Transradial Approach [LEft vs right] aNd procedural Times during percutaneous coronary procedures:...
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Transradial Approach [LEft vs right]
aNd procedural Times during
percutaneous coronary
procedures: TALENT study
ALESSANDRO SCIAHBASI, MD
UO Cardiologia, Policlinico Casilino – ASL RM B,
Rome, Italy
Background
Coronary transradial procedures may be performed through right or left radial artery approach (RRA and LRA respectively)
Most of studies assessing feasibility of the transradial approach have been performed through RRA, but the LRA may have some important anatomical advantages.
Aim of this study was to evaluate safety and efficacy of RRA versus LRA approach in coronary diagnostic and interventional procedures.
PoliclinicoCASILINO
MethodsFrom January 2009 to December 2009 all
patients who underwent percutaneous coronary procedures (diagnostic or PCI)
Exclusion criteria: previous CABG, acute STEMI,
haemodynamic instability, ischemic Allen test.
Right Radial Approach
Left Radial Approach
Policlinico Casilino
Policlinico Gemelli
PoliclinicoCASILINO
Primary end point: fluoroscopy time and the Dose Area Product (DAP) adsorbed by the patients.
Secondary end-points: contrast amount, cannulation time, access shift rate, number of catheters employed, major complications.
A sub-analysis regarding patient’s age and operator’s
skillness (senior compared to fellow) was also pre-specified
Methods
PoliclinicoCASILINO
1540 consecutive patients were randomized to LRA (770) or RRA (770)
1467 patients
735 LRA 732 RRA
Diagnostic Group (coronary angiography)
688 patients
344 LRA 344 RRA
PCI Group (PCI post angiography or stand alone)
Methods
PoliclinicoCASILINO
Results
Right Radial
(n=770)
Left Radial
(n=770)P
Age (years) 65.7 ± 11.2 66.4 ± 10.9 0.27
Sex (Male) 526 (68%) 527 (68%) 0.95
Height (cm) 168 ± 8 168 ± 9 0.94
Weight (Kg) 77 ± 14 77 ± 14 0.95
BMI 27 ± 4 28 ± 4 0.82
Diabetes (%) 208 (27%) 238 (31%) 0.09
Hypertension (%) 539 (70%) 520 (68%) 0.30
Creatinine (mg/dl) 1.05 ± 0.6 1.04 ± 0.5 0.80
GFR (ml/min) 90 ± 36 89 ± 35 0.58
Hemoglobin (g/dl) 13.5 ± 1.7 13.4 ± 1.7 0.88
Mean ± standard deviation; BMI: body mass index, GFR: glomerular filtration rate
PoliclinicoCASILINO
Results
RRA (n= 732)
LRA (n= 735)
168
149
se
co
nd
s
Fluoroscopy time
0
150
170
(32-1238)
(31-1290)
P= 0.0025
12.1
10.7
0
11
13
Dose Area Product (Fluoroscopy)
Gy
/cm
2
(0.9-229)
(0.8-378)
P= 0.004 23.3 23.5
Dose Area Product (Fluorography)
0
20
25
Gy
/cm
2
(6.4-172) (1.9-328)
P= 0.40
Results are expressed as median with range in brackets
Diagnostic Group (n= 1467)
PoliclinicoCASILINO
695
614
Fluoroscopy time
0
600
700
se
co
nd
s
(54-5087)
(62-5653)
P= 0.087
63.1
53.7
Dose Area Product (Fluoroscopy)
0
55
65
Gy
/cm
2
(2.4-1058)
(4.1-784)
P= 0.17
Results are expressed as median with range in brackets
PCI Group (n= 688)
RRA (n= 344)
LRA (n= 344)
37.8 41.5
Dose Area Product (Fluorography)
0
30
50
Gy
/cm
2
(1.8-285) (5.7-307)
P= 0.60
Results
PoliclinicoCASILINO
Right Radial
(n=770)
Left Radial
(n=770)P
Cannulation Time (min)† 5 (2-85) 5 (2-60) 0.27
Cross over to femoral 6 (0.8%) 9 (1.2%) 0.43
Stroke/TIA 1 (0.1%) 0 (0%) 0.31
Subclavian Tortuosity 125 (16%) 65 (8%) <0.001
Coronay angiography
Contrast medium (ml)* 68 ± 35 65 ± 32 0.098
>2 Catheters 84 (11%) 84 (11%) 0.98
Coronary intervention
Contrast medium (ml)* 165 ± 91 160 ± 92 0.44
>1 Catheter 43 (13%) 42 (12%) 0.91
* Mean ± standard deviation; † Median with ranges
Results
PoliclinicoCASILINO
Cross-over to femoral:Incidence and classification
RRA (n= 770)
LRA (n= 770)
Overall 14 puncture and radial failure vs 1 epi-aortic failure, p= 0.0008
Puncture Failure
Lack of radialcanalization
0
1
2
3
4
5
Cas
es
P= 0.41
Radial Failure
Radialtortuosity/anomalies
Severe spasm
P= 0.70
P= 0.31
Epi-Aortic Failure
Subclavian-aortictortuosity
P= 0.31
Results
PoliclinicoCASILINO
0.01 0.1 1 5 10 50
Radial tortuosity
OR=18.5; 95%CI, 6.4-54, p< 0.001
Multivariate analysis
Predictors of cross over to femoral
OR=2.6; 95%CI, 1.8-3.7, p< 0.001
Age >70 years
0.1 0.5 1 2 5 10
Predictors of subclavian tortuosity
OR=2.7; 95%CI, 1.9- 4, p< 0.001
Right radial approach
Results
PoliclinicoCASILINO
Results are expressed as median with range in brackets
Diagnostic Group (n= 1467)
9.39
Dose Area Product (Fluoroscopy)0
5
10
Gy
/cm
2
(0.9-201)
(0.8-197)
P= 0.26
140
132
se
co
nd
s
Fluoroscopy time
0
130
150
(32-1238)
(31-1282)
P= 0.11
SENIOR
RRA (n= 487)
LRA (n= 478)
FELLOW
256
208
0
200
260
se
co
nd
s
(58-1170)
(35-1290)
P= 0.001
Fluoroscopy time
RRA (n= 245)
LRA (n= 257)
22.4
17.3
0
15
30
Gy
/cm
2
(2.2-229)
(1.3-378)
P= 0.002
Dose Area Product (Fluoroscopy)
Results
PoliclinicoCASILINO
Results are expressed as median with range in brackets
Diagnostic Group (n= 1467)
11.1
10.2
Gy
/cm
2
0
10
12
(0.9-193)
(0.8-305)
P= 0.11
158
138
Fluoroscopy time
0
130
160
se
co
nd
s
(32-990)
(32-1282)
P= 0.048
Age <70 years
RRA (n= 430)
LRA (n= 425)
Dose Area Product (Fluoroscopy)
199
171
Fluoroscopy time
0
170
200
se
co
nd
s
(56-1238)
(31-1290)
P= 0.01
14.2
11.2
0
10
15
(1.7-229)
(0.9-378)
P= 0.001
Age ≥70 years
RRA (n= 302)
LRA (n= 310)
Dose Area Product (Fluoroscopy)
Gy
/cm
2
Results
PoliclinicoCASILINO
Conclusions
LRA for coronary angiography and interventions is
associated with slight but significant lower
fluoroscopy time and radiation dose compared to
RRA
The LRA advantage seems to be confined to operators
at the beginning of learning curve (fellows) and to
be more pronounced in older patients
PoliclinicoCASILINO