Consensus Document on the Radial Approach in Percutaneous Cardiovascular Interventions: Position Paper by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care and Thrombosis of the European Society of Cardiology

Perspective:

The following are 10 points to remember about this consensus document:

1. Radial access use has been growing steadily but, despite encouraging results, still varies greatly among operators, hospitals, countries, and continents.

2. The superficial position of the distal radial artery, free of other anatomical structures, makes it easy to find and puncture, and safe to compress after sheath removal. A default radial approach is feasible in routine practice after appropriate training (both in stable and unstable patients including ST-segment elevation myocardial infarction [STEMI] patients), but proficiency in the femoral approach is required because it may be needed as a bailout strategy or when large guiding catheters are required. Better results with radial access are expected with increasing procedural volume of operators.

3. The radial approach offers lower access-site bleeding, particularly in patients at higher risk of either ischemia or hemorrhage. A combined reduction of both access- and nonaccess-site bleeding is expected when the radial approach is associated with optimized anticoagulation according to current recommendations.

4. Procedure duration and time of catheter handling have been associated with an increased risk of both silent and symptomatic stroke; therefore, special caution is required especially during the learning curve in setting up a transradial approach program.

5. Magnitude of radiation exposure in transradial procedures relative to femoral procedures is still unclear; however, it is highly influenced by operator experience. Specific attention to radiation exposure and protection is mandatory, whatever access site is used, and is critical during the learning phase, particularly when using the right radial approach.

6. Transradial intervention (TRI) does not negatively affect the clinical effectiveness of percutaneous coronary intervention and, when performed by trained operators, provides better outcomes, including survival, by reducing vascular access site-related bleeding in STEMI patients.

7. To achieve the best results in TRI, individual operators and institutional teams should aim at maintaining the highest feasible rate of TRI. However, a reasonable objective for achieving an average satisfactory proficiency is aiming, after the learning curve has been completed, for over 50% radial access in routine practice with a minimum of 80 procedures/year per operator (including diagnostic and interventional procedures).

8. All radial-proficient teams should aim to maintain optimal proficiency in femoral procedures as well. Some low-risk patients for femoral access site complications and procedures requiring femoral access (intra-aortic balloon pump [IABP], radial access failure, or if guiding catheters ≥8 Fr are required) should provide a volume of cases to maintain adequate training in femoral artery puncture.

9. Operators should expect anatomical variations and have a plan to overcome them. In the vast majority of cases, caution advancing wires and catheters, angiographic assessment, and using specific wires will yield a successful TRI. In cases of high take-off of the radial artery associated with a remnant or slender radial artery, an alternative approach, like femoral or contralateral radial access, is preferable to avoid unnecessary prolongation of the procedure.

10. Infrequent and sometimes anecdotal complications have been associated with radial access. Radial occlusion should be prevented during and after the procedure, and a systematic assessment of arterial patency should be performed. Spasm prevention is recommended routinely. Specific early and delayed post-procedural attention to forearm hematomas is a must.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Spasm, Myocardial Infarction, Radial Artery, Hemorrhage, Consensus, Percutaneous Coronary Intervention


< Back to Listings