Samir B. Pancholy, MD, FACP, FACC, FSCAI
Program Director
Cardiology Fellowship
Wright Center for Graduate Medical Education
Associate Professor of Medicine
The Commonwealth Medical College
Scranton, PA, USA

Sanjay Shah, MD, DM
Department of Cardiology
Apex Heart Institute
Assistant Professor of Cardiology
Smt. N.H.L. Municipal Medical College
Sheth V. S. General Hospital
Ahmedabad, India



Patient Selection, Cath Lab Set-Up and Patient Preparation

Tejas Patel, MD, DM, FACC, FSCAI, FESC

Sanjay Shah, MD, DM

Samir Pancholy, MD, FACP, FACC, FSCAI

An experienced radialist can complete virtually every coronary angiogram and intervention through the radial route. However, when an interventionalist is first establishing a radial program, it is important that the first 200 cases be chosen carefully. Being selective in the beginning will build the understanding and confidence needed to convert oneself into a seasoned radialist. In this chapter, the essential patient selection criteria for inclusion and exclusion for the beginning radialist are listed. These initial standards for patient selection have been used successfully to start transradial programs. The Modified Allen’s Test, the Inverse Allen’s Test and alternative tests are discussed in detail. Although many expert radialists no longer perform these tests, the new radial operator will build confidence by incorporating them into the procedure.



Radial and Brachial Regions: Understanding and Addressing the Issues

Tejas Patel, MD, DM, FACC, FSCAI, FESC

Sanjay Shah, MD, DM

Samir Pancholy, MD, FACP, FACC, FSCAI

Rajnikant Radadiya, MD

Alok Ranjan, MD, DNB, MRCP, DM

In this chapter, the normal and relevant abnormal anatomy of the radial and brachial arteries will be discussed. Classic examples of spasm, atherosclerosis, calcification, tortuosity, abnormal origin of the radial artery (from high brachial and axillary artery), radial artery (RA) perforation, RA occlusion, and types of loops and curvatures are shown. Techniques to address these issues successfully are shown. Normal Anatomy of Brachial and Radial Artery The RA commences at the bifurcation of the brachial artery near the elbow, and passes along the radial side of the forearm to the wrist. The RA extends from the neck of the radius to the front of the styloid process. The upper part lies on the medial side of radius and the lower part lies on the bone. The upper part is deep and lies below the muscle (brachioradialis) in most cases. The lower part is superficial, covered by skin, and superficial and deep fascia. The RA is slightly smaller in caliber than the ulnar artery (UA).



TRA for Addressing Bifurcation Lesions

Yves Louvard, MD, FSCAI

Sanjay Shah, MD, DM

Tejas Patel, MD, DM, FACC, FSCAI, FESC

Bifurcation stenting is a very important subset of coronary intervention. A sizable work history has been done by researchers across the globe, including animal experiments, bench-testing and human studies. As a result, techniques have evolved to address this area. Important techniques include provisional T-stenting, crush technique, reverse-crush technique, culottes technique and simultaneous kissing stent (SKS) technique. It is possible to use all these techniques through TRA. We prefer provisional T-stenting, as it is easily reproducible and offers consistent results. The issue of LMCA bifurcation stenting will be discussed separately.



TRA for Addressing Chronic Total Occlusions

Tejas Patel, MD, DM, FACC, FSCAI, FESC

Ramon Quesada, MD, FACP, FACC, FSCAI

Sanjay Shah, MD, DM

Chronic total occlusion (CTO) intervention is a challenging area. The success rate has increased from 60% to almost 90% among experienced operators. This increased success is largely due to the development of procedure-specific hardware, in particular CTO-specific guidewires, balloons, microcatheters and other relevant devices. While TFA is the traditionally preferred approach, in the last decade, many studies have documented feasibility, efficacy and reasonable success rates using TRA. An experienced radialist should be able to achieve an acceptable success rate in practically all subsets of CTO.



