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J O U R N A L O F T H E AM E R I C A N C O L L E G E O F C A R D I O L O G Y VO L . 7 1 , N O . 1 0 , 2 0 1 8

ª 2 0 1 8 B Y T H E AM E R I C A N C O L L E G E O F C A R D I O L O G Y F O UN DA T I O N

P U B L I S H E D B Y E L S E V I E R

REVIEW TOPIC OF THE WEEK

The Radial Artery for PercutaneousCoronary Procedures or Surgery?

Mario Gaudino, MD,a Francesco Burzotta, MD, PHD,b Faisal Bakaeen, MD,c Olivier Bertrand, MD,d Filippo Crea, MD,b

Antonino Di Franco, MD,a Stephen Fremes, MD,e Ferdinand Kiemeneij, MD, PHD,f Yves Louvard, MD,g

Sunil V. Rao, MD,h Thomas A. Schwann, MD,i James Tatoulis, MD,j Robert F. Tranbaugh, MD,a

Carlo Trani, MD, PHD,b Marco Valgimigli, MD, PHD,k Pascal Vranckx, MD, PHD,l David P. Taggart, MD, PHD,m

for the Arterial Grafting International Consortium Alliance

ABSTRACT

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This article summarizes the current research on the benefits of using the transradial approach for percutaneous procedures

and the radial artery as a conduit for coronary artery bypass surgery. Based on the available evidence, the authors provide

recommendations for the use of the radial artery in patients undergoing percutaneous or surgical coronary procedures.

(J Am Coll Cardiol 2018;71:1167–75) © 2018 by the American College of Cardiology Foundation.

R ecently, there has been renewed interest inthe radial artery (RA) both for cardiovascularsurgery and for percutaneous intervention.

Among surgeons, the publication of long-termfollow-up data and randomized comparative studieshas established the role of the RA as a more durablegraft than the saphenous vein (SV) for coronary arterybypass operations (CABG) (1). Among cardiologists,transradial access (TRA) has been shown to be a supe-rior alternative to the classic femoral approach fordiagnostic catheterization and percutaneous inter-ventions (2–6), and TRA procedures have becomeincreasingly popular. This convergence of interests,however, has elicited concerns that, after TRA, theRA may not be a suitable CABG conduit due tocatheter-induced trauma predisposing to premature

N 0735-1097/$36.00

m the aDepartment of Cardiothoracic Surgery, Weill Cornell Medicine, N

ore, Rome, Italy; cCleveland Clinic, Cleveland, Ohio; dQuebec Heart and Lu

art Centre, Sunnybrook Health Science, University of Toronto, Toronto, On

dical Center, Lelystad, the Netherlands; gInstitut Cardiovasculaire Paris

nical Research Institute, Durham, North Carolina; iUniversity of Toled

spital, Melbourne, Victoria, Australia; kSwiss Cardiovascular Center, Bern

sselt and Faculty of Medicine and Life Sciences Hasselt University, Jessa Z

ford, Oxford, United Kingdom. Dr. Burzotta has received speakers and co

o has served as a consultant for Medtronic and Terumo. Dr. Trani has rece

d Terumo; and consultant fees from Biotronik. All other authors have rep

tents of this paper to disclose. Drs. Gaudino and Burzotta contributed eq

ck, MD, served as Guest Editor for this paper.

nuscript received October 31, 2017; revised manuscript received January

graft failure and mitigating long-term survivalbenefits (7).

To date there are no guidelines for the approach tothe RA in patients with known or possible coronaryartery disease (8). In this paper, we provide guidancefor the use of the TRA approach for percutaneousintervention based on the best evidence and use ofthe RA as a conduit for CABG and suggest recom-mendations for optimal use of the RA in patients withcoronary artery disease.

METHODS

WRITING PANEL. A writing panel was organized byconvening 17 physicians from the fields of clinicalcardiology (n ¼ 2), cardiothoracic surgery (n ¼ 7), and

https://doi.org/10.1016/j.jacc.2018.01.013

ew York, New York; bUniversità Cattolica Del Sacro

ng Institute, Quebec City, Quebec, Canada; eSchulich

tario, Canada; fDepartment of Cardiology, Zuiderzee

Sud, Hopital Jacques Cartier, Massy, France; hDuke

o Medical Center, Toledo, Ohio; jRoyal Melbourne

University Hospital, Bern, Switzerland; lHartcentrum

iekenhuis, Hasselt, Belgium; and the mUniversity of

nsultant fees from Abbott and St. Jude Medical. Dr.

ived speaker fees from Medtronic, Abbott, Abiomed,

orted that they have no relationships relevant to the

ually to this work and are joint first authors. Michael

4, 2018, accepted January 5, 2018.

