One arterial puncture: Radial, please; if two? Make one radial, please

Abstract

There is less bleeding with a radial approachThere is less bleeding with a radial approach See aboveThe authors, from nine high-volume cardiovascular interventional centers in Italy, went back and reviewed cases requiring two vascular approaches for either structural cardiac intervention, complex percutaneous coronary intervention (PCI), endovascular aortic repair (EVAR), or complex lower limb angioplasty.The radial approach (TR) was used in a long list of structural, coronary, valvular, aneurysm, and peripheral interventions, all complex in nature by any standard. Most cases were structural interventions; mostly being transcatheter aortic valve implantation, while complex coronary interventions and EVAR/peripheral interventions represented the remainder. While not unexpected, the TR approach was associated with significantly longer procedural and fluoroscopy times than the transbrachial/transfemoral (TB/TF) group. However, and this is what being a physician is all about, the rate of significant bleeding was significantly lower in the TR group as compared to TF/TB group (6.7% vs. 19.7%; P < 0.001), and the TR approach was associated with significantly reduced length of hospital stay, and a reduced need for transfusions (P < 0.001). This was not surprising based on previous TR to TF reports in coronary and transcatheter aortic valve intervention (TAVI) procedures [1][2][3].The longer procedural time was actually an average of 30 min and may reflect some learning as it has for most radialists in their early experience. However, it may also reflect some limitations with regard to positioning during complex cases as well as the use of suboptimal catheters for procedures far from the intended treatment sites (e.g., iliac interventions). What, if anything, is the downside? The physicians involved were exposed to additional radiation. While statistically significant, the mean fluoroscopy time differed by only 7 min and the longest procedure times only differed by 4 min. These limitations are easily remedied as the change to radial interventions becomes more the norm and equipment will be developed to address some technical and length limitations, respectively. The latter already is already happening.As expected, bleeding events were more frequent with femoral ancillary needs compared to cases where a radial site was employed.This could be blamed on the larger bore catheters used in the patients where the femoral rather than radial approach was implemented, 6.6 Fr versus 5.9 Fr (P < 0.001). This was not a randomized trial, after all, but this should not dissuade anyone who does not believe that technical advances will make "larger bore" devices smaller in the years to come (i.e., radial approach possible).Bleeding and the transfusions that follow increase the risk of post-procedural death [4]. This has been shown to be true in multiple other trials. We should only be asking ourselves the following questions? How soon this will be the norm, why are we not doing so currently or at a minimum, why are we not planning to do ...