Author + information
- Olivier F. Bertrand, MD, PhD⁎ (, )
- Sunil V. Rao, MD and
- Tift Mann, MD
- ↵⁎Institut Universitaire de Cardiologie et de Pneumologie de Québec, Cardiology, 2725 Chemin Ste Foy, QuebecCity G1V 4G5, Quebec, Canada
We thank Dr. Feld for his interest in our paper (1). His points are very timely and extremely pertinent. In summary, he was surprised by the very large predominance (∼90%) of right radial artery, compared with left radial artery, use as the default access site. We looked back into our data to see if these patterns were consistent across different subgroups. For female operators, the preferred side for transradial approach (TRA) was the right in 96% and the left in 4%, whereas for male operators, the right side was preferred in 89% and the left side in 11%. The right side was preferred by 80% of young operators (≤30 years old), 91% of operators >30 to ≤40 years old, 89% of operators >40 to ≤60 years old, and still preferred by 89% of operators older than 60 years. For operators performing <5% of their diagnostic cases by TRA, right side was preferred by 83%, whereas it was 91% for those performing >90% of their diagnostic cases by TRA. Furthermore, for operators performing ≥50% of percutaneous coronary intervention (PCI) by TRA, the right side was preferred in 92% of cases compared with 85% of cases for operators performing <50% of PCI by TRA. Interestingly, the right side was preferred by only 78% of operators performing <100 PCI per year, compared with more than 90% for operators performing >100 PCI per year.
As we reported, in most cases, the right radial artery is used, although the left radial artery is also appropriate. However, as operators are used to working from the patient's right side, it is likely that many of them avoid the left radial approach because of the uncomfortable position, leaning over the patient to reach the left wrist to manipulate catheters. In many centers, left radial access is reserved for patients with previous coronary artery bypass surgery to facilitate imaging of the left internal mammary artery. In some recent reports, investigators have compared left and right radial artery approaches with little differences between the 2 approaches, at least in lean patients (2,3). In the TALENT (Transradial Approach [LEft vs Right] aNd Procedural Times During Percutaneous Coronary Procedures) study, Sciahbasi et al. (2) reported that the left radial artery was an appealing vascular access alternative, especially for physicians learning the technique. Several institutions now routinely teach fellows the radial technique using left radial side as primary access. In addition, subclavian tortuosity, an important predictor of transradial access failure, is less common with left transradial catheterization procedures. This can be useful in elderly patients, women, or patients with short stature.
If there is one trick to be remembered from the right side, it is to have the patient take a deep breath as the catheter approaches the innominate-ascending aorta junction as this elongates the ascending aorta, thus facilitating catheter entry into the ascending aorta. Any time there is difficulty cannulating selectively the coronary arteries, this simple maneuver may help. It may also help if you need to deeply intubate with a guiding catheter seeking more support.
In fact, we have found that “all roads lead to Rome” and in contrast to femoral approach where position and catheters use are rather monolithic, the transradial approach offers much more versatility. At the end, you should use the side and the catheters that you are the most comfortable with. Ultimately, benefits for the patients, as described by Dr. Feld, will depend little from operators' position or choice of catheter.
- American College of Cardiology Foundation