ABBR EV I A T I ON S

AND ACRONYMS

CABG = coronary artery bypass

operations

CAD = coronary artery disease

PCI = percutaneous coronary

intervention

RA = radial artery

RCT = randomized controlled

trial

RITA = right internal thoracic

artery

SV = saphenous vein

TFA = transfemoral approach

TRA = transradial access

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interventional cardiology (n ¼ 8), highlyexperienced in the use of the RA for CABG orTRA. The members of the panel agreed toreview the best available research and toprovide a document with recommendations.Treatment algorithms were drafted whengeneral agreement among panelists wasreached.

SEARCH METHOD. In August 2017, acomprehensive search to identify studiesthat evaluated the use of the RA for TRA andCABG was performed in the following data-bases from inception to present: Ovid MED-LINE, Ovid EMBASE, and the CochraneLibrary (Cochrane Database of Systematic

Reviews, Cochrane Central Register of ControlledTrials [CENTRAL], and Cochrane Methodology Reg-ister). Search keywords included “radial artery” incombination with “coronary surgery,” “myocardialrevascularization,” “coronary artery bypass,” “coro-nary angiography,” and “percutaneous coronary in-terventions.” Relevant abstracts were reviewed, andthe related articles function was used for all includedpapers. References for all selected studies were cross-checked. The writing groups selected the most rele-vant papers according to both methodological andclinical considerations. Observational series wereconsidered only in the absence of data from ran-domized controlled trials (RCTs). Details of the searchare given in Online Figure 1.

USE OF THE RADIAL ARTERY FOR TRANSRADIAL

PROCEDURES. Due to the superficial position andeasy compressibility of the RA, TRA has been devel-oped as an alternative to the conventional trans-femoral approach (TFA) to reduce the risk ofprocedure-related vascular complications.

A limitation of TRA is the higher crossover ratethan that of the TFA, particularly during the learningcurve (2,3). However, the crossover rate declinessignificantly with operator’s experience (3). Cross-overs are generally due to the smaller size, the widerange of anatomic variations, and the high suscepti-bility to spasm of the RA (Online Table 1) (4).

The assessment of the adequacy of the ulnarcollateral circulation has been conventionallyconsidered necessary before TRA. However, recentfindings suggest that the patency of the palmar archesis highly dynamic and that the vascular reserve of thehand circulation can be recruited during and afterTRA, even in patients with poor collateral circulationat baseline (5). The safety of using the TRA withoutprevious evaluation of the ulnar collateral circulation

has been recently shown in a large cohort of patientswith acute coronary syndromes (6).

BENEFITS OF USING THE TRA FOR ANGIOGRAPHY

AND PERCUTANEOUS INTERVENTIONS. Random-ized and observational studies have shown that theuse of the TRA significantly reduces vascular accesssite complications and bleeding compared to the TFA.A meta-analysis of >600,000 patients from bothobservational and randomized trials comparing TRAand TFA found that radial access was associated witha 78% reduction in major bleeding and an 80%reduction in post-procedure transfusions (9). Threeprospective randomized trials comparing TRA withTFA in the setting of acute coronary syndromesconsistently showed that TRA reduced majorbleeding, major adverse cardiovascular events, andmortality (6,9,10). The reduction in major vascularcomplications with TRA has been similar for patientsundergoing angiography and percutaneous coronaryintervention (PCI) (10). Some data suggest that thebenefits of the TRA in terms of mortality, but not ofbleeding and vascular complications, are significantlyinfluenced by operator experience (6).

The TRA is also associated with benefits in patientsatisfaction, catheter laboratory throughput, andcosts. It has been shown that patients prefer TRA overTFA (11). The enhanced recovery associated with TRAincreases catheter laboratory efficiency and same-daydischarge, leading to significant savings for the healthsystem. A large contemporary observational studyshowed that adoption of TRA can save $3,689 perprocedure. Combining TRA and same-day dischargehas the potential to save $300 million per year in theUnited States (12).

TRA IN SPECIFIC PATIENTS’ SUBSETS. The advan-tages of the TRAhave been confirmed in the elderly (6).However, elderly patients have more complexvascular anatomy, and the TRA may be more chal-lenging in this population. In case of elderly patientspresenting with ST-segment elevation myocardialinfarction, the use of TRA has been shown to be asso-ciated with a significantly reduced risk of stroke andlower rate of vascular complications andmortality (13).

Adoption of the TRA has been shown to be asso-ciated with clinical benefits in patients with chronicrenal disease, particularly in terms of reduction ofpost-procedural acute kidney injury (14). However,the possible need for an upper extremity arteriove-nous fistula for dialysis is a possible argument againstthe use of the TRA in this group of patients.