TRA for Acute Myocardial Infarction (AMI) Interventions

Tejas Patel, MD, DM, FACC, FSCAI, FESC

Chistopher Pyne, MD, FACC, FSCAI

Sanjay Shah, MD, DM

Samir Pancholy, MD, FACP, FACC, FSCAI

Interventions in AMI have been performed for nearly two decades. This is the only subset offering mortality benefit. Worldwide, TFA has traditionally been the preferred route. Since 1999, studies have been published documenting feasibility, reproducibility and results of TRA in this subset. It is well known that, compared to TFA, TRA generally reduces bleeding and related complications, and is also more economically efficient. These are additional benefits of TRA for AMI interventions, which carry a higher risk of bleeding due to higher intensity of anticoagulation. A recently completed, large, multicenter randomized clinical trial demonstrated a marked survival advantage for STEMI patients treated with TRA compared to the femoral approach. There are certain problems with TRA in this situation, including a learning curve and additional mental pressure on the operator to reduce door-to-balloon time, however they tend to resolve with experience.



TRA for Addressing Renal Artery Stenosis

Tejas Patel, MD, DM, FACC, FSCAI, FESC

Josef Ludwig, MD, PhD

Sanjay Shah, MD, DM

Renal artery stenting (RAS) technique once required the use of large, 8 Fr sheaths or guide catheters to allow the passage of bulky stent systems over 0.035-inch guidewires. It has evolved and, now, contemporary 6 Fr-compatible devices are used over 0.014-inch PTCA guidewires. This revolution in hardware has actually increased the safety and efficacy of RAS, leading to its performance in coronary-like fashion, and to the development of TRA as an effective alternative approach for TFA.



Transradial Approach: Present Status and Future Directions

Mitchell Krucoff, MD, FACC, FAHA, FSCAI, FAPSIC

As evidenced by the growing number of clinical reports, symposia and training programs, and procedural volume, transradial catheterization and intervention (TRI) is rapidly emerging as a widely practiced technique, with progressive advocacy for use as a first-line option rather than for bail-out scenarios. As shown in Tables 1 and 2, which compare and contrast femoral and radial approaches, in the hands of experienced operators, advantages of TRI include • lower bleeding risk, • fewer vascular-access complications, • less post-procedure management, • increased patient comfort and satisfaction, and • potentially lower costs. Despite these perceptions, after more than a decade, uptake of radial technique remains regionally diverse worldwide, with the lowest rates of adoption in some of the world’s largest interventional communities such as the United States. Even within single centers, individual practitioners frequently vary in both perspectives and practices.



How to Develop a Transradial Program

Jennifer Tremmel, MD, MS

Pinak Shah, MD, FACC, FSCAI

Starting a transradial (TR) program within a catheterization laboratory can be a challenging undertaking for operators and catheterization laboratories accustomed to performing procedures via the transfemoral (TF) approach. Any change in catheterization laboratory operations that affects a large number of patients will undoubtedly be met with skepticism given the comfort level achieved by staff and operators with the present standard of care. Such a wholesale change in practice will, of course, come with a loss of efficiency within the laboratory as personnel get used to a new protocol for patient preparation and post-procedure care. Therefore, it is paramount that the physicians leading the transition take a methodical and patient approach to making this change. A haphazard attempt at transitioning to TR access may lead to longer procedure times and potentially increased patient discomfort, which will dampen enthusiasm for continuing with attempts at transition. This chapter will outline important steps that should be taken when starting a TR program in order to increase the likelihood of success and make the transition as seamless as possible.



Same Day, Outpatient Practice Using Transradial Approach

Olivier Bertrand, MD, PhD, FSCAI

Each year, more than 3 million percutaneous coronary interventions (PCI) are performed worldwide, with almost 50% done in the United States. The current outlook estimates that the largest increases in the future will occur in emerging countries such as Brazil, China and India. While the percentages of patients diagnosed with chronic angina have remained stable, catheterization laboratories have been busier, primarily because more patients are being referred for acute coronary syndromes (ACS). This is because fast-track PCI improves ACS outcomes, compared with medical management, as shown in several multicentre international trials. This increased activity in PCI laboratories creates a significant burden for hospital bed turnover and management. With the advent of coronary stents and antithrombotic regimens, PCI have also become much safer than a decade ago. Several other medical disciplines have witnessed the development of outpatient programs, a direct consequence of improved care with planned surgical procedures. Laparoscopic cholecystectomy, eye surgery and selected vascular surgeries under general anesthesia are now performed with same-day discharge. Percutaneous procedures in interventional radiology for renal, peripheral arteries or carotid arteries are also often performed as outpatient practice.