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Background Recently, several meta-analyses of randomized controlled trials (RCTs) have shown that transradial access (TRA) reduces mortality compared to transfemoral access (TFA). However, a critical appraisal of these RCTs suggests that the findings could have resulted from a greater incidence of adverse events in the TFA groups rather than a beneficial effect of TRA. Methods Scientific databases and websites were searched for RCTs. Patients were divided into groups based on access type and whether the operator was a radial expert (RE) or non-radial expert (NRE). The groups were TFA-RE, TFA-NRE, TRA-RE, and TRA-NRE. Both a traditional meta-analysis and a network meta-analysis using mixed-treatment comparison models were performed. Results Data from 13 trials including 15,615 patients were analyzed. The mortality rate for TFA-RE (3.54%) was more than double compared to TFA-NRE (1.61%). In pairwise meta-analysis, TFA-RE was associated with increased risk of mortality (RR: 1.72, 95% CI: 1.13–2.62; p = 0.011) compared to TFA-NRE. In subgroup analysis, TFA-RE was associated with increased mortality (RR: 1.70, 95% CI: 1.24–2.34; p = 0.001) compared to TRA, but TRA-NRE was not. Similarly, in mixed comparison models, TFA-RE was associated with increased mortality compared to TRA-NRE, TRA-RE, and TFA-NRE, but TFA-NRE was not, compared to TRA-RE and TRA-NRE. Conclusion Recently-reported survival differences between TRA and TFA may have been driven by adverse events in the TFA groups of the RCTs rather than a beneficial effect of TRA. This issue needs further investigation before labeling radial access a lifesaving procedure in invasively-managed patients with ACS. [ABSTRACT FROM AUTHOR]

Background The transradial route has become the primary approach for coronary angiography with the presence of radial artery anomalies found to be 10–20%. There has been limited study on the influence of these anomalies on procedural pain. Our aims were to determine local prevalence of the high radial origin (HRO) anatomical variant; to investigate factors influencing transradial procedural pain; and to determine if HRO specifically was associated with increased pain. Methods Radial artery anatomy was characterized by arteriography in sequential patients undergoing angiography. Patients were asked to mark their perceived procedural pain on a visual analog scale, which was converted to a pain score. Results 382 patients were enrolled, 5 were excluded. There were 259 males (68.7%) and 118 females (31.3%). HRO was present in 51 patients (13.5%). Overall mean pain score was 2.6 (SD 2.5). HRO was associated with a higher mean pain score than normal anatomy (3.3 (SD 2.9) vs. 2.4 (SD 2.4) p = 0.027). HRO was not associated with increased procedural failure, screening time or procedure time. When pain score was dichotomized into mild pain (< 4.0) and moderate-to-severe pain (≥ 4.0), HRO was associated with almost double the frequency of moderate-to-severe pain (37.2% vs. 21.1%, p = 0.012). Using a logistic regression model, only female gender, younger age and HRO remained significant predictors of moderate-to-severe pain. Conclusions There was significantly increased pain in patients with HRO without increased procedure/screening time or procedural failure. Female gender and younger age were also found to be significant predictors of increased pain. [ABSTRACT FROM AUTHOR]

Background Radial artery occlusion (RAO) remains the Achilles' heel of transradial coronary procedures. Standard over lower systemic anticoagulation levels are believed to reduce RAO rates but this is ill-supported by scientific evidence. We compared whether standard in comparison with less intensive anticoagulation was superior in preventing vessel closure. Methods and results The two arms of this analysis included 731 pooled patients with the same inclusion and exclusion criteria. We assessed forearm arterial access site occlusion rate by unfractionated heparin (UFH) dose in an individual participant data meta-analysis of this randomized study and of consecutive eligible patients from our previous trial. We randomized 308 consecutive patients undergoing transradial coronary angiography with 5 French (5Fr) catheters without need to crossover to receive 2500 or 5000 UFH units. The primary end-point was the ultrasonographically determined vessel occlusion rate. Incident RAOs in the randomized arm were 15.9% vs. 14%, in the low and standard UFH dose, respectively (p = 0.7). Corresponding figures for forearm arterial occlusion rates in the pooled population were 13.0% vs. 9.9% (relative risk: 1.3, 95% confidence interval -- CI: 0.88-1.98; p = 0.2). Procedural and fluoroscopy duration was less than 15 and 3 min, respectively. The mean UFH dose difference was 3.52 (95% CI: - 0.45 to 7.49) units per kilo body weight between occluded (n = 84) and patent forearm arteries (n = 647); (p = 0.053). Conclusions Incident forearm arterial occlusions were high despite using 5Fr catheters for a short-lasting procedure. Systemic anticoagulation with standard over lower UFH dose did not reduce the frequency of RAOs after coronary angiography. [ABSTRACT FROM AUTHOR]

Objective The aim of this study is to evaluate the efficacy and safety of two doses of heparin, a low dose (2500 IU) and a standard dose (5000 IU) in patients who underwent transradial coronary angiography (TRCAG). Methods A total of 459 consecutive patients were included in the present study, 217 in the 2500-IU heparin group and 242 in the 5000-IU heparin group. Radial artery patency was evaluated one month after the TRCAG with Doppler ultrasonography. Results The RAO was observed in 15 (3.3%) patients. The RAO was significantly higher in 2500 IU heparin group than 5000 IU heparin group (5.5% vs 1.2% p = 0.010, respectively). Female gender (Odds ratio (OR) = 66.135, p = 0.002, 95% confidence interval (CI) = 4.584-954.131), sheath removal time (OR = 1.496, p < 0.001, 95% CI = 1.254-1.784) and administration of 2500 IU heparin (OR = 9.758, p = 0.034, 95% CI = 1.195-79.695) were the independent predictors of RAO in multivariate regression analysis. While the presence of hypertension was independently associated with radial artery patency in multivariate regression analysis (OR = 0.022, p = 0.005, 95% CI = 0.002-0.307). Conclusion The patients in the standard dose heparin group had lower RAO rates compared to low dose group in this study. This suggests that using the current technique, standard dose of heparin is still required for transradial diagnostic angiography. [ABSTRACT FROM AUTHOR]

