Download PDF
Kardiologie up2date 2013; 09(04): 307-322
DOI: 10.1055/s-0033-1358998
Koronare Herzerkrankung und Atherosklerose
© Georg Thieme Verlag KG Stuttgart · New York

Radialer Zugang bei Koronarinterventionen

Claudia Walther
,
Catharina Horstmann
,
Christian Hamm
Further Information

Publication History

Publication Date:
13 January 2014 (online)

Also available at
    Permissions and Reprints All articles of this category

Abstract

There is ongoing discussion about the optimal access site for PCI and stent implantation. The transradial access (TRA) is being increasingly used over the past years. Recent studies in patients with acute coronary syndrome (RIVAL study) and in patients with STEMI (RIFLE-STEACS study), revealed a reduced access site-related bleeding and a better cardiovascular outcome in patients with TRA compared to patients with transfemoral access (TFA). This was especially true in high risk patients and in experienced interventionalists in centres with high radial volume. Within this manuscript we will describe the pros and cons of the TRA versus the TF approach as well as current evidence from the literature. In conclusion the TRA should be the favourite and first choice approach for almost all of our patients.

Kernaussagen

  • In der interventionellen Kardiologie spielt der Radialiszugang in den letzten Jahren eine immer wichtigere Rolle.

  • Bei Patienten mit akutem Koronarsyndrom und STEMI (RIVAL-Studie) oder STEMI (RIFLE-STEACS-Studie) waren die zugangsbedingten Blutungskomplikationen und die kardiovaskuläre Morbidität und Mortalität niedriger als bei transfemoral behandelten Patienten. Insbesondere traf diese Beobachtung auf Patienten mit erhöhtem Risiko zu.

  • Die Erfolgs- und Komplikationsrate der Radialisuntersuchung hängt von der Expertise des Untersuchers und dem Volumen der transradialen Untersuchungen/Interventionen/Jahr ab. Das Konsensusdokument einiger Fachgesellschaften fordert einen Curriculum zur transradialen Untersuchung. Um eine Expertise zu bekommen und zu erhalten, sollten mindestens 50 % der Katheteruntersuchungen und Koronarinterventionen pro Jahr transradial durchgeführt werden, mindestens aber 80 Prozeduren pro Untersucher und Jahr.

  • Zu den Komplikationen nach Radialisuntersuchung gehört in bis zu 10 % der Verschluss der A. radialis. Wahrscheinlich ist er noch häufiger, weil er aufgrund der dualen Blutversorgung der Hand über den Arcus palmaris oft asymptomatisch verläuft. Insbesondere die Wahl der Schleusen- und Kathetergröße sowie die postinterventionelle Kompression und Hämostase sind dabei entscheidende Faktoren. Wichtig ist, dass während der Kompression ein Restfluss im Gefäß erhalten bleibt. Die Kompressionsdauer sollte 2 – 4 Stunden nicht überschreiten.

  • Die Dauer der Durchleuchtung und der Prozedur selbst können bei der Radialisuntersuchung länger sein als bei einem transfemoralen Zugang, wobei auch diese Parameter deutlich von der Expertise des Untersuchers abhängen.

  • Insgesamt hat der Radialiszugang in der interventionellen Kardiologie einen hohen Stellenwert und sollte als Routinezugang eingesetzt werden, insbesondere bei Patienten mit akutem Koronarsyndrom oder STEMI.

 

