Transradial approach: Do we have gain without excessive pain?

Abstract

Transradial approach (TRA) was described over 60 years back, but it was not gained much attention due to equipment and technical limitations (1). Then it received new interest after the work of Campeau et al. (2) some 25 years back. After him, Kiemeneij et al. (3) introduced successful interventional procedures via radial approach. Since then, TRA has become popular in many parts of the world and many centers across the world has been adopting and developing transradial catheterization training programmes (4, 5).Although TRA is being used more commonly due to increased convenience for the patient, early mobilization and decreased access site bleeding complications. However, concerns have been raised about increased radiation exposure and prolonged procedure time (6, 7). It is due to the fact that TRA is technically more demanding and bearing specific challenges in comparison with the transfemoral approach (TFA) (8). These include radial and subclavian artery anomalies, access failure, and radial artery spasm (RAS) (9). Among them RAS is the most common complication (9). This spasm often makes the procedure painful for the patient. Moreover, it results in difficulty in catheter manipulation and thus makes the procedure complexed, time consuming and sometimes may end up with procedure failure or crossover to TFA. The SPASM study shows that young and female are the independent predictors of RAS (10). Other studies show that the diameter of radial artery and diabetes mellitus are the predictors of RAS (11,12).In this March issue of Anatolian Journal of Cardiology published Aktürk et al. (13) reported the problem of RAS in the perspective of pain levels. Author compared the pain levels of transradial and transfemoral coronary catheterization in a reasonably good number of patients. He assessed pain levels in a very well defined manner by using visual analogue scale (VAS). Aktürk et al. (13) reported that TRA group showed higher VAS scores than those in TFA group. It was further reported in his study that patients having BMI <24 kg/m 2 and/or wrist circumference <16.7 cm predicted unacceptable pain.It is indeed an interesting piece of information not only for interventional cardiologist but those who prefer to choose radial approach for various other interventions. In the above mentioned study highly skilled operators approach radial artery under good sedation (Diazepam 7.5 mg PO) in addition to intravenous dose of nitroglycerine and verapamil. Even then they encountered the problem of RAS in more than 21% of patents. This shows that with the current practice we cannot completely abolish this problem and until new techniques/equipments are freely available to avoid RAS we should be more selective while intervene the patients. This should not be the matter of ego for radialists. Being selective for radial or femoral approach keeping consideration various factors is a good and sensible strategy for patients as well as for operators. This selectivity is highly recommended especially if someone is going to do complex int...