Reusing the Radial: Repeat Transradial Access Safe and Feasible, Even Within 24 Hours

In patients who previously underwent transradial coronary angiography or PCI, operators can safely return to the same radial artery for repeat procedures done within 30 days of the first, a new study shows.

Over a 2-year period at a single center, repeat cardiac catheterization via a radial artery was performed in 92% of 626 patients who required the second procedure, with just 2.7% of patients crossing over to femoral access. Overall, physicians performed the repeat procedure via the same ipsilateral radial artery in 73% of cases.

The results, according to the researchers, “suggest that repeat early radial access within 30 days of the index procedure is feasible and safe,” although the success rate is lower the second time than it is in patients undergoing an initial cardiac catheterization using radial access.

“Whatever the timing between two procedures . . . go for it and use the same radial artery,” senior researcher Olivier Bertrand, MD (Laval University, Quebec City, Canada), told TCTMD. “The limitation is that you should take care to optimize hemostasis and to preserve access in case of possible future procedures.”

In a previous study published in 2013, the researchers reported the feasibility of using the same radial artery in multiple procedures, up to 10 times in some patients undergoing successive catheterizations. The rate of transradial use for each successive angiography/intervention declined as the patients returned for repeat procedures, noted Bertrand.

“This was a bit of warning sign to consider the risk of radial artery occlusion and to perhaps emphasize this limitation,” he said. Additionally, the time between repeat interventions was longer in their previous study, and for that reason they wanted to study the safety and feasibility of early (≤ 30 days) repeat access.

As physicians switch to transradial PCI, repeat transradial procedures are increasingly common in clinical practice. For example, a patient might be treated emergently for ACS and then be followed up with a staged PCI in 24 or 48 hours, said Bertrand. Additionally, a repeat procedure might be necessary because of suspected complications, such as subacute thrombosis.

Mamas Mamas, BMBCh (Keele University, Stoke-on-Trent, England), who was not involved in the study, said the paper is relevant given the absence of clinical data about the feasibility of early repeat radial procedures and their associated outcomes.

“This is particularly important as the reasons for undertaking such very early procedures include the management of acute complications such as stent thrombosis where much more aggressive pharmacological strategies would be used and the patients would be more hemodynamically unstable, placing them at particularly high risk of access site related bleeding complications,” Mamas told TCTMD via email. “This is borne out by the high risk of femoral complications in this study in the femoral cases.”

Nearly 75% Return to Same Radial Artery

The new study, published online last week in the American Journal of Cardiology, consists of all consecutive patients who underwent two or more diagnostic coronary angiographies or PCIs at the Quebec Heart and Lung Institute between 2012 and 2014.

In total, 626 patients underwent a diagnostic angiography or PCI via transradial access and had one or more subsequent repeat procedures within 30 days of the index procedure (median time 4 days). The majority of patients had the index procedure via the right radial artery  

 “Some patients will come back into the lab within 30 days and undergo repeat transradial access—either with the right or the left—but not necessarily the same artery,” said Bertrand. “In that case, the operator uses transradial access in more than 90% of patients. If they use the right artery in the first attempt and the patient returns the next day or the day after, they will sometimes go left to preserve access.”

There’s probably a psychological barrier for the operator to use the same radial artery very early on after the initial procedure. Olivier Bertrand

Among the patients, 459 of the 626 underwent repeat catheterization using the same ipsilateral artery for the second procedure, while 25 of 38 patients who had a third procedure had the same radial artery used for access.

When the repeat intervention was performed within 24 hours of the index procedure, operators used the same ipsilateral radial artery in 53% of their cases.  For patients who had a third procedure within 24 hours, 73% of patients were treated via the same radial artery used in the index catheterization. As time increased between the index procedure and second or third angiography/PCI, reuse of the ipsilateral radial artery also increased.

“There’s probably a psychological barrier for the operator to use the same radial artery very early on after the initial procedure,” said Bertrand.

More Bleeding With Femoral Access

In the repeat cases where physicians crossed over to femoral access, failed arterial puncture, poor guiding support, radial spasm/inability to advance catheter, and tortuosity/stenosis were the main reasons for the switch.

At the repeat procedure, there was a trend toward more frequent bleeding complications/hematoma in patients who underwent femoral access compared with radially-treated patients or patients who crossed over to femoral access. In transradial patients, there were no access-site complications aside from hematoma and one case of symptomatic radial artery occlusion (which occurred after two repeat procedures).   

The rate of primary access failure—where the physician chose femoral access for the repeat cardiac catheterization without attempting the radial approach—was 5.8% and 13.0% for the second and third procedures, respectively.

For Bertrand, the main message of their study is that “for patients coming back very early on, you can still do transradial, especially if you shift and go to the other side, or you can still use the same artery.”  

Given the rate of femoral complications, Mamas told TCTMD the data “would make a strong case for considering use of the contralateral radial artery in such high-risk cases if catheterization is not feasible through the ipsilateral approach, rather than deferring to the femoral approach.”   

Regarding the overall use of the ipsilateral radial artery in repeat procedures, Mamas said their numbers are in line with those of the Canadian researchers. Hematomas around the puncture site and radial artery occlusion are reasons that likely explain the relatively low utilization of same radial artery for repeat cases. 

Overall, radial injury for transradial catheterization is more widespread than appreciated, and particular care needs to be taken in patients for whom there is an expectation of a repeat procedure, said Mamas. This includes minimizing spasm to avoid injury and close monitoring of the access site during patent hemostasis to reduce the risk developing hematomas or occlusion.