthe
percutaneous coronary intervention (PCI), occur- practicinginterventionalcardiologist.Theissuein-
ring in up to 10% of patients. A substantial pro- cludessuchtopicsasradialarterialaccess,hemo-
portion of bleeding is related to the vascular stasis and radial artery occlusion; traversing the
accesssite,andstudiesindicatethatsuchcompli- arm and chest vasculature; and diagnostic and
cations are associated with increased morbidity, guide catheter selection. Also found in the issue
mortality, and costs. These complications are areadvancedtopicssuchassheathlesstechniques,
alsolargelypreventable.Themosteffectivestrat- transradialprimaryPCIforSTEMI,useofradialac-
egytoreducebleedingriskfromPCIistousethe cessforperipheralarterialprocedures,andrecog-
radialarteryinsteadofthefemoralartery.Transra- nition and management of complications. In
dialPCIisbeingincreasinglyadopted,butthereis addition, topics such as the radial learning curve
substantial international variation in its use. In andtheinteractionbetweenaccesssiteandantith-
particular, certain countries, such as the United rombotictherapyarealsoexplored.
States, lag behind other countries, such as India Importantly,eacharticlefocusesonpracticalin-
andJapan.Thismaybeduetothelackofconcise formation that is readily translatable to clinical
information on best practices and techniques. practice.Takentogether,thiscompendiumrepre-
There also has been a significant increase in the sentsthebestcontemporaryinformationonradial
number of publications on the radial approach access,whichwillcontributetoimprovingthecare
examining high-risk subsets and clinical and ofpatientsundergoingPCI.
nonclinical outcomes. Observational and random-
izedstudieshaveshownthatradialaccessreduces SunilV.Rao, MD,FACC,FSCAI
mortality in patients with ST-segment elevation DukeUniversityMedical Center
myocardial infarction (STEMI) and reduces hospi- DurhamVAMedical Center
tal length of stay and costs compared with tradi- 508FultonStreet (111A)
tional femoral access. Durham,NC27705,USA
This issue of Interventional Cardiology Clinics E-mailaddress:
providesanin-depthexaminationofrelevanttrans- [email protected]
InterventCardiolClin4(2015)ix
http://dx.doi.org/10.1016/j.iccl.2015.01.005
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