As more peripheral interventions become radial, the AHA offers some insights

New advances are propelling a move toward transradial access in the peripheral vascular intervention (PVI) space, but amid optimism and potential benefits for patients, a number of hurdles remain before it becomes a preferred access route, according to a scientific statement by the american. Heart Association.

The authors of the statement say they aimed to include information that is relevant to all members of vascular care teams, particularly in light of the increased interest in radial access for PVI, which is driven by expanding device options in the endovascular treatment of PAD, stroke cerebral, and elective embolization procedures.

Writing Chair Jason C. Kovacic, MBBS, PhD (Icahn School of Medicine at Mount Sinai, New York, NY and Victor Chang Heart Research Institute, Sydney, Australia), said that with so much data for radial use in the coronary field, it is not surprising that interventionalists are increasingly interested in applying the knowledge they have acquired to their PVI procedures.

“What we know from the coronary field is that radial access is preferred by the patient, reduces bleeding complications, is safer, and in some settings can actually improve mortality and significant outcomes,” Kovacic said.

He and his coauthors say the paper comes at a time when radial considerations for PVI are at a stage of evolution comparable to what they were for coronary interventions between about 2005 and 2010.

Technology and technique

Published online 4 December 2024, ahead of print in Circulation: cardiovascular interventions, the AHA document outlines a number of technical considerations when choosing radial access and anticipated benefits that would improve existing procedures and patient care.

Delving into the available literature, Kovacic and colleagues examine the anatomic location of the target lesion and the characteristics of the lesion that favor opting for a transradial approach, as well as considerations for using a left or right approach.

Another important consideration when applying radial access to PVI is sheath dimensions, which are often larger than what would be used in coronary procedures and may present a potential for complications ranging from minor hematoma and spasm of the radial artery to perforation artery, hand ischemia and compartment syndrome. . The paper reviews known predictors of more common complications, as well as technical needs and preparation tips.

In neurovascular interventions, the writing group says the literature is evolving rapidly, particularly with the availability of smaller devices, including a sheathless balloon guiding catheter for radial access in cases of stroke thrombectomy.

Treatment of iatrogenic embolism is an area where the committee says research is needed to understand the optimal site of access to minimize cerebral infarcts hidden on diffusion-weighted magnetic resonance imaging (DWI). Once considered insignificant, they are increasingly recognized as contributors to negative long-term outcomes. Whether the radial approach can reduce the risk compared to the femoral approach is an important consideration, according to Kovacic and colleagues.

Beyond the Periphery

Additional endovascular procedures that are covered in the AHA paper include renal, mesenteric, uterine, and other artery interventions in the abdomen or pelvis, with a discussion of the advantages and disadvantages of femoral and radial access for each.

A section of the statement on lower extremity interventions reviews what is known about radial versus femoral and pedal access in terms of technical success, complications, and radiation use. The authors note that in TRIACCES In the study, radial and pedal access were associated with fewer access site complications than femoral access, while pedal access was associated with a reduction in radiation exposure.

Radiation is discussed several times in the document and is a significant consideration in peripheral procedures because, compared to coronary procedures, they may lend themselves to more radiation and longer exposure times due to the often complex nature of lesions in PAD and chronic limbs. threatening ischemia.

But for TCTMD, Kovacic said that radial access is not automatically associated with more radiation for operators.

“We mention in two places the option of a feet-first patient position (with radial access, then possible via the L-arm in an abducted position) – this can reduce radiation exposure compared to a head-first patient position,” a he said in an email.

He also pointed to a warning from the AHA writing committee that additional clinical trials and randomized trials are needed to investigate “the different steps and indications of new techniques in transradial arterial access for PVI. The primary aim is to claim reduced access site complications and shortened ambulation times compared to transfemoral arterial access. Enhanced radiation safety could be another goal.”

For care teams that don’t see a lot of radial access procedures for PVI, the paper suggests “brief refresher cross-training on transradial arterial access and closure with the interventional cardiology team,” including physicians, nurses, technicians.

Finally, the committee concludes that practical challenges will need to be addressed in the design of future studies that include radial access in PVI.

“These include choosing the best outcome measure (eg, access site complications, brain hits on DWI). Additionally, study enrollment may become difficult because the increasing number of proceduralists performing high-volume PVIs with transradial-arterial access may be reluctant to randomize patients to (a transfemoral approach),” they write.