ESC Report Recommends Radial Access as Default Approach for PCI

Based on 2 decades of experience and data, a largely European panel of experts has recommended radial access as the first choice for angiography and percutaneous coronary intervention (PCI) when performed by operators experienced with the method. The panel produced a comprehensive up-to-date statement on the radial approach, defining its role in contemporary practice and providing guidance on technique and training.


“Twenty years from its introduction, it was felt that the time had come to develop a common evidence-based view on the technical, clinical, and organizational implications of using the radial approach,” write Martial Hamon, MD, of the University Hospital of Caen (Caen, France), and colleagues in a consensus statement published online January 28, 2013, ahead of print in EuroIntervention. The document is the work of experts selected by the European Association of Percutaneous Cardiovascular Interventions, the Acute Cardiovascular Care Association, and the Working Group on Thrombosis of the European Society of Cardiology. 

Despite steady growth of the technique, its use “varies greatly among operators, hospitals, countries, and continents,” the authors note. For example, although more than half of procedures in France, the United Kingdom, Spain, and Italy are performed radially, in Germany fewer than 10% of catheterizations are done via radial access, according to an accompanying press release. Data from the NCDR CathPCI Registry puts US radial procedures at 11% in 2011. 

Radial Should Be First Choice

The authors assert that cumulative evidence from trials and registries shows that radial access is feasible as a default approach in routine practice. “It is now clear after the RIFLE and RIVAL trials that radial access reduces major bleeding at the vascular access site and as a consequence improves patient outcomes, including survival, especially in STEMI,” Dr. Hamon said in a press release. “It is therefore essential that PCI centers use radial access as the strategy of choice in high-risk ACS patients in conjunction with current recommendations regarding optimal antithrombotic strategies.”

Other advantages cited for radial access include greater patient comfort and quicker ambulation after the procedure as well as cost-effectiveness.

The authors advise that proficiency with femoral access should be maintained since it may be needed as a bailout strategy. Potential drawbacks of the radial approach such as longer procedure duration and catheter manipulation near the neck, which are correlated with radiation exposure and stroke risk, respectively, depend largely on operator experience and warrant special attention during the learning curve, they say.

Because radial technique is demanding, the authors observe, operators and institutions should aim for the highest feasible procedure volume. After the learning curve, “satisfactory proficiency” can be achieved when over half of cases are performed radially, with a minimum of 80 procedures per year for each operator. The paper offers a stepwise model for competence in different PCI settings, with ACS and STEMI patients requiring the highest number of previous cases.

In addition, it is important that nurses and other cath lab personnel understand how to manage radial patients before, during, and after the procedure.

The authors also offer numerous recommendations regarding patient selection, choice of left vs. right wrist and radial vs. ulnar artery, and preprocedural preparation.

Expert Authors Give Paper Added Weight

In a telephone interview with TCTMD, Ian C. Gilchrist, MD, of Hershey Medical Center (Hershey, PA), said the report carries considerable authority. “The writers are all high-volume radialists who really know what they’re talking about, and that adds to the richness of it,” he observed.

The document “codifies some principles that have evolved since the development of transradial PCI in Europe [20 years ago],” wrote Sunil V. Rao, MD, of the Duke Clinical Research Institute (Durham, NC), in an e-mail communication with TCTMD, and it is particularly compelling because the senior author is radial pioneer Ferdinand Kiemeneij, MD. Dr. Rao served as an expert reviewer for the paper.

The ESC document “highlights the differences between the United States and the rest of the world in terms of what is being published on this issue,” Dr. Gilchrist said. For example, he pointed out, although radial PCI has been shown to reduce mortality in acute MI, the recent updated STEMI guidelines from the American College of Cardiology/American Heart Association do not even mention it, while the current document recommends radial access as the default approach.

Consensus Documents Provide Needed Push

Distilling and publishing “the best ideas” about how to perform radial PCI is especially important because the strategy is not associated with a commercial product and so does not have financial backing for its dissemination, Dr. Gilchrist said. On the other hand, the fact that radial PCI has been a ‘grassroots’ movement has promoted cooperation among proponents, he suggested, and a consensus document “is a great way to let those who are just starting learn from our experience,” he added.

The document “helps shatter some myths,” Dr. Rao noted. For example, he added, “there is a belief that [radial access] is complicated and requires fancy equipment. It doesn’t. All it requires is a hydrophilic sheath, a homeostasis device, a dedicated physician, and a dedicated cath lab team.”

Reinforcing the latter point, Dr. Gilchrist noted that cath lab personnel not only must learn how to prepare patients and deal with complications but also adapt post-procedure protocol. For instance, he said, unlike femoral patients, radial patients can often be discharged early and drive the next day. If nurses are unaware of this, or simply treat all PCI patients alike, these advantages are lost.

Dr. Rao endorsed a stepwise approach to achieving different levels of radial competence, but added, “an underlying principle is that at some point, an operator should adopt a ‘radial first’ approach. Dabbling in radial is the surest way to fail.”

Dr. Gilchrist agreed but echoed the authors’ admonition not to neglect femoral skills. These are needed not just as backup in case of radial failure but increasingly to perform procedures involving devices such as percutaneous valves or heart assist devices that are too large for radial arteries, he noted.

A Tipping Point for Radial in the United States?

As for why the United States continues to lag behind much of the world in radial uptake, Dr. Rao said, “It’s probably a combination of operators not believing the data, the lack of large-scale US-based data, and a dearth of training opportunities.” Another contributor, Dr. Gilchrist suggested, is “wishful thinking” about prospects for the perfect closure device that would minimize femoral access-site bleeding.

Dr. Rao said that “the next generation of interventionalists will probably lead the charge” for radial use in the United States. Dr. Gilchrist was also optimistic about increasing adoption by US operators. “Seeing well-known cardiologists agreeing that radial should be the default approach has got to make American operators who don’t do radial think twice,” he commented.

 


Source:
Hamon M, Pristipino C, Di Mario C, et al. 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. EuroIntervention. 2013;Epub ahead of print.

 

 

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Disclosures
  • Drs. Hamon, Rao, and Gilchrist report no relevant conflicts of interest.

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