17 May 2022
Celebrating 30 years of transradial artery access!
Thirty years ago, the interventional cardiology field was transformed with the emergence of a new access site – the radial artery was used for coronary angioplasty and stent implantation for the first time on 14 August 1992.
Traditionally, transfemoral access (TFA) was used due to its large arterial size allowing for easier cannulation of the artery, manipulation of catheters, simultaneous placement of mechanical support devices and short door-to-balloon times. However, rates of major bleeding complications and early stent thrombosis with TFA were high, requiring intense anticoagulation and immobilisation in hospital for days.
Alternative access sites were explored, and successful percutaneous transradial angiography was first reported in 1989 by Lucien Campeau from the Montreal Heart Institute.1 Coronary stenting was not standard practice at that time, but with Campeau’s work for inspiration and with the availability of smaller catheters, Ferdinand Kiemeneij from the Amsterdam Department of Interventional Cardiology-OLVG used transradial access (TRA) for a PCI procedure (TRI) for the first time.2
We asked pioneers and experts to tell us what they think of TRA and how it has revolutionised practice.
Mirvat Alasnag interviews the Father of Radial Access: Ferdinand Kiemeneij
A pioneer’s view
After Lucien Campeau’s first successful TRA for percutaneous coronary angiography, I think it was only a matter of time before someone used TRA for PCI once we had smaller guides. At the OLVG hospital in Amsterdam, we were aiming to reduce major access-site bleeding complications and associated mortality – the major endpoints of all key studies comparing TRA with TFA – but for me, the procedure was just as much about getting patients immediately mobilised and improving their wellbeing before, during and after the intervention.
Ferdinand Kiemeneij teaching TRI, Hanoi,2002
After the first TRI procedures were performed and all interventional cardiologists and cardiology staff at the OLVG were trained, the main challenge was acceptance in a world where TFA was the standard. TRI’s first international exposure was at the 66th Scientific Sessions of the ACC in 1993, where I presented a poster that described our findings from the first 100 patients undergoing transradial balloon angioplasty and stenting. Although I could see that some people were attracted to the concept, I could see that many instantly dismissed the idea. But in many ways, TRI then sold itself. Following the poster, international colleagues visited our department, among which were Jean Fajadet and Yves Louvard. Seeing that arterial sheaths could be removed immediately after the procedure, that haemostasis could be obtained with a simple and effective compression bandage, and that patients were walking around immediately had a real impact.
On the ward, there were bedridden patients in whom the sheath could not be removed from their groin because they were not properly adjusted to antithrombotics. And suddenly, there were patients who had had a radial procedure who walked from the cathlab into the ward with only a compression bandage on the wrist.
We had come up with a solution that was patient-friendly and that improved safety and cost-effectiveness (by reducing hospital stays, surgery, transfusions and expensive closure devices), but we realised that for the operator, TRA was more complex than TFA.
In general, the more convenient a procedure for the patient, the more skills it requires from the operator. The reward of your sweat is the smile of the patient.
A radial handshake! Professor Ferdinand Kiemeneij and Shigeru Saito, Beijing, 2004
There were no specific tools for TRA at the time and no one to train us, so the early pioneers faced a steep learning curve in developing the technique. The learning curve was particularly steep for Jean Fajadet when he performed the first live case during the TCT congress in 1993, only 2 weeks after his visit to our hospital, but he did a great job showcasing the technique, and we continued to spread the word about TRI, developing our own skills and training others.
Over the years, we have gone from single-centre research in the absence of dedicated tools to the manufacture of high-quality products, international trials and global training programmes. We have now got to the stage where TRI has literally opened the door to outpatient or day-care strategies. The first outpatient stent procedures were performed in 1996 in Amsterdam. In 2006, we established a dedicated outpatient lounge, which was quite revolutionary and is still in use. Of course, not all patients are eligible, but for the majority, the outpatient strategy with TRI is patient-friendly, safe and cost-effective.
Despite its success in the minds of many, we still do not have 100% acceptance of TRI, and that remains puzzling to me. Every fellow who is exposed to TRA immediately picks it up, but there may be something off-putting about working with small arteries and challenging arm anatomy that deters some operators, and this is something we need to overcome.
In addition, as the number of TRA interventions increases, radial artery occlusion has become an issue. Our best answer to date is distal TRA (dTRA), which has a low forearm radial artery occlusion rate due to preserved radial artery flow through the superficial palmar branch, and the absence of proximal puncture and haemostasis trauma, due to short and light compression in the snuffbox. Although the distal site is only a couple of centimetres away from the conventional site, dTRA is again more patient-friendly and has advantages for the operator and nursing staff too. We are also learning that dTRA is safe in terms of the delicate structures of the hand – results will be presented from the RATATOUILLE study on hand function here at EuroPCR 2022.
Training dTRA with Professor khaled Shokry, Cairo, 2018
I am pleased to say that TRA has now expanded into other fields and is becoming increasingly important in interventional radiology and neurointerventional radiology. I hope that the acceptance by these colleagues will take less than 30 years because of the work that many dedicated radialists have already done. I certainly see a sunny future ahead for TRA!
An operator’s view
In our region, TRA is gradually becoming the default approach. Many of the early-career operators have been well trained during their fellowships, and many mid- or late-career operators have already incorporated TRA into their practice. TRA is increasing as the interventional community is learning tips and techniques to navigate loops and tortuousities, manage spasm, adopt distal radial access and engage grafted vessels. In addition, there are more and more case reports of transradial aortic valvuloplasty, carotid interventions and peripheral vascular interventions. Industry pioneers have also responded to calls for slender sheaths, longer sheaths that permit peripheral interventions and railway sheaths.
As our experience grows and with a parallel development of the technology, I believe TRA will become the default approach globally very soon.
Mirvat Alasnag using TRA, Jeddah, 2022
Advanced cathlabs have become adept at setting up not only TRA but also alternative sites, such as popliteal, pedal and axillary access. Thirty years ago, we gained a new access site, and explorations regarding access continue to this day.
The experts’ view
“TRA has transformed PCI procedures into same-day procedures with almost no bleeding risk. It is rare that such a simple innovation has such a big impact. It is an honour to be a part of that journey”
"In the last two decades, TRA has revolutionised the practice of interventional cardiology in the UK. The latest national audit data report that TRA is now used in over 92% of all PCI cases. This change in practice has resulted in huge benefits to our patients and health care systems. This is a shining example of the power of innovative pioneers who established the technique and brought these benefits to our patients"
“More than 95% of PCI, even complex cases, can be performed transradially”
“How we get in? RADIAL…what else!?”
“Distal radial first, conventional radial second!”
“Patients seek centres doing TRA and get heavily disappointed if TRA is not feasible”
“The radial approach has really entered the common imagination – you can tell it from the disappointment in patients' faces when you tell them that you have to switch”
References
- Campeau L. Cathet Cardiovasc Diagn. 1989;16:3–7
- Kiemeneij F, Laarman GJ. Cathet Cardiovasc Diagn. 1993;30:173–178.
- Valgimigli M, et al. Lancet. 2015;385:2465–2476.
- Jolly SS, et al. Lancet. 2011;377:1409–1420.
Authors