  • Literatur

  • 1 Patel MR, Dehmer GJ, Hirshfeld JW et al. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 appropriateness criteria for coronary revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology. J Am Coll Cardiol 2009; 53: 530-553
    CrossrefPubMedGoogle Scholar
  • 2 Doyle BJ, Rihal CS, Gastineau DA et al. Bleeding, blood transfusion, and increased mortality after percutaneous coronary intervention: implications for contemporary practice. J Am Coll Cardiol 2009; 53: 2019-2027
    CrossrefPubMedGoogle Scholar
  • 3 Eikelboom JW, Mehta SR, Anand SS et al. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation 2006; 114: 774-782
    CrossrefPubMedGoogle Scholar
  • 4 Radner S. Thoracal aortography by catheterization from the radial artery; preliminary report of a new technique. Acta radiol 1948; 29: 178-180
    PubMedGoogle Scholar
  • 5 Kiemeneij F, Laarman GJ, Odekerken D et al. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol 1997; 29: 1269-1275
    CrossrefPubMedGoogle Scholar
  • 6 Mann T, Cubeddu G, Bowen J et al. Stenting in acute coronary syndromes: a comparison of radial versus femoral access sites. J Am Coll Cardiol 1998; 32: 572-576
    CrossrefPubMedGoogle Scholar
  • 7 Romagnoli E, Biondi-Zoccai G, Sciabahsi A et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol 2012; 60: 2481-2489
    CrossrefPubMedGoogle Scholar
  • 8 Jolly SS, Yusuf S, Cairns J et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomized, parallel group, multicenter trial. Lancet 2011; 377: 1409-1420
    CrossrefPubMedGoogle Scholar
  • 9 Mamas MA, Ratib K, Routledge H et al. Influence of Arterial Access Site Selection on Outcomes in Primary Percutaneous Coronary Intervention. J Am Coll Cardiol Intv 2013; 6: 698-706
    CrossrefPubMedGoogle Scholar
  • 10 Hamon M, Pristipino C, DiMario C et al. Consensus document on the radial approach in percutaneous cardiovascular interventions: position paper by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care and Thrombosis oft the European Society of Cardiology. EuroIntervention 2013; 8: 1242-1251
    CrossrefPubMedGoogle Scholar
  • 11 Rao SV, Ou FS, Wang TY et al. Trends in the Prevalence and Outcomes of Radial and Femoral Approaches to Percutaneous Coronary Intervention: A Report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv 2008; 1: 379-386
    CrossrefPubMedGoogle Scholar
  • 12 Karrowni W, Vyas A, Giacomino B et al. Radial Versus Femoral Access for Primary Percutaneous Interventions in ST-Segment Elevation Myocardial Infarction Patients. A Meta-Analysis of Randomized Controlled Trials. J Am Coll Cardiol Intv 2013; 6: 814-823
    CrossrefPubMedGoogle Scholar
  • 13 Agostoni P, Biondi-Zoccai GL, De Benedictis ML et al. Radial Versus Femoral Approach for Percutaneous Coronary Diagnostic and Interventional Procedures Systematic Overview and Meta-Analysis of Randomized Trials. J Am Coll Cardiol 2004; 44: 349-356
    CrossrefPubMedGoogle Scholar
  • 14 Ball WT, Sharieff W, Jolly SS et al. Characterization of operator learning curve for transradial coronary interventions. Circ Cardiovasc Interv 2011; 4: 336-341
    CrossrefPubMedGoogle Scholar
  • 15 Rodríguez-Niedenführ M, Vázquez T, Nearn L et al. Variations of the arterial pattern in the upper limb revisited: a morphological and statistical study, with a review of the literature. J Anat 2001; 199: 547-566
    CrossrefPubMedGoogle Scholar
  • 16 Varenne O, Je'gou A, Cohen R et al. Prevention of Arterial Spasm During Percutaneous Coronary Interventions Through Radial Artery: The SPASM Study. Catheterization and Cardiovascular Interventions 2006; 68: 231-235
    CrossrefPubMedGoogle Scholar
  • 17 Burzotta F, Trani C, Mazzari MA et al. Vascular complications and access crossover in 10,676 transradial percutaneous coronary procedures. Am Heart J 2012; 163: 230-238
    CrossrefPubMedGoogle Scholar
  • 18 Kotowycz MA, Dzavik V. Radial artery patency after transradial catheterization. Circ cardiovasc Interv 2012; 5: 127-133
    CrossrefPubMedGoogle Scholar
