Author + information
- Ferdinand Kiemeneij, MD, PhD∗ ( and )
- Gerard J.J. Boink, MD, PhD
- ↵∗Reprint requests and correspondence:
Dr. Ferdinand Kiemeneij, Back Office Department of Cardiology, Tergooi Hospital, Rijksstraatweg 1, 1261 AN Blaricum, Blaricum, the Netherlands.
Since the first reports on transradial coronary angiography (1) and interventions in 1992 (2,3), the superiority of this technique over conventional femoral access has been demonstrated by a steadily growing body of evidence. Superiority is predominantly driven by a reduction of bleeding complications (4,5). Transradial access (TRA) has been declared by the European Society of Cardiology to be the default technique for patients requiring percutaneous coronary intervention for ST-segment elevation myocardial infarction (6) and non–ST-segment elevation myocardial infarction (7). A consensus document released by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care and Thrombosis of the European Society of Cardiology recommends radial access as the default technique for coronary interventions in general (8). Today, TRA is practiced in virtually all interventional centers worldwide, although differences in acceptation rates between centers, countries, and continents remains substantial (9). This increased interest in radial access as default approach for coronary cannulation comes with a substantial risk of losing radial artery patency in the long term. Radial artery occlusion (RAO) rates of >30% have been reported, but usually incidences in “real-world” situations are around 5% (10). The most common risk factors for RAO are failure to maintain radial artery patency during hemostasis, diabetes, female gender, under-heparinization, and sheath–radial artery diameter mismatch (11–13).
The most important clinical consequence of RAO is that it deprives the patient of a potential safe access site for future coronary interventions. So does this loss of radial artery patency support the prophecy that TRA will succumb under its own success? The PROPHET-II trial (PROPhylactic Hyperperfusion Evaluation Trial) by Pancholy et al. (14) in this issue of JACC: Cardiovascular Interventions fortunately declares another prophecy. After TRA, prophylactic ipsilateral ulnar compression during hemostasis can reduce RAO to 0.9% in a selected group of patients.
Previous studies have indicated that such ipsilateral ulnar artery compression can be used to prevent RAO (15,16), yet the PROPHET-II trial is the first study to investigate this approach in a large cohort of 3,000 randomized patients receiving diagnostic cardiac catheterization. The primary endpoint was radial artery patency evaluated by reverse Barbeau test at 30 days after the procedure and showed a significant reduction in RAO for prophylactic ipsilateral ulnar artery compression as compared to standard patent hemostasis (0.9% vs. 3.0%). This result was achieved without any demonstrable damage to the ulnar artery as evaluated in an ultrasound substudy.
From a methodologic standpoint, the PROPHET-II trial in many ways represents a well carried out clinical trial. Radial access was obtained via standard counter-puncture technique by a highly experienced operator team. A 5-F hydrophilic introducer was inserted followed by bolus injections of nitroglycerin (200 μg), verapamil (2.5 mg), and unfractionated heparin (5,000 IU), and after completion of the diagnostic procedure, patients randomly received either standard patent hemostasis (achieved by Terumo’s inflatable TR band applied for 2 h; control group), or prophylactic ipsilateral ulnar compression in addition to patent hemostasis. In terms of puncture technique, sheath and pharmacologic cocktail this set-up provides a relatively representative setting for many of the transradial procedures. However, the standard patent hemostasis is not always immediately straightforward. In around 4% of the patients, this technique requires a manual hold to obtain the desired effect (17). In addition, in 26% of the patients of the PROPHET-II trial, antegrade flow could not immediately be reestablished, requiring frequent and careful evaluation of the level of applied pressure (i.e., every 15 min). As a result, compliance with patent hemostasis protocols, either using inflatable device or compressive dressing, in the “real-world” may be substantially lower as compared with the highly controlled setting of this clinical trial (18). Interestingly, in patients who received ipsilateral ulnar artery compression patent hemostasis was achieved substantially more frequently (96% vs. 74%), which may facilitate implementation in daily practice. Finally, the trial design excluded several patient categories such as ad hoc percutaneous interventions, history of ipsilateral TRA, scleroderma, warfarin therapy, and heparin intolerance. Although these exclusions facilitate homogeneity of the study population and interpretation of results, they may complicate translation to some of the patient categories such as those receiving ad hoc interventions.
Regardless of the discussed limitations, the robust outcomes, in terms of reducing incidence of RAO in combination with the simplicity and inexpensiveness of ipsilateral ulnar artery compression, ask for rapid implementation in clinical practice. Such prompt implementation should further be used to increase awareness of the ongoing issue of RAO aiming to maximally reduce this important complication.
The investigators are to be congratulated with achieving the lowest incidence of RAO currently reported. It is a major step forward in maintaining radial artery patency. At present, there are no recommended strategies to restore radial artery patency after iatrogenic occlusion, making prophylaxis of RAO essential. Together with other measures, such as adequate hemostasis, downsizing equipment, and improved operator skill and puncture techniques, it must be possible to make RAO a rare occasion after TRA.
Our general recommendation, after almost 25 years of TRA experience, is to be kind to the radial artery and give it back to the patient, who allowed us to use this vessel for the procedure that we have proposed to perform. As a result, the patient can enjoy the benefits of radial access in case of future necessity for coronary procedures.
↵∗ Editorials published in JACC: Cardiovascular Interventions reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Interventions or the American College of Cardiology.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Campeau L.
- The Task Force on the management of ST-elevation acute myocardial infarction of the European Society of Cardiology (ESC),
- Steg P.G.,
- James S.K.,
- Atar D.,
- et al.
- Roffi M.,
- Patrono C.,
- Collet J.P.,
- et al.,
- Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology
- Hamon M.,
- Pristipino C.,
- Di Mario C.,
- et al.
- Feldman D.N.,
- Swaminathan R.V.,
- Kaltenbach L.A.,
- et al.
- ↵Pancholy SB, Bertrand OF, Patel T. Comparison of a priori versus provisional heparin therapy on radial artery occlusion after transradial coronary angiography and patent hemostasis (from the PHARAOH study). Am J Cardiol 2012;110:173–6.
- Pancholy S.B.,
- Bernat I.,
- Bertrand O.F.,
- Patel T.M.
- Pancholy S.,
- Coppola J.,
- Patel T.,
- et al.