Abstract: Background: Radial artery access is a mainstay in the diagnosis and treatment of coronary artery disease. However, there is uncertainty on the comparison of right versus left radial access for coronary procedures. We thus undertook a systematic review and meta-analysis comparing right versus left radial access for coronary diagnostic and interventional procedures. Methods: Pertinent studies were searched in CENTRAL, Google Scholar, MEDLINE/PubMed, and Scopus, together with international conference proceedings. Randomized trials comparing right versus left radial (or ulnar) access for coronary diagnostic or interventional procedures were included. Risk ratios (RR) and weighted mean differences (WMD) were computed to generate point estimates (95% confidence intervals). Results: A total of 5 trials (3210 patients) were included. No overall significant differences were found comparing right versus left radial access in terms of procedural time (WMD=0.99 [−0.53; 2.51]min, p=0.20), contrast use (WMD=1.71 [−1.32; 4.74]mL, p=0.27), fluoroscopy time (WMD=−35.79 [−3.54; 75.12]s, p=0.07) or any major complication (RR=2.00 [0.75; 5.31], p=0.49). However, right radial access was fraught with a significantly higher risk of failure leading to cross-over to femoral access (RR=1.65 [1.18; 2.30], p=0.003) in comparison to left radial access. Conclusions: Right and left radial accesses appear largely similar in their overall procedural and clinical performance during transradial diagnostic or interventional procedures. Nonetheless, left radial access can be recommended especially during the learning curve phase to reduce femoral cross-overs. [Copyright &y& Elsevier]

Abstract: Background: Transradial access (RA) is associated with less complications and is preferred by patients. Vascular closure devices (VCDs) may improve discomfort and may reduce complications associated with transfemoral access. Aim was to evaluate complications and discomfort associated with percutaneous coronary procedures employing RA or VCDs. Methods: We enrolled 1492 consecutive patients who underwent percutaneous coronary procedures with RA (604 procedures), femoral approach with manual compression (MC) (276 procedures), or with either Angioseal™ (311 procedures) or Starclose™ (301 procedures) closure device. Discomfort was assessed using procedure-specific questions. Major vascular complications were evaluated during hospitalization. Results: RA significantly reduced major complications (0.7%) compared to either the MC (2.9%, p =0.03) or the VCDs (Starclose™ 2.7%, Angioseal™ 3.9%, p =0.003). There were no significant differences in major complications between MC and either the Angioseal™ or the Starclose™. At multivariate analysis the RA was predictor of reduced complications (OR 0.26, 95% CI 0.08–0.85, p =0.03 vs MC, and OR 0.19, 95% CI 0.07–0.57, p =0.003 vs VCDs). The RA was associated with a significant reduction in procedural discomfort with 44.2% of patients referring no discomfort (p <0.0001). Starclose™ and Angioseal™ were better tolerated than MC (27.8%, 29.3% and 8.9% patients respectively without discomfort, p <0.0001). Conclusions: RA is associated with a significant reduction in major vascular complications compared to femoral approach even if two different VCDs are employed. VCDs are better tolerated than MC but the RA was associated with the lowest discomfort. [Copyright &y& Elsevier]

Coronary artery anomalies (CAAs) are a rare angiographic finding, sometimes associated with acute coronary events. We report on a case of primary angioplasty for inferior acute myocardial infarction (AMI) in a 66-year-old woman with a solitary coronary ostium in the right Sinus of Valsalva and a “superdominant” right coronary artery. We also discuss two potential pitfalls of primary angioplasty: correct interpretation of coronary anatomy and approach to challenging lesions. [Copyright &y& Elsevier]

Abstract: There have been reports of local sterile inflammatory reactions with the use of Cook hydrophilic-coated sheaths (HCS) for transradial coronary angiography/intervention. Our aim was to gauge the extent of radial artery access site complications following radial artery canulation and to compare the incidence of such complications with HCS versus non-coated sheaths in our hospital. We undertook a retrospective questionnaire-based postal study, receiving replies from 1283 patients who had transradial coronary angiography/percutaneous coronary intervention in our institution between Feb 2005 and Oct 2006. HCS had been used in 856 of these patients. Patients reported adverse local reactions at the access site in 12.9% of cases, including pain (57.2%), swelling (27.7%) and non-specific sensory abnormalities (13.2%). A total of 5.0% of patients sought medical help for their problem, mainly (78.1%) from their general practitioner. The use of a HCS compared to a non-coated sheath was associated with a significant excess of patient-reported adverse reactions (14.6% vs. 9.6%, p =0.015). A logistic regression analysis confirmed that the use of a hydrophilic sheath (OR 1.5, (1.05–2.26)) and female gender (OR 1.9, (1.4–2.8)), were independent predictors of self-reported adverse outcomes after controlling for possible confounders. [Copyright &y& Elsevier]

Abstract: A sterile inflammatory response has been observed at the access site in a small number of patients who have undergone radial artery cannulation with a hydrophilic sheath. This reaction generally appears from several days to weeks after use of the sheath, and while a distinct cause has not been established it is not thought to be due to infection. This particular risk of use of hydrophilic radial sheaths must therefore be weighed against its potential benefits. [Copyright &y& Elsevier]