  • 19 Uhlemann M, Möbius-Winkler S, Mende M et al. The Leipzig Prospective Vascular Ultrasound Registry in Radial Artery Catheterization Impact of Sheath Size on Vascular Complications. J Am Coll Cardiol Intv 2012; 5: 36-43
    CrossrefPubMedGoogle Scholar
  • 20 Rademakers LM, Laarman GJ. Critical hand ischaemia after transradial cardiac catheterisation: an uncommon complication of a common procedure. Neth Heart J 2012; 20: 372-375
    CrossrefPubMedGoogle Scholar
  • 21 Kotowycz MA, Dzavik V. Radial artery patency after transradial catheterization. Circ cardiovasc Interv 2012; 5: 127-133
    CrossrefPubMedGoogle Scholar
  • 22 Burstein JM, Gidrewicz D, Hutchison SJ et al. Impact of radial artery cannulation for coronary angiography and angioplasty on radial artery function. Am J Cardiol 2007; 99: 457-459
    CrossrefPubMedGoogle Scholar
  • 23 Brancati MF, Burzotta F, Coluccia V et al. The occurrence of radial artery occlusion following catheterization. Expert Rev Cardiovasc Ther 2012; 10: 1287-1295
    CrossrefPubMedGoogle Scholar
  • 24 Rao SV. Observations from a transradial registry. Editorial comment. Our remedies oft in ourselves do lie. J Am Coll Cardiol Intv 2012; 5: 44-46
    CrossrefPubMedGoogle Scholar
  • 25 Pancholy SM, 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: 173-176
    CrossrefPubMedGoogle Scholar
  • 26 Bernat I, Bertrand OF, Rokyta R et al. Efficacy and Safety of Transient Ulnar Artery Compression to Recanalize Acute Radial Artery Occlusion After Transradial Catheterization. Am J Cardiol 2011; 107: 1698-1701
    CrossrefPubMedGoogle Scholar
  • 27 Jang JS, Jin HY, Seo JS et al. The transradial versus the transfemoral approach for primary percutaneous coronary intervention in patients with acute myocardial infarction: a systematic review and meta-analysis. Eurointervention 2012; 8: 501-510
    CrossrefPubMedGoogle Scholar
  • 28 Tizón-Marcos H, Barbeau GR. Incidence of compartment syndrome of the arm in a large series of transradial approach for coronary procedures. J Interv Cardiol 2008; 21: 380-384
    CrossrefPubMedGoogle Scholar
  • 29 Mercuri M, Mehta S, Xie C et al. Radial Artery Access as a Predictor of Increased Radiation Exposure During a Diagnostic Cardiac Catheterization Procedure. J Am Coll Cardiol Intv 2011; 4: 347-352
    CrossrefPubMedGoogle Scholar
  • 30 Jolly SS, Cairns J, Niemela K et al. for the RIVAL Investigators Effect of Radial Versus Femoral Access on Radiation Dose and the Importance of Procedural Volume. A Substudy of the Multicenter Randomized RIVAL Trial. J Am Coll Cardiol Intv 2013; 6: 258-266
    CrossrefPubMedGoogle Scholar
  • 31 Pristipino C, Roncella A, Trani C et al. On behalf of the Prospective REgistry of Vascular Access in Interventions in Lazio region (PREVAIL) study group. Identifying factors that predict the choice and success rate of radial artery catheterisation in contemporary real world cardiology practice: a sub-analysis of the PREVAIL study data. EuroIntervention 2010; 6: 240-246
    CrossrefPubMedGoogle Scholar
  • 32 Iqtidar AF, Jeon C, Rothman R et al. Reduction in operator radiation exposure during transradial catheterization and intervention using a simple lead drape. Am Heart J 2013; 165: 293-298
    CrossrefPubMedGoogle Scholar
  • 33 Amin AP, House JA, Safley DM et al. Costs of transradial percutaneous coronary intervention. JACC Cardiovasc Interv 2013; 6: 827-834
    CrossrefPubMedGoogle Scholar
  • 34 Chase AJ, Fretz EB, Warburton WP et al. The association of arterial access site at angioplasty with transfusion and mortality the M. O. R. T. A. L study: Mortality benefit of Reduced Transfusion after PCI via the Arm or Leg. Heart 2008; 94: 1019-1025
    CrossrefPubMedGoogle Scholar
  • 35 Cooper CJ, El-Shiekh RA, Cohen DJ et al. Effect of transradial access on quality of life and cost of cardiac catheterization. A randomized comparison. Am Heart J 1999; 138: 430-436
    CrossrefPubMedGoogle Scholar
  • 36 Brewster S, Khimdas K, Cleary N et al. Impact of a dedicated “radial lounge” for percutaneous coronary procedures on same-day discharge rates and bed utilization. Am Heart J 2013; 165: 299-302
    CrossrefPubMedGoogle Scholar