Predictors of Access Site Crossover in Patients Who Underwent Transradial Coronary Angiography

doi:10.1016/j.amjcard.2015.04.051

The American Journal of Cardiology

Volume 116, Issue 3, 1 August 2015, Pages 379-383

https://doi.org/10.1016/j.amjcard.2015.04.051 Get rights and content

Despite increasing use of the transradial approach (TRA) for coronary angiography, TRA failure and subsequent access site crossover remain a barrier to TRA adoption. The aim of this study was to elucidate patient and procedural characteristics associated with TRA to transfemoral approach (TFA) crossover and examine TRA to TFA crossover by operator experience over time. This retrospective analysis identified 1,600 patients who underwent coronary angiography with possible percutaneous coronary intervention through TRA by operators with varied TRA experience in an urban tertiary care center from October 2010 to August 2013. Univariate and multivariable logistic regression were used to identify independent predictors of access site crossover, from TRA to TFA, and strength of association is presented as odds ratio (OR, 95% confidence interval [CI]). Access site crossover was noted in 166 patients (10.4%). Multivariable predictors of access site crossover included age >75 years (OR 1.90, 95% CI 1.23 to 2.91, p = 0.004) and operator experience (OR 2.98, 95% CI 1.96 to 4.52, p <0.0001). Less experienced operators (≤5 years TRA experience) had a decrease in access site crossover over time (quartile 1: 8.9%, quartile 2: 18.8%, quartile 3: 16.4%, and quartile 4: 8.6%, p <0.001), which paralleled an increase in the proportion of procedures using initial TRA over time (quartile 1: 38.0%, quartile 2: 53.7%, quartile 3: 54.8%, and quartile 4: 70.3%, p <0.001). Experienced operators (>5 years TRA experience) had no significant change in proportion of access site crossover over time (quartile 1: 2.8%, quartile 2: 6.4%, quartile 3: 5.6%, quartile 4: 5.8%, p = 0.54). In conclusion, rate of access site crossover in the contemporary era is relatively low and can be mitigated with operator experience.

Section snippets

Methods

This is a retrospective study of consecutive patients who underwent a diagnostic coronary angiography with or without PCI using TRA at a tertiary care center from October 2010 to August 2013. Patients who underwent a planned PCI without a diagnostic component were not included. For patients who had >1 procedure using TRA during the study period, only the first chronological procedure was selected. During this study period, transition to the opposite radial or ulnar artery was not routinely

Results

Of the 1,600 patients who met inclusion and exclusion criteria, 166 patients (10.4%) experienced access site crossover. Baseline characteristics of the group that did versus those that did not undergo access site crossover are listed in Table 1. The proportion of female patients >75 years did not differ between the crossover versus no crossover groups (7.2% vs 5.6%, p = 0.383).

Procedural characteristics of access site crossover versus no crossover groups are listed in Table 2. Timing of access

Discussion

This is one of the larger contemporary studies to examine access site crossover (from TRA to TFA) in an all-comers population who underwent coronary angiography with possible PCI by operators with varied TRA experience in a US center. In this study, the proportion of access site crossover appears to be largely driven by patient age and operator experience. Rate of access site crossover in those with less TRA experience decreases over time as operator utilization of TRA increases, suggesting

Disclosures

Dr. Shah was partially funded by a National Institutes of Health grant UL1 TR000038. Part of the data analysis and statistical support was provided by the New York University School of Medicine Cardiovascular Outcomes Group. Dr. Coppola is a consultant for Terumo and speaker for Medtronic. The authors have no conflicts of interest in relation to this article.

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Use of the CHA<inf>2</inf>DS<inf>2</inf>-VASc Score in Assessing Transradial Approach Failure
2022, Cardiovascular Revascularization Medicine
Radial access is now considered the preferred approach for coronary angiography and percutaneous coronary intervention because of the low risk of vascular complications. However, radial access failure is not uncommon, leading to crossover to a different access site. The CHA₂DS₂-VASc score is used to estimate stroke risk in patients with atrial fibrillation. Our study aimed to assess the CHA₂DS₂-VASc score in predicting failure of the transradial approach, resulting in crossover to transfemoral access (TFA) for coronary angiography.
We performed a single-center, non-randomized, retrospective study. The study included 1775 patients who underwent coronary angiography with or without subsequent percutaneous intervention between July 2018 and October 2019. The study population was divided into three groups based on the CHA₂DS₂-VASc score: low (≤2), intermediate (3–4), and high score (≥5) groups. The association between the CHA₂DS₂-VASc score and radial access failure was evaluated and compared between the groups.
A total of 197 patients (11.1%) had crossover to the femoral artery. A large percentage of patients (19.2%) had radial access failure in the high CHA₂DS₂-VASc score group (≥5) compared with 12.5% in the intermediate score group (3–4) and only 6.3% in the low score group (≤2). The highest crossover rate (42.9%) was observed in patients with a CHA₂DS₂-VASc score of 8. Higher CHA₂DS₂-VASc scores were also associated with increased fluoroscopy time, contrast administration, and radiation exposure.
The CHA₂DS₂-VASc score can predict failure of the transradial approach, with a score of ≥5 having the highest correlation of failure requiring crossover to TFA.
Randomized Comparison Between Radial and Femoral Large-Bore Access for Complex Percutaneous Coronary Intervention
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The aim of this study was to investigate whether transradial (TR) percutaneous coronary intervention (PCI) is superior to transfemoral (TF) PCI in complex coronary lesions with large-bore guiding catheters with respect to clinically relevant access site–related bleeding or vascular complications.
The femoral artery is currently the most applied access site for PCI of complex coronary lesions, especially when large-bore guiding catheters are required. With downsizing of TR equipment, TR PCI may be increasingly applied in these patients and might be a safer alternative compared with the TF approach.
An international prospective multicenter trial was conducted, randomizing 388 patients with planned PCI for complex coronary lesions, including chronic total occlusion, left main, heavy calcification, or complex bifurcation, to either 7-F TR access (TRA) or 7-F TF access (TFA). The primary endpoint was defined as access site–related clinically significant bleeding or vascular complications requiring intervention at discharge. The secondary endpoint was procedural success.
The primary endpoint event rate was 3.6% for TRA and 19.1% for TFA (p < 0.001). The crossover rate from radial to femoral access was 3.6% and from femoral to radial access was 2.6% (p = 0.558). The procedural success rate was 89.2% for TFA and 86.0% for TRA (p = 0.285). There was no difference between TFA and TRA with regard to procedural duration, contrast volume, or radiation dose.
In patients undergoing PCI of complex coronary lesions with large-bore access, radial compared with femoral access is associated with a significant reduction in clinically relevant access-site bleeding or vascular complications, without affecting procedural success. (Complex Large-Bore Radial Percutaneous Coronary Intervention [PCI] Trial [Color]; NCT03846752)
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Citation Excerpt :
This can be used in the following situations1: when bleeding risk of femoral approach is very high2; TFA is not available because of PAD3; contralateral radial and ulnar artery are unavailable4; to elucidate ipsilateral ulnar artery beforehand by imaging if TUA is anticipated especially with prior use of ipsilateral radial access; and5 when radial failure is due to loop or hypoplastic radial artery. Hand ischemia while performing TUA can be avoided with1: use of small sheath size if possible2; use of intense appropriate anticoagulation (UFH 100IU/KG); and3 short duration of post-procedural compression (less than 2 h). We did not perform Allen’s test as recent data are not in favor to predict hand ischemia.5
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Our results in terms of specificity and NPV, which neared 95% for both coronary thresholds (>50% and >70%), are in line with those of two studies based on the CORE320 data. In those works, in which CTA/CTP + coronary CTA (>50%) was compared to SPECT + ICA, specificity values were close to 90% [2,19]. TPR outperformed visual analysis as well as MA and MPRI.
To compare performance of visual and quantitative analyses for detecting myocardial ischaemia from single- and dual-energy computed tomography (CT) in patients with suspected coronary artery disease (CAD).
Eighty-four patients with suspected CAD were scheduled for dual-energy cardiac CT at rest (CTA) and pharmacological stress (CTP). Myocardial CT perfusion was analysed visually and using three parameters: mean attenuation density (MA), transmural perfusion ratio (TPR) and myocardial perfusion reserve index (MPRI), on both single-energy CT and CT-based iodine images. Significant CAD was defined in AHA-segments by concomitant myocardial hypoperfusion identified visually or quantitatively (parameter < threshold) and coronary stenosis detected by CTA. Single-photon emission CT and invasive coronary angiography were used as reference. Perfusion-parameter cut-off values were calculated in a randomly-selected subgroup of 30 patients.
The best-performing thresholds for TPR, MPRI and MA were 0.96, 23 and 0.5 for single-energy CT and 0.97, 47 and 0.3 for iodine imaging. For both CT-imaging modalities, TPR yielded the highest area under receiver operating characteristic curve (AUC) (0.99 and 0.97 for single-energy CT and iodine imaging, respectively, in vessel-based analysis) compared to visual analysis, MA and MPRI. Visual interpretation on iodine imaging resulted in higher AUC compared to that on single-energy CT in per-vessel (AUC: 0.93 vs 0.86, respectively) and per-patient (0.94 vs 0.93) analyses.
Transmural perfusion ratio on both CT-imaging modalities is the best-performing parameter for detecting myocardial ischaemia compared to visual method and other perfusion parameters. Visual analysis on CT-based iodine imaging outperforms that on single-energy CT.
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Coronary Artery DiseasePredictors of Access Site Crossover in Patients Who Underwent Transradial Coronary Angiography

Section snippets

Methods

Results

Discussion

Disclosures

Lancet

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

JACC Cardiovasc Interv

J Am Coll Cardiol

Am Heart J

Am Heart J

Am J Cardiol

JACC Cardiovasc Interv

J Am Coll Cardiol

Coronary Artery Disease
Predictors of Access Site Crossover in Patients Who Underwent Transradial Coronary Angiography