International Journal of Cardiology 173 (2014) 347–348
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Editorial
Think left and think right and think low and think high. Oh, the thinks you can think up if only you try! (Theodore Seuss Geisel, a.k.a. Dr. Seuss) Christian Pristipino ⁎ Interventional Cardiology Unit, San Filippo Neri Hospital, Via A. Poerio, 140-00152 Roma, Italy
a r t i c l e
i n f o
Article history: Received 20 January 2014 Accepted 14 March 2014 Available online 20 March 2014 Keywords: Radial approach Left radial approach Right radial approach Meta-analysis
Compared to a femoral approach, radial access significantly reduces vascular access-related haemorrhages and, in STEMI patients, it generally yields better outcomes [1]. However, the feasibility, associated radiation exposure, and duration of radial approach procedures are subject to considerable variability across studies, relative to femoral access [2]. This variability has been attributed to differences in operator expertise, because proficiently accessing the radial artery requires both an adequate learning curve and a consistent ongoing procedural volume of interventions [3]. However, following Dr. Seuss' suggestion, if you look closely enough, considering the “radial approach” as a single entity is misguided. Instead, left and right radial approaches should be considered separately, because they are so different. For example, the right radial approach is often considered more challenging. This is because there are more arterial tortuosities in the dominant arm, more tortuosities in the anonymous trunk versus the left subclavian artery, and a different pathway for catheters to reach the aortic root relative to left-sided routes [4]. Despite these difficulties, a number of operators still prefer it. One main reason relates to the physician's comfort, since they need not bend over the patient either during arterial puncture or during the subsequent procedure, a fact that may become critical in case of obesity of the patient. In addition, using the right side may expose the operator to a lower radiation dose. The preference for right versus left access is supported by evidence indicating that left and right radial approaches exhibit similar feasibility and success rates during interventional procedures. This being said, some of these studies suggest that there may be a difference in radiation exposure and in procedure duration between the two techniques. ⁎ Tel.: +39 0633062481; fax: +39 0633062516. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2014.03.094 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
In this issue, De Rosa et al. greatly expand a previous meta-analysis already published in the International Journal of Cardiology [5], adding more recent randomized studies, as well as non-randomized studies into their analysis. They show that, in spite of similar procedural success rate and total procedural time, the left radial approach is associated with a statistically-significant reduction in radiation exposure and administered contrast media than the right radial approach in 7603 procedures. This is of unclear clinical importance. Indeed, the average 43 s difference in the patient's radiation exposure and the 4 ml reduction in contrast media are not likely to impact outcomes. In observational trials, these differences are more marked than in randomized trials, but still insufficient to render them clinically significant. Nonetheless, the main message of this meta-analysis is that the right radial approach is, on average, technically more demanding than achieving access via the left, apparently in an independent way from operator's proficiency. The small observed difference may also be considered a statistical anomaly secondary to inhomogeneous populations, different procedures and different operators. Likely, there are situations that may magnify the clinical significance of the differences in radiation exposure and contrast use between right and left radial approaches. Consequently, future research should be directed towards clarifying which patients benefit most from a left versus right radial approach, and vice versa. This implies that the disadvantages of a right radial approach, despite being clinically negligible on average, might become critical in particular conditions; for example, when operators are insufficiently trained or still on their learning curve. This point also highlights that, in research on non-pharmacological interventions in which outcomes are operator-dependent, special caution must be taken, both when interpreting results and earlier when designing the study, taking into account a number of neglected variables like individual operator and centre proficiency. Unfortunately, the majority of studies on which De Rosa et al.'s meta-analysis is based lack any quantification of operator or team proficiency in either left or right radial approach. This should be a requirement of all contemporary radial approach studies, so that their internal validity can be determined. Another point that needs to be addressed in future studies is the safety of left versus right radial access in terms of cerebral embolization [6], which has been insufficiently studied in the available researches. Finally, an overall higher degree of patient exposure during a procedure does not necessarily translate into greater exposure for the operator. Indeed, if the operator can be more easily shielded with a right radial approach because of his or her position relative to the patient, the final result could render the higher radiation dose irrelevant [7].
348
Editorial
radiation is suggested in the learning phase with the right radial approach. As such, a radial approach should be considered primary routine access when indications are present and operators have sufficient training, paying particular attention to achieving optimal proficiency in both left and right access approaches, possibly following EAPCI/ESC recommendations for the learning curve for each side of access (Fig. 1), so as to overcome any differences inherent between the two sides.
References
Fig. 1. Proposed framework for learning steps and competency levels for TRI. (Reprinted from EuroIntervention Vol 8 / number 11, Hamon M, Pristipino C, Di Mario C, et al, Consensus document on the radial approach in percutaneous cardiovascular interventions: position paper by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care and Thrombosis of the European Society of Cardiology. Page 1447, Copyright (2013), with permission from Europa Digital & Publishing.)
Again, specific studies must be directed towards clarifying such a question. Taking all these data and considerations together, it is possible to corroborate the recently-issued ESC EAPCI consensus document on radial approaches [1], suggesting no preference for one access route over the other at this stage; though more attention to
[1] Hamon M, Pristipino C, Di Mario C, et al. Consensus document on the radial approach in percutaneous cardiovascular interventions: position paper by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care and Thrombosis of the European Society of Cardiology. EuroIntervention 2013;8:1242–51. [2] Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;44:349–56. [3] Pristipino C, Roncella A, Trani C, et al. Prospective Registry of Vascular Access in Interventions in Lazio region (PREVAIL) study group. Identifying factors that predict the choice and success rate of radial artery catheterisation in contemporary real world cardiology practice: a sub-analysis of the PREVAIL study data. EuroIntervention 2010;6:240–6. [4] Norgaz T, Gorgulu S, Dagdelen S. A randomized study comparing the effectiveness of right and left radial approach for coronary angiography. Catheter Cardiovasc Interv 2012;80:260–4. [5] Biondi-Zoccai G, Sciahbasi A, Bodí V, et al. Right versus left radial artery access for coronary procedures: an international collaborative systematic review and meta-analysis including 5 randomized trials and 3210 patients. Int J Cardiol 2013;166:621–6. [6] Pristipino C, Hamon M. Letter by Pristipino and Hamon regarding article, “cerebral microembolism during coronary angiography: a randomized comparison between femoral and radial arterial access”. Stroke 2011;42:e418. [7] Pristipino C. Radial artery catheterization and radiological exposure. Eur Heart J 2008;29:2316–7.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Editorial
Think left and think right and think low and think high. Oh, the thinks you can think up if only you try! (Theodore Seuss Geisel, a.k.a. Dr. Seuss) Christian Pristipino ⁎ Interventional Cardiology Unit, San Filippo Neri Hospital, Via A. Poerio, 140-00152 Roma, Italy
a r t i c l e
i n f o
Article history: Received 20 January 2014 Accepted 14 March 2014 Available online 20 March 2014 Keywords: Radial approach Left radial approach Right radial approach Meta-analysis
Compared to a femoral approach, radial access significantly reduces vascular access-related haemorrhages and, in STEMI patients, it generally yields better outcomes [1]. However, the feasibility, associated radiation exposure, and duration of radial approach procedures are subject to considerable variability across studies, relative to femoral access [2]. This variability has been attributed to differences in operator expertise, because proficiently accessing the radial artery requires both an adequate learning curve and a consistent ongoing procedural volume of interventions [3]. However, following Dr. Seuss' suggestion, if you look closely enough, considering the “radial approach” as a single entity is misguided. Instead, left and right