Radial Artery Angiograms Save Time, May Reduce Complications in Radial PCI for STEMI

ROME, Italy—(UPDATED) Radial artery anomalies are present in nearly one in ten patients undergoing radial access PCI for STEMI and are a key reason for transradial failure, according to the analysis of a large, consecutive series. Authors say their findings support the use of preprocedural radial artery angiograms in all patients.

Biljana Zafirovska, MD (SS Cyril and Methodius University, Skopje, Macedonia), and colleagues presented their findings at a poster session on the opening day of the European Society of Cardiology Congress 2016.

“Our center is definitely a transradial center—in the last 5 years we have done 95% of procedures transradially and the other 5% using mostly other wrist interventions, with transfemoral only very little,” Zafirovska told TCTMD. “So we are definitely concerned with the subject [of] radial art anomalies. . . . We wanted to know how many interventions are crossed over to another access [route], or how often there is a need to cross over, and the necessity of preprocedural radial artery angiography.”

Zafirovska and colleagues reviewed all PCI cases performed at their center between March 2011 and December 2014. In all, 2,891 out of 19,292 PCI procedures were for STEMI, with more than 95% of cases being performed via a radial approach. Radial artery angiograms were performed before all cases.

Radial angiography identified radial artery anomalies in 8.4% of patients. The most common anomalies were high-bifurcating radial artery origin from the axillary and brachial arteries—seen in 167 (5.7%) of patients—followed by full radial loop in 29 (1.0%) of patients and extreme radial artery tortuosity in 45 (1.5%) of patients. Two patients (0.6%) had hypoplastic radial artery.

Identification of an anomaly on the preprocedure angiogram was key to better planning and swifter completion of the STEMI procedures, Zafirovska said. While a full 94.7% of anomalies were ultimately crossed transradially, alternative access was used in 5.3% of patients—ipsilateral transulnar artery in six patients, left radial artery in five patients and femoral artery in two patients. The presence of a radial artery loop was the most common reason for crossovers, with nine out of 13 patients found to have radial artery loop ultimately requiring treatment via another access route.

“Preprocedural radial artery angiography in STEMI patients gives the operator a roadmap to successfully plan the strategy for crossing the anomaly or transfer to a new approach in the interest of saving time and reducing primary PCI procedure time,” the authors conclude.

Fast When the STEMI ‘Clock Is Ticking’

Zafirovska believes this study represents the largest series documenting the incidence of radial artery anomalies—her center now routinely performs radial artery angiography prior to every procedure. “It only takes a second,” she said. “We have seen a reduction in our access site complications, because we know what to expect,” she said. “We film it, and we know there is a loop there. And we make a strategy based on that whether to cross over to another approach or pass the anomaly if we can.” The films also help with better catheter sizing, she added.

She clarified that experienced operators can typically cross a radial artery anomaly, but that in her group, if a radial artery loop is seen on angiography in a STEMI patient, the operator will chose another approach simply to save time.

Commenting on the strategy for TCTMD, Sunil Rao, MD (Duke University Medical Center, Durham, NC), said he’s familiar with the technique used by the Macedonian group. “What they do is to inject a small amount of contrast through the access cannula, which is very slender—much smaller than an introducer sheath. If there is an issue with the radial, . . . they just remove the cannula and go to the other radial or the ulnar. Since no sheath was placed in the original radial artery, there is no arterial injury.”

Overall, he continued, “I think it is a very valuable technique,” although, he conceded that “hardly anyone does it, so it is like a lot of things that are beneficial but have been slow to be adopted.”

Ultrasound guidance for femoral access faced the same slow uptake, he noted. “The key is to just start doing it, preferably in stable patients, so that it can get integrated into your practice. What is impressive about the series [reported by Zafirovska] is that the patients are all STEMI patients, where the door-to-balloon clock is ticking. Since radial angiography is part of their routine, they take very little time to perform the radial angiogram and then are able to increase procedure success by avoiding anatomical challenges.”

By contrast, however, Robert Yeh, MD (Harvard Clinical Research Institute, Boston, MA) told TCTMD in an email that he’s unlikely to adopt a strategy of routine radial angiography. For one, he said, “anomalies are rare,” two, “many are quickly crossable with a few advanced methods,” and three, “you can quickly determine whether you can cross without doing an angiogram. I certainly think the idea is novel but the benefit of doing this seems small.”

Moreover, he added: “I think you'd have to demonstrate that doing this routinely saved time before people starting adopting it.”

To TCTMD, Zafirovska said that she and her colleagues have a follow-up analysis planned, comparing data before and after they started performing routine radial artery angiography (before and after 2011) to see whether the strategy has reduced access site complications and saved time.

Source:

• Zafirovska B, Petkoska D, I. Vasilev I, et al. Radial artery anomalies in STEMI interventions. Presented at: European Society of Cardiology Congress 2016. August 27, 2016. Rome, Italy.

Disclosures:

• Zafirovska reports no conflicts of interest.

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