Catheterization and Cardiovascular Diagnosis 39:371 (1996)

Editorial Comment

Coronary Angiography by the Left Radial Approach: A Limited But Useful Technique

David A. Clark, MD Diagnostic and lnterventional Cardiology Stanford, California

Radial artery cannulation has long been recognized as a safe and efficacious entry site to the human arterial system. Articles by Bedford [ 11 and Slogoff et al. [2] concluded that long-term radial artery cannulation for pressure monitoring in critical care patients is generally free of serious sequelae. Campeau [3] reported a re- markably low complication rate in 1 0 0 patients undergoing per- cutaneous coronary angioplasty by the right radial artery approach utilizing two important techniques: a 23-cm-long sheath to prevent radial artery spasm during catheter changes, and the administration of 5,000 units of heparin through the side arm of the sheath.

The present article by Spaulding et al. presents a prospective study of the left radial approach for coronary angiography. Uti- lizing the left radial artery has an important advantage over the right radial approach, namely, the ability to successfully cannulate the coronary arteries using kinder, gentler Judkins shape catheters. The ability to use Judkins catheters should both increase proce- dural success with less procedural time and decrease trauma to the radial, brachial, and subclavian systems during catheter insertion. Two strong selection criteria for patients selected for the per-

cutaneous radial approach are clear: a palpable ulnar pulse, and a normal Allen test. As suggested by earlier reports, the adminis- tration of 5,000 IU of heparin is critical to prevent radial artery

occlusion, a fact that the current report confirms. This prospective study clearly indicates that the longer procedural times and fluo- roscopy times and the increased procedural failure rate (vs. the percutaneous femoral approach) should improve with operator ex- perience.

There is probably little advantage to this technique over the Sones cutdown technique in laboratories with practitioners well- trained in the Sones technique. But for practitioners with little or no formal training in the Sones technique, the left radial approach may well offer the best alternative for an upper extremity approach for coronary angiography and angioplasty . Since this technique would potentially be limited (given the greater ease and success in general of the transfemoral approach), the aspiration to high-qual- ity care in any given laboratory would dictate that an adequate number of procedures by this approach be performed by each credentialed physician, to assure both attainment and maintenance of competence and to provide safe patient care. The selection criteria (presence of ulnar pulse and a normal Allen test) and the intraprocedural technique (use of a long sheath and administration of 5,000 IU of heparin) should be mandated as standard procedural technique for each case.

With proper training and experience, the left radial approach for coronary angiography can be useful as an upper extremity ap- proach for coronary studies in a non-Sones laboratory.

REFERENCES

1. Bedford RF: Long-term radial artery cannulation: Effects on sub-

2. Slogoff S, Keats AS, Arlund C On the safety of radial artery

3. Campeau L: Percutaneous radial artery approach for coronary

sequent vessel function. Crit Care Med 6:64-67, 1978.

cannulation. Anesthesiology 59:42-47, 1983.

angiography. Cathet Cardiovasc Diagn 16:3-7, 1989.

0 1996 Wiley-Liss, Inc.