In patients with a previous CABG, the use of theTRA requires dedicated skills and techniques (15). In

TABLE 1 Clinical and Procedural Characteristics Associated With

Post-Catheterization Radial Artery Occlusion

EarlyOcclusion

LateOcclusion

Clinical characteristics (Online Ref. #)

Age (1,2) X

Female sex (1,2) X

Smaller body weight (1,3,4) X

Small radial artery size (4) X

No statin therapy at the time ofcatheterization (5)

X

Peripheral artery disease (2) X

Diabetes (6) X

Present or former smoking habit (7,8) X

Procedural characteristics (Online Ref. #)

Sheath-to-artery ratio $1 (2,9,10) X

No use of hydrophilic sheaths (2,11) X

No use of appropriate anticoagulation(heparin >50 IU/kg) (12–16)

X

No use of patent hemostasis technique (1) X

Prolonged post-procedure high-pressurecompression (17)

X X

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the RADIAL-CABG (Radial Versus Femoral Access forCoronary Artery Bypass Graft Angiography andIntervention) trial, the TRA was associated withgreater use of contrast, longer procedure time,greater access cross-over, and increased operatorexposure to radiation than TFA (16). However, thistrial was not conducted in a high-RA use center, and ina meta-analysis of 9 studies in CABG patients, the useof the TRAwas associatedwith lower risk of access-sitecomplications, similar procedural and fluoroscopytimes, and higher rate of cross-over than TFA (17).

Caution should be used when using the TRA inpatients with severe hemodynamic compromise dueto the usually longer delay in initiation of coronaryintervention. On the other hand, the reductionin access site complications associated with theTRA can be particularly important for critically illpatients. A recent multicenter study in patientsundergoing high-risk PCI found that the use of theTRA was associated with a significant reduction inadverse clinical events compared to the TFA (18).Of note, due to the very high-risk clinical scenario,the possibility of a treatment allocation bias withmore experienced operators using the TRA cannotbe excluded.

EFFECT OF TRA ON THE RADIAL ARTERY. In a meta-analysis of 66 studies and >31,000 patients, theincidence of RA occlusion after TRA was found to be7.7% at 1 day and 5.5% at >7 days after the procedure(19). Of note, late RA occlusion occurring weeks ormonths after TRA has also been described. RA oc-clusion is usually asymptomatic due to the dual blood

supply to the hand. However, sporadic cases of suc-cessful treatment of symptomatic occlusion after TRAhave been reported (20).

As intra-arterial thrombosis plays a major role indetermining RA occlusion, the use of anticoagulationand modified compression techniques has beenshown to significantly reduce its incidence after TRA,with series reporting RA occlusion rate as low as 1% to2% (19). Distal RA access has also been proposed (21).A list of the possible factors contributing to occlusionis presented in Table 1.

The effect of the TRA on the vascular wall andfunction of the RA has been recently summarized in areview article (8). Studies using histologic and high-resolution intravascular imaging have shown thatthe use of the TRA is associated with a high incidenceof endothelial damage and a lower but not negligiblerate of medial dissection (Figure 1) (8,22). Of note, thevessel wall damage is higher in the distal part of theRA, but it is evident even in the proximal portion ofthe artery (8). The functional counterpart of the his-tologic damage is a significant reduction ofendothelium-dependent vasodilation and a nonsig-nificant impairment of endothelium-independentvasodilation as shown by Antonopoulos et al. (23) ina recent meta-analysis. The impairment in vaso-dilatory function may persist for several months afterTRA, and to date, no clear evidence of a return tobaseline function with the time exists.

Chronic intimal thickening occurs in a high pro-portion of patients after TRA, with histologic studiesreporting intimal hyperplasia in 60% to 70% of cases(8). RA spasm occurs frequently during TRA. A recentreview of the studies reported that the mean inci-dence of RA spasm after TRA is 14.7% (24). Endothe-lial dysfunction does not predict RA spasm, whereasartery sheath mismatch is a strong risk factor (25).Reduction of mechanical friction between the sheathand catheter and the arterial wall by hydrophiliccoatings and use of pharmacologic vasodilation withnitroglycerin or verapamil or a combination of the 2agents may significantly reduce RA spasm. Pressure-mediated dilation is a new and promising RA vaso-dilator strategy (26).

EVALUATION AND HARVESTING OF THE RADIAL

ARTERY FOR CABG. There is no formal agreement onthe best method to pre-operatively evaluate the RAfor CABG. The adequacy of ulnar collateral flow canbe assessed using the clinical Allen test, but manysurgeons prefer to rely on a more objective method(Doppler ultrasonography, oximetry, or plethysmog-raphy) (27). Many authors also advocate ultrasonog-raphy of the artery to evaluate calcification and

FIGURE 1 Optical Coherence Tomography Documentation of Different Radial Artery Damages Induced by Catheterization

(A) Radial artery spasm documented at procedure’s end. (B) Radial artery intimal tear documented at procedure’s end. (C) Radial artery media

dissection documented at procedure’s end. (D) Radial artery intima thickening documented 6 months after a first transradial procedure.

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diameter. Diffuse calcification, diameter <2.0 mm,Raynaud phenomenon, collagen vascular diseases,poor ulnar collateral flow, and major forearm traumaare considered contraindications to use of RA.Caution is recommended in patients with renal failuredue to the potential need for dialysis access. In pub-lished CABG series, the percentage of RA judgedinadequate for use ranges from 5% to 15% (27).Although RA harvesting from the nondominant armhas conventionally been recommended, harvestingfrom the dominant or bilateral arm is also performed(25). The left RA is the RA of choice for most surgeonsas it can be more easily harvested simultaneouslywith harvesting of the left internal thoracic artery.Endoscopic harvest as opposed to open harvest canalso be used with similar clinical and angiographicoutcomes (28). The overall incidence of local com-plications including wound infection or dehiscence

and permanent neurological deficits after RA har-vesting is <1%, and reports of ischemic hand com-plications are exceedingly rare (27).

