Researchers make case for increased use of left radial access PCI
Left radial access (LRA) for percutaneous coronary intervention (PCI) remains rare in the United Kingdom, according to a registry analysis—but it is associated with similar clinical outcomes as right radial access (RRA) and possibly a reduced risk of stroke.
Despite these positive outcomes, RRA patients undergoing a repeat PCI received transfemoral access about five times more often than a switch to LRA (23.5 percent versus 4.5 percent). Lead author Muhammad Rashid, MBBS, and colleagues believe their findings should spur more operators to consider a left-sided approach because the radial techniques have been proven to have clinical and patient satisfaction advantages over transfemoral access.
“Given the established advantages of radial access in terms of reducing major bleeding and access site complications, there may be benefits in using the LRA site as the default in such circumstances,” lead author Muhammad Rashid, MBBS, and colleagues wrote in JACC: Cardiovascular Interventions. “These observations have implications for training. Trainees should be exposed to LRA early in their training so that the potential benefits of TRA (transradial access) can still be offered in the event of RRA failure.”
Rashid et al. studied all PCIs performed via radial access in the U.K. between 2007 and 2014. Out of more than 340,000 cases, 96 percent used RRA—although LRA increased from 3.2 percent at the beginning of the study to 4.6 percent in the final year.
Previous coronary artery bypass graft surgery was associated with nearly 10-fold increased odds of a patient receiving LRA, while other independent predictors included renal failure, mechanical ventilation, PCI to vein graft, Asian ethnicity and shorter-statured patients.
After multivariable adjustment, rates of in-hospital mortality, 30-day mortality, major adverse cardiac events and major bleeding were similar between the two treatment strategies. However, in a propensity-matched analysis, LRA was linked to a significant 48 percent reduced risk of stroke.
But given the low event rates, the researchers estimated more than 1,800 PCI procedures would need to be completed for one stroke to be prevented with LRA versus RRA use. For this reason, they didn’t suggest overhauling the current standard of RRA—just increased use of LRA when RRA isn’t feasible.
The right-sided approach is more popular largely because of the way cath labs are set up, the authors explained. Leaning over to reach the opposite side of the patient is both uncomfortable and places clinicians closer to radiation sources.
“RRA is more commonly practiced by radial operators because of ergonomics of the cardiac catheter lab, previous training experience, and increased operator discomfort due to the need of having to bend over to the left side of the patient,” they wrote. “On the other hand, a recent meta-analysis of 12 prospective randomized trials enrolling 6,450 patients confirmed that LRA provides more favorable anatomy for catheter manipulation and coronary engagement, translating into a small, but statistically significant, reduction in fluoroscopy time and contrast use.”
Procedural measures such as fluoroscopy time, operator and patient radiation exposure and contrast use weren’t captured in the UK-wide database, the authors noted.
In an accompanying editorial, two cardiologists pointed out the LRA technique could further improve patient comfort and recovery because the majority of patients are right-handed. They said LRA should also be considered for treating chronic total occlusions where more than one access site is required simultaneously.
Ferdinand Kiemeneij, MD, PhD, and Ahmed A. Hassan, MD—both with MC Zuiderzee Hospital in the Netherlands—recommended gaining access on the dorsal side of the hand to improve the physical efficiency of performing LRA PCI.
“A practical solution to overcome these inconveniences and risks may be left distal radial approach, in which the left radial artery is punctured in the anatomical snuffbox,” Kiemeneij and Hassan wrote. “Although this technique is young and still needs validation, its use is getting more and more popular. If the left distal radial approach proves to be safe and at least just as feasible and effective as conventional radial approach, it would combine the advantages for the operator, in terms of ergonomics and distance from radiation source, with those of the patient, in terms of safety and convenience.”
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.