Selective coronary angiography was first performed by the brachial artery. It then evolved to transfemoral access(TFA) with the Judkins technique and now TRA is frequently utilised for cardiac catherization and PCI. Just as TFA gradually replaced the brachial artery cutdown, TRA is becoming the standard practice worldwide.
These advancements have reduced vascular complications while increasing patient satisfaction. TRA has a clear qualitative benefit to patients and a higher proportion of patients prefer TRA to TFA. Well-designed clinical studies and randomised clinical trials soon followed, which began to quantify the clinical benefits (including mortality benefits) of radial access.
Clinical trials (SCAAR, RIFLESTEACS and RIVAL) have clearly documented the superiority of T.R.I. over T.F.I. in patients who come for primary PCI especially in a high volume trans-radialcentre or performed by high volume trans-radial operator. MATRIX trial also evaluated the effects of TRA in patients undergoing PCI for acute coronary syndrome and found that TRA decreased the net composite end point of death, myocardial infarction, stroke or bleeding academic research consortium (BARC) major bleeding. Inparticular patients treated with TRA had a lower risk of death and bleeding. In the sites with the highest proportion of patients undergoing TRA, the effects of TRA on mortality and bleeding were the greatest. Hulme et al add further observational evidence in support of both TRA and the relationship between TRA volume and outcomes.
TRA has been recommended as default access site for primary PCI. ” 2015 ESC guideline for the management of acute coronary syndrome in patient presenting without persistent ST segment elevation”, radial access for coronary angiography and PCI is recommended over femoral one with highest degree of recommendation (1A). ESC recommends that in centres experienced with radial access, a radial approach is recommended for coronary angiography and PCI . It is recommended that centre treating ACS patients implement a transition from trans femoral to trans radial access and at the same time they need to maintain proficiency in T.F.A. as well.
Despite such strong clinical evidence and recommendations, radial access remains a road less often travelled. The reason is technical difficulties encountered by the trans radial operators leading to long and steep learning curve. Majority of technical challenges are related to the success of transradial puncture and the challenges while traversing the radial, brachial and axillary artery for example; radial tortuosity, radial spasm, radial artery hypoplasia (congenital and acquired), diffuse atherosclerosis of radial artery, radio-cubital trunk, 360 degree loops of radial artery, anatomical variations of the arteries, non elastic compartments of forearm&several branches which originates from the system and can be damaged/dissected by the guidewire. All these challenges need special care and specific technique to make the procedure easy for the operator and also to make T.R.I. even more comfortable and safe for the patient. The purpose of discussing clinical challenges faced and their solutions while traversing radial and brachial artery would be discussed by me so as to help new operators shorten this learning curve and achieve proficiency in transradial intervention.
The author Dr RK Jaswal is the Director Cardiology at Fortis Hospital, Mohali In his more than 22 yrs in the field of Interventional Cardiology has done>27000 transradial invasive procedures and >12000 transradial interventions including complex transradial coronary interventions. He is presenting on the Traversing through Radial and Brachial Region at IndiaLive 2018