COMPARISON BETWEEN THE RADIAL ARTERY AND

THE SAPHENOUS VEIN. Three large RCTs havedirectly compared the patency of RA and SV graftsused for CABG (Table 2). The 2 trials that extendedfollow-up beyond the first postoperative year foundsignificantly higher patency for the RA. Six meta-analyses summarized the results of these and othersmaller comparative RCTs. In all analyses with amean follow-up >1 year, the use of the RA was asso-ciated with a significantly lower incidence of graftfailure (Table 3).

All the RCTs had primary angiographic outcomesand were individually underpowered to detect dif-ferences in clinical outcomes. A meta-analysis of all

TABLE 2 Randomized Trials With Sample Size >100 Grafts Comparing the Patency Rate

of the Radial Artery With That of the Saphenous Vein

Trial/YearNumber of

Grafts RestudiedMean

Follow-Up Main Finding

RSVP/2008 134 5 yrs Better patency rate for the RA (p ¼ 0.004)

VA/2011 266 1 yr No difference in patency (p ¼ 0.98)

RAPS/2012 269 7.7 yrs Better patency rate for the RA (p ¼ 0.002)

RA ¼ radial artery; RAPS ¼ Radial Artery Patency Study; RSVP ¼ Radial Artery Versus Saphenous Vein Patencytrial; VA ¼ Veterans Affairs trial.

TABLE 3 Meta-Analyses of Randomized Trials Comparing the Patency Rate of the Radial

Artery With That of the Saphenous Vein

First Author(Online Ref. #), Year

Number ofPatients/Grafts

Follow-Up,yrs Main Finding

Benedetto (1), 2010 936 mean 1.8 No difference in patency

Hu (2), 2011 3,889 1–6 Better patency rate for the RA(RR: 0.51; 95% CI: 0.41–0.63)

Athanasiou (3), 2011 1,157 >5 Lower patency rate for the SV(OR: 2.28; 95% CI: 1.32–3.94)

Cao (4), 2013 1,708 >4 Better patency rate for the RA(OR: 0.31; 95% CI: 0.14–0.68)

Zhang et al. (5), 2014 1,860 1.7–7 Better patency rate for the RA(OR: 0.52; 95% CI: 0.37–0.73)

Benedetto et al. (6),2015

2,780 1.7–7 Lower patency rate for the SV(OR: 2.36; 95% CI: 1.37–4.06)

CI ¼ confidence interval; OR ¼ odds ratio; RA ¼ radial artery; RR ¼ relative risk; SV ¼ saphenous vein.

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published RCTs found significantly lower rate ofrepeat revascularization and a trend toward reducedincidence of cardiac death and myocardial infarctionin the RA group (29). Due to the small number ofpostoperative events in CABG patients in the modernera, it is likely that even this pooled analysis wasunderpowered to detect survival differences.

A meta-analysis of the observational reportscomparing the RA and the SV is summarized inFigure 2. The use of the RA was associated withsimilar operative risk and a highly significant 26%relative risk reduction in long-term mortalitycompared to the use of the SV.

COMPARISON BETWEEN THE RADIAL ARTERY AND

THE RIGHT INTERNAL THORACIC ARTERY. A largerandomized trial showed similar patency for the RAand the right internal thoracic artery (RITA) (30). Anetwork meta-analysis of 9 RCTs confirmed similarpatency for the RA and the RITA, despite a nonsig-nificant trend toward reduced functional occlusionfor the RITA (1).

Clinical outcomes between the 2 arterial grafts aremore controversial. Observational studies have yiel-ded conflicting results (31,32). A recent meta-analysisof propensity matched studies found a survivaladvantage with the RITA (33), but an RCT reportedequivalent clinical outcomes (30).

Of note, the recently published interim analysis ofthe ART (Arterial Revascularization Trial) showed nodifferences in mid-term survival and event-free sur-vival for patients receiving 1 or 2 internal thoracicarteries. However, in a post hoc analysis, the ARTinvestigators showed how the addition of the RA toboth groups significantly reduced the rate of majoradverse cardiac events (34).

THE RA IN SPECIFIC PATIENT SUBSETS. Due to theirsuperior patency and possibly improved survival,additional arterial grafting (using RA or RITA) tosupplement the mammary artery to the left anteriordescending artery bypass is a Class IIA recommen-dation in the current European guidelines for patientswith reasonable life expectancy undergoing multi-vessel CABG (35). In the 2011 American College ofCardiology/American Heart Association guidelines,multiarterial grafting receives a Class IIB recommen-dation (36); in 2016, the Society of Thoracic Surgeonsclinical practice guidelines assigned a Class IIA basedon a more recent survey of published articles (7).

Use of RA in contrast to use of RITA does not in-crease the risk of sternal wound complicationsincluding mediastinitis, an important considerationdue to increasing prevalence of diabetes and obesityin CABG patients.

In diabetics, a large propensity matched studyshowed similar in-hospital and long-term mortalityusing the RA or the RITA as the second arterial graft(37). Another study confirmed similar rates of survivalfor RITA and RA but found that the use of the RITAwas associated with increased sternal wound com-plications (32). A post hoc analysis of the randomizedRadial Artery Patency study showed that RA is pro-tective against graft occlusion regardless of diabetes(38), suggesting that RA may be the arterial graft ofchoice in diabetics (due to their increased risk forsternal complications).

RA use also improves survival in reoperations (39).In this situation, the RA is often the best availableconduit due to previous use of the mammary arteriesand the SV. Finally, technically, the RA length is moreadequate than the RITA to graft distal or multipletargets.

USE OF RADIAL ARTERY GRAFTS FOR CABG AFTER

TRANSRADIAL PROCEDURES. The only 2 studiesthat have compared the patency of RAs submitted toTRA to noncatheterized RAs have reported signifi-cantly lower patency for TRA-RAs. Kamiya et al. (40)reported 23% occlusion at 30 days for TRA-RAs versus2% for control RA grafts (p ¼ 0.001). The authors also

FIGURE 2 Operative and Long-Term Mortality in Patients Receiving the Radial Artery or Saphenous Vein as the Second Conduit

Peri-operative mortality: radial artery vs. saphenous vein Study name Statistics for each study

Oddsratio

Anyanwu 2001 0.3910.9431.0001.5082.0321.161

1.0000.2371.657

0.6361.812

0.4991.1011.021

0.0400.4830.3400.251

0.6040.3620.0620.0110.1030.273

0.6040.0450.4650.733

3.7991.8442.9429.0806.8323.724

16.2124.979

26.7061.4845.4365.518

2.6061.422

–0.809–0.1710.0000.4491.1460.251

0.000–0.9260.356

–1.0461.060

–0.5660.2190.123

0.4180.8641.0000.6540.2520.8021.0000.3540.7220.2950.2890.571

0.8260.902

0.01 1001010.1RA

A

SVG

Benedetto 2013Cohen 2001Goldman 2011Lin 2013Locker 2013Petrovic 2015Santarpino 2010Shapira 1997Shi 2016Taggart 2017Tranbaugh 2010Zacharias 2004

Lowerlimit

Upperlimit Z-Value p-Value

Odds ratio and 95% CI

Long-term mortality: radial artery vs. saphenous vein grafting

0.7500.6000.7600.5600.7200.7900.8300.7100.6700.748

0.5720.3780.5980.3780.5620.7060.5410.5530.4590.692

0.9830.951

0.9660.8300.9230.8841.2730.911

0.9780.809

0.0370.0300.0250.0040.0090.0000.3930.0070.0380.000

–2.081–2.173

–2.240–2.892–2.594–4.089–0.854–2.687–2.076

–7.311

0.01 1001010.1

B

RA SVG

Benedetto 2013Cohen 2001Lin 2013Locker 2013Petrovic 2015Shi 2016Taggart 2017Tranbaugh 2010Zacharias 2004

Point(raw)

Lowerlimit

Upperlimit Z-Value p-Value

Study name Statistics for each study Point (raw) and 95% CI

For details of the meta-analysis, see the Online Appendix. CI ¼ confidence interval; RA ¼ radial artery; SVG ¼ saphenous vein graft.

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described a trend toward association between thenumber of TRAs and the risk of graft occlusion(p ¼ 0.07). In a similar study, Ruzieh et al. (41) re-ported a 6- to 18-month patency of 59% in the TRA-RAgroup compared to 78% in the control RA group(p ¼ 0.03).

The current Society of Thoracic Surgeons guide-lines suggest an interval of at least 3 months betweenTRA and use of the RA for CABG, even though theyrecognize that clinical data are insufficient to desig-nate a safe wait time (7).

However, the attitude of surgeons toward the useof RA grafts after TRA varies considerably. Evenamong the panelists, some surgeons consider TRA anabsolute contraindication to use of RA use, othersconsider the conduit usable at 3 to 6 months afterTRA; and others routinely use the freshly cathe-terized RA, discarding the most distal portion of theRA containing the puncture site. Noninvasive evalu-ation of the endothelial function seems an attractiveoption to preoperatively assess the RA after TRA, butno data on its use have been published to date.

CENTRAL ILLUSTRATION Flowchart for Transradial Approach for Percutaneous Procedures

Acute Coronary Syndrome

TRA(possibly through right RA)

PCI

YesNo

Angiography

– High clinical suspicion of severe CAD– Lack of conduits for CABG– Surgeons use RA for CABG

Stable presentation

Consider TRA through the sitewith worst ulnar compensation

or alternative approaches

Gaudino, M. et al. J Am Coll Cardiol. 2018;71(10):1167–75.

CABG ¼ coronary artery bypass grafting; CAD ¼ coronary artery disease; PCI ¼ percutaneous coronary intervention; RA ¼ radial artery;

TRA ¼ transradial access.

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RECOMMENDATIONS FOR THE USE OF THE RA IN

PATIENTS UNDERGOING PERCUTANEOUS OR

SURGICAL CORONARY PROCEDURES. As describedabove, the use of the RA either as vascular access forpercutaneous coronary procedures or as conduit forCABG is associated with significant clinical benefits.However, catheterization is associated with RAdamage that may ultimately preclude the use of thisartery as a conduit for CABG. Hence, every effortshould be made to preserve short and long-term RApatency after TRA. Because many patients with cor-onary artery disease will undergo repeat catheteri-zation and/or PCI over the years, post-TRA RAocclusion has major clinical implications. Beyond theshort-term benefit of offering repeat access by thepreviously used artery, cardiologists should ideallyalso be concerned about preserving, if possible, an“untouched” RA as a potential conduit if patientsrequire CABG.

Although not yet universally practiced, the use of acombination of smaller catheters, better profiled

hydrophilic sheaths, intravenous anticoagulationduring TRA procedures, and patent hemostasis withshorter compression time after procedure completionare key to preserve the RA for future use. For cardi-ologists, it is time to consider the potential additionalbenefit of the RA not only as preferred access to thecoronary circulation but also as a better conduit forCABG, which might impact long-term quality of life aswell as survival.

The decision to use the RA at the time of percuta-neous procedures or surgery must be individualizedand based on the characteristics of the single patient,including the current clinical status, and likely futurescenarios.

Based on the current evidence, this panel haselaborated the following recommendations:

1. The TRA should be preferred over the TFA fordiagnostic angiography and PCI. This is particu-larly important in acute coronary syndromes andwhen intervention is required.

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2. When appropriate, the RA should be used in pref-erence to the SV to achieve multiarterial CABGbecause of its superior patency and potential forimproved patient longevity. In particular, the RAmay be the preferred second arterial conduit inpatients who are at high risk for sternal woundcomplications.

3. Ideally, an effort should be made to reserve one RAfor TRA and the other for potential use as a conduitfor CABG. Generally, the use of both RAs for TRAor for CABG is not advisable, unless there areclinical indications or conduits shortage.

4. The laterality of the RA for use is at the discretionof the TRA operator. As most catheter laboratoriesare set up to use the right RA for TRA and mostsurgeons prefer to harvest the left RA, it seemsreasonable to recommend that, whenever possible,TRA interventions should be performed throughthe right forearm, and the left arm should bereserved for possible use at surgery.

5. Recommendation 4 may result in a small percent-age of cases where the left RA is unusable at sur-gery due to lack of ulnar compensation.Consequently, in stable patients undergoing angi-ography, where there is a high likelihood of severecoronary artery disease and limited available con-duits for bypass in institutions where the RA isused for CABG, one may consider discussion withthe patient regarding alternatives to radial accessor TRA on the side with the worst ulnarcompensation.

6. Every effort should be made to adopt strategies tominimize RA damage during TRA, including theuse of the most distal RA access point, use ofminiaturized equipment, optimal intravenousantithrombotic treatment, and patent hemostasistechniques.

7. In patients previously submitted to TRA, the non-punctured artery should be used for CABG. In sit-uations where the punctured RA is the onlyavailable conduit, consideration should be given tothe risk of delaying surgery, although the specifictime interval required to optimize graft patency isunknown at present.

CONCLUSIONS

Future studies are urgently needed in order to, first,identify additional strategies to minimize the risk ofradial artery damage during TRA, and second, corre-late the extent of RA endothelial damage assessednoninvasively with the patency of RA grafts used forCABG to establish an eventual optimal waiting inter-val for the use of catheterized RA for CABG.

A flowchart that summarizes, in part, the currentrecommendations is presented in the CentralIllustration.

ADDRESS FOR CORRESPONDENCE: Dr. Mario Gau-dino, Department of Cardiothoracic Surgery, WeillCornell Medicine, 525 East 68th Street, New York,New York 10065. E-mail: mfg9004@med.cornell.edu.

RE F E RENCE S

1. Benedetto U, Raja SG, Albanese A, Amrani M,Biondi-Zoccai G, Frati G. Searching for the secondbest graft for coronary artery bypass surgery: anetwork meta-analysis of randomized controlledtrials. Eur J Cardiothorac Surg 2015;47:59–65;discussion 65.

2. Jolly SS, Amlani S, Hamon M, Yusuf S,Mehta SR. Radial versus femoral access for coro-nary angiography or intervention and the impacton major bleeding and ischemic events: a sys-tematic review and meta-analysis of randomizedtrials. Am Heart J 2009;157:132–40.

3. Hess CN, Peterson ED, Neely ML, et al. Thelearning curve for transradial percutaneous coro-nary intervention among operators in the UnitedStates: a study from the National CardiovascularData Registry. Circulation 2014;129:2277–86.

4. Burzotta F, Brancati MF, Trani C, et al. Impact ofradial-to-aorta vascular anatomical variants onrisk of failure in trans-radial coronary procedures.Catheter Cardiovasc Interv 2012;80:298–303.

5. Valgimigli M, Campo G, Penzo C, et al. Trans-radial coronary catheterization and intervention

across the whole spectrum of Allen test results.J Am Coll Cardiol 2014;63:1833–41.

6. Valgimigli M, Gagnor A, Calabró P, et al. Radialversus femoral access in patients with acute cor-onary syndromes undergoing invasive manage-ment: a randomised multicentre trial. Lancet 2015;385:2465–76.

7. Aldea GS, Bakaeen FG, Pal J, et al. The Societyof Thoracic Surgeons clinical practice guidelines onarterial conduits for coronary artery bypassgrafting. Ann Thorac Surg 2016;101:801–9.

8. Mounsey CA, Mawhinney JA, Werner RS,Taggart DP. Does previous transradial catheteri-zation preclude use of the radial artery as aconduit in coronary artery bypass surgery? Circu-lation 2016;134:681–8.

9. Bertrand OF, Bélisle P, Joyal D, et al. Compar-ison of transradial and femoral approaches forpercutaneous coronary interventions: a systematicreview and hierarchical Bayesian meta-analysis.Am Heart J 2012;163:632–48.

10. Jolly SS, Yusuf S, Cairns J, et al. Radial versusfemoral access for coronary angiography and

intervention in patients with acute coronary syn-dromes (RIVAL): a randomised, parallel group,multicentre trial. Lancet 2011;377:1409–20.

11. Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Ef-fect of transradial access on quality of life and costof cardiac catheterization: a randomized compari-son. Am Heart J 1999;138:430–6.

12. Amin AP, Patterson M, House JA, et al. Costsassociated with access site and same-daydischarge among medicare beneficiaries undergo-ing percutaneous coronary intervention: an eval-uation of the current percutaneous coronaryintervention care pathways in the united states.J Am Col Cardiol Intv 2017;10:342–51.

13. Alnasser SM, Bagai A, Jolly SS, et al.Transradial approach for coronary angiographyand intervention in the elderly: a meta-analysisof 777,841 patients. Int J Cardiol 2017;228:45–51.

14. Andò G, Cortese B, Russo F, et al. Acute kidneyinjury after radial or femoral access for invasiveacute coronary syndrome management: AKI-MA-TRIX. J Am Coll Cardiol 2017;69:2592–603.

J A C C V O L . 7 1 , N O . 1 0 , 2 0 1 8 Gaudino et al.M A R C H 1 3 , 2 0 1 8 : 1 1 6 7 – 7 5 RA for Percutaneous Procedures or CABG?

1175

15. Burzotta F, Trani C, Hamon M, Amoroso G,Kiemeneij F. Transradial approach for coronaryangiography and interventions in patients withcoronary bypass grafts: tips and tricks. CatheterCardiovasc Interv 2008;72:263–72.

16. Michael TT, Alomar M, Papayannis A, et al.A randomized comparison of the transradial andtransfemoral approaches for coronary arterybypass graft angiography and intervention: theRADIAL-CABG Trial (RADIAL Versus Femoral Ac-cess for Coronary Artery Bypass Graft Angiographyand Intervention). J Am Col Cardiol Intv 2013;6:1138–44.

17. Rigattieri S, Sciahbasi A, Brilakis ES, et al.Meta-analysis of radial versus femoral arteryapproach for coronary procedures in patients withprevious coronary artery bypass grafting. Am JCardiol 2016;117:1248–55.

18. Romagnoli E, De Vita M, Burzotta F, et al.Radial versus femoral approach comparison inpercutaneous coronary intervention with intra-aortic balloon pump support: the RADIAL PUMPUP registry. Am Heart J 2013;166:1019–26.

19. Rashid M, Kwok CS, Pancholy S, et al. Radialartery occlusion after transradial interventions: asystematic review and meta-analysis. J Am HeartAssoc 2016;5:e002686.

20. Pasha AK, Elder MD, Malik UE, Khalid AM,Noor Z, Movahed MR. Symptomatic radial arterythrombosis successfully treated with endovascularapproach via femoral access route. CardiovascRevasc Med 2014;15:357–9.

21. Kiemeneij F. Left distal transradial access in theanatomical snuffbox for coronary angiography(ldTRA) and interventions (ldTRI). Euro-Intervention 2017;13:851–7.

22. Ul Haq MA, Rashid M, Kwok CS, Wong CW,Nolan J, Mamas MA. Hand dysfunction aftertransradial artery catheterization for coronaryprocedures. World J Cardiol 2017;9:609–19.

23. Antonopoulos AS, Latsios G, Oikonomou E,et al. Long-term endothelial dysfunction aftertrans-radial catheterization: a meta-analyticapproach. J Card Surg 2017;32:464–73.

24. Kristi�c I, Lukenda J. Radial artery spasm duringtransradial coronary procedures. J Invasive Cardiol2011;23:527–31.

25. van der Heijden D, van Leeuwen MAH,Janssens GN, et al. Endothelial dysfunction andthe occurrence of radial artery spasm during

transradial coronary procedures: the ACRA-spasmstudy. EuroIntervention 2016;12:1263–70.

26. Collet C, Corral JM, Cavalcante R, et al. Pres-sure-mediated versus pharmacologic treatment ofradial artery spasm during cardiac catheterisation:a randomised pilot study. EuroIntervention 2017;12:e2212–8.

27. Gaudino M, Crea F, Cammertoni F, Mazza A,Toesca A, Massetti M. Technical issues in the useof the radial artery as a coronary artery bypassconduit. Ann Thorac Surg 2014;98:2247–54.

28. Rahouma M, Kamel M, Benedetto U, et al.Endoscopic versus open radial artery harvesting: ameta-analysis of randomized controlled and pro-pensity matched studies. J Card Surg 2017;32:334–41.

29. Zhang H, Wang ZW, Wu HB, Hu XP, Zhou Z,Xu P. Radial artery graft vs. saphenous vein graftfor coronary artery bypass surgery: which conduitoffers better efficacy? Herz 2014;39:458–65.

30. Hayward PA, Buxton BF. Mid-term results ofthe Radial Artery Patency and Clinical Outcomesrandomized trial. Ann Cardiothorac Surg 2013;2:458–66.

31. Caputo M, Reeves B, Marchetto G, Mahesh B,Lim K, Angelini GD. Radial versus right internalthoracic artery as a second arterial conduit forcoronary surgery: early and midterm outcomes.J Thorac Cardiovasc Surg 2003;126:39–47.

32. Hoffman DM, Dimitrova KR, Lucido DJ, et al.Optimal conduit for diabetic patients: propensityanalysis of radial and right internal thoracic ar-teries. Ann Thorac Surg 2014;98:30–7; discussion36–7.

33. Benedetto U, Gaudino M, Caputo M, et al.Right internal thoracic artery versus radial arteryas the second best arterial conduit: Insights from ameta-analysis of propensity-matched data onlong-term survival. J Thorac Cardiovasc Surg2016;152:1083–91.

34. Taggart DP, Altman DG, Flather M, et al. As-sociations between adding a radial artery graft tosingle and bilateral internal thoracic artery graftsand outcomes: insights from the arterial revascu-larization trial. Circulation 2017;136:454–63.

35. Authors/Task Force members, Windecker S,Kolh P, et al. 2014 ESC/EACTS guidelines onmyocardial revascularization: the Task Force onMyocardial Revascularization of the European So-ciety of Cardiology (ESC) and the European

Association for Cardio-Thoracic Surgery (EACTS)developed with the special contribution of theEuropean Association of Percutaneous Cardiovas-cular Interventions (EAPCI). Eur Heart J 2014;35:2541–619.

36. Hillis LD, Smith PK, Anderson JL, et al. 2011ACCF/AHA guideline for coronary artery bypassgraft surgery. A report of the American College ofCardiology Foundation/American Heart Associa-tion Task Force on Practice Guidelines. Developedin collaboration with the American Association forThoracic Surgery, Society of Cardiovascular Anes-thesiologists, and Society of Thoracic Surgeons.J Am Coll Cardiol 2011;58:e123–210.

37. Raza S, Blackstone EH, Houghtaling PL, et al.Similar outcomes in diabetes patients after coro-nary artery bypass grafting with single internalthoracic artery plus radial artery grafting andbilateral internal thoracic artery grafting. AnnThorac Surg 2017;104:1923–32.

38. Deb S, Singh SK, Moussa F, et al. The long-term impact of diabetes on graft patency aftercoronary artery bypass grafting surgery: a sub-study of the multicenter Radial Artery Patencystudy. J Thorac Cardiovasc Surg 2014;148:1246–53; discussion 1253.

39. Zacharias A, Schwann TA, Riordan CJ, et al.Late outcomes after radial artery versus saphe-nous vein grafting during reoperative coronaryartery bypass surgery. J Thorac Cardiovasc Surg2010;139:1511–8.e4.

40. Kamiya H, Ushijima T, Kanamori T, et al. Use ofthe radial artery graft after transradial catheteri-zation: is it suitable as a bypass conduit? AnnThorac Surg 2003;76:1505–9.

41. Ruzieh M, Moza A, Siddegowda Bangalore B,Schwann T, Tinkel JL. Effect of transradial cathe-terisation on patency rates of radial arteries usedas a conduit for coronary bypass. Heart Lung Circ2017;26:296–300.

KEY WORDS coronary artery bypass,percutaneous procedures, radial artery

APPENDIX For details of the meta-analysisreported in Figure 2 and supplementalreferences as well as a supplemental table andfigure, please see the online version of thispaper.