Left, Right Radial Procedures Equally Effective, but Right Access Takes Longer

Download this article's Factoid in PDF (& PPT for Gold Subscribers)

While failure rates for percutaneous coronary intervention (PCI) are equally low when using the left or right radial artery, radial-access procedures from the right side are associated with longer procedure times and increased radiologic exposure in real-world practice, according to results published online June 4, 2012, ahead of print in the American Journal of Cardiology.

Researchers led by Francesco Pelliccia, MD, PhD, of Sapienza University of Rome (Rome, Italy), performed a prespecified subanalysis of the prospective PREVAIL study, which looked at patients in contemporary practice receiving invasive cardiovascular procedures over a 1-month period at 9 centers in the Lazio region of Italy. For the subanalysis, the researchers focused on 509 patients who received procedures via radial artery access, comparing left (n = 205) and right (n = 304) approaches.

High-, medium-, and low-volume radial centers were included, and the choice of left or right radial access was left to the operator’s discretion. Of the 42 participating operators, 16 (38%) reported a high volume of radial procedures (> 65% of their caseload).

Failure Rates Low, Equivalent

Clinical presentation was more often stable angina in the left radial group while ACS was more common in the right radial group. Both groups underwent similar proportions of PCI vs. diagnostic angiography. Failure of first access was low in both the left (8%) and right (5%) access groups (P = 0.17), as was PCI failure (1% vs. 3%; P = 0.56). PCI complete success rates were also similar (P = 0.57).

However, right radial access was associated with longer procedure and fluoroscopy times along with higher total dose-area product (table 1).

Table 1. Procedural Characteristics with Radial Procedures

No major ischemic events were observed in either group, while minor hemorrhages at radial artery access sites occurred in 3 patients in each group. There were no associations between procedure duration and operator volume, and the overall results remained unchanged when only patients treated by high-volume operators were analyzed.

On propensity analysis-adjusted logistic regression, choice of left radial artery access was an independent predictor of procedure duration time (beta coefficient 11.38; 95% CI 5.02-17.74; P < 0.001) and total dose-area product (beta coefficient 60.27; 95% CI 31.59-88.95; P < 0.001), with fluoroscopy time just missing statistical significance (beta coefficient 139.10; 95% CI -22.06 to 300.26; P = 0.091).

Based on the results, the authors conclude that while left and right radial access are equally feasible and effective for angiography and PCI, “[i]n the real world, . . . patients undergoing the left radial route had shorter procedures and lower radiologic exposure compared to those undergoing a right radial approach.”

Dr. Pelliccia and colleagues note that there is no consensus in the literature as to which side is better for radial access. Some studies agree with the current results, while others have shown equivalent or longer procedure and fluoroscopy times with left radial access.

Reasons for Leaning Left

PCI via the left radial artery may be advantageous, though, since it allows easier catheter manipulation, lower subclavian tortuosity, and greater patient comfort, the authors observe.

Regardless, based on these findings, “the left radial artery approach should be recommended apart from patients with left internal mammary artery grafts and in those subgroups of patients in whom a faster approach (ie, urgent cases) and/or a decreased radiation dose (ie, younger patients) are mandatory,” Dr. Pelliccia and colleagues conclude.

While not advocating a universal shift to the left for all radial procedures, James Tift Mann III, MD, of Wake Heart and Vascular Associates (Raleigh, NC), did note in a telephone interview that the study “reinforces that for at least low- to medium-volume operators and beginners, left radial access is easier.”

For more experienced operators, though, it is standard to achieve radial access from the right, he told TCTMD. “For the experienced operators, the data to move to the left radial is not there,” Dr. Mann said. “I don’t see any great movement toward that, particularly based on a [nonrandomized] trial like this.”

He also noted significant pushback from US cath labs regarding left-side radial procedures. “It comes from the fact that the procedure is usually done from the right side of the table, and to get access from the left radial, you have to lean across the patient,” Dr. Mann said. “Many patients are obese and you can’t get to the left radial in a very convenient way. There is just a general perception that access is more difficult, even though everybody agrees that catheter manipulation is easier, fluoro times are less, and procedure times are less.”

It’s Very European

Dr. Mann described a practice in many European cath labs of gaining access via the left radial from the left side of the table, redraping the patient, and then performing the actual procedure from the right side of the table.

“Nobody anywhere does procedures from the left side of the table, but many places put the sheath in from the left,” he said. “In fact, in many places in Europe, the sheath is actually inserted in the holding area outside the cath lab, so when the patient comes into the lab, the sheath is already there.”

Dr. Mann did mention one subgroup that might benefit from left radial access—STEMI patients. “Clearly we now know there’s a mortality benefit from going radial as long as you can do it expeditiously,” he said. “That might be a clinical scenario, as you move up the learning curve, where an operator might consider [left radial access] once he feels comfortable [as a way of alleviating any concerns about prolonged door-to-balloon times].”

Study Details

Patients receiving left radial access had a higher prevalence of diabetes and peripheral/coronary artery disease, and a higher rate of previous radial access and CABG.

 

---

Source:
Pelliccia F, Trani C, Biondi-Zoccai GGL, et al. Comparison of the feasibility and effectiveness of transradial coronary angiography via right versus left radial artery approaches (from the PREVAIL study). Am J Cardiol. 2012;Epub ahead of print.

 

 

Related Stories:

• Learning from the Left Quicker for Radial Procedures
• Pick a Side: Left or Right Access Equally Good for Radial Procedures

Click here for a listing of companies that provide support to the Cardiovascular Research Foundation, owner and operator of TCTMD.