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Objectives for this course:
1- Master the essentials of a successful complex PCI by using the radial approach
2- Essential questions on radial approach and the use of the specific radial device(s)
3- Clinical case strategy and radial approach limits
4- Anatomical variations in the Radial artery.
5- Master the essential steps of a successful radial procedure.

During this lecture, we discuss “The Comparison of Traditional Radial Access and Novel Distal Radial Access for Cardiac Catheterization”

The traditional radial access (TRA) has been used almost routinely in coronary interventions in our clinic. Recently, we have started to use distal radial artery point as distal radial access (DRA) more frequently. The aim of this study is to compare these techniques (DRA and TRA) in terms of their safety, feasibility, and effectiveness.

Recently, the distal transradial access techniques have started to be used in coronary interventions more often. Traditional radial access (TRA) has lower incidence of access-site complications, earlier patient ambulation, decreased patient discomfort, and decreased length of stay in comparison to femoral artery access.

Thus, the popularity of TRA has increased and it is being used for coronary interventions more and more. However, it is known that TRA has certain significant complications, such as radial artery spasm (RAS), radial artery occlusion (RAO), pseudoaneurysm and arteriovenous fistula.

However, the use of TRA is not free of limitations, as the radial artery due to its small diameter is prone to spasm and often presents severe tortuosity which can lead to obligatory crossover to other arterial access, increasing the procedure time and the possibility of complications.

In fact, radial artery occlusion is a common complication with reported rates between 0.8% and 30%, which can preclude the repeated use of the same artery for future coronary interventions, for hemodialysis fistulas preparations or as a coronary artery bypass graft.

Additionally, patients with orthopedic injuries, usually find it difficult to keep their wrist in the supine position needed for TRA, whereas operator's bending over the patient for the left TRA is quite inconvenient especially in cases of obese patients.

In order to overcome these limitations, Kiemeneij has recently proposed the left distal radial access (DRA), via the anatomical snuffbox, as an alternative radial artery cannulation site.

The use of the left radial artery allows catheter placement similar to the femoral artery approach and provides direct access to the left internal mammary artery for angiography in patients with previous coronary artery bypass grafts. The right radial artery has also been criticized for higher radiation as compared to femoral and left radial approach.
Provided the absence of significant subclavian disease and tortuosity, good spasmolytic premedication of the artery, and the use of hydrophilic sheaths, completing the cardiac catheterization from the radial artery is successful.

The major disadvantage of utilizing the left radial is the lack of good ergonomics to the operator, given the need to bend over the patient. Also, the discomfort that may be caused to the patient given their supinated arm across their body during the case.

The Trans-radial approach (TRA) PCI was introduced two decades ago. Trans-ulnar approach has been proposed for elective procedures in patients not suitable for trans-radial approach. The trans-ulnar approach is as safe and effective as the trans-radial approach for coronary angiography and intervention. It is an attractive option for experienced operators who are skilled in this technique, particularly in cases of anatomic variations of the radial artery or weak radial pulse.

Anatomical dissections and radionuclide flow studies of the ulnar and radial arteries at the wrist failed to demonstrate any difference between the anatomical dimensions of these vessels, but the radial artery was shown to have a statistically greater blood flow compared with the ulnar artery.

The possible methods of reaching the coronary vasculature using a percutaneous technique are limitless: radial, femoral, brachial, ulnar, subclavian, and axillary arteries and even direct puncture of the aorta from a translumbar approach, have been utilized in the past.
During 1989 till 1999, percutaneous radial artery approach started to be applied by cardiology interventionists. There was a considerable amount of articles that discussed the conversion to predominantly radial access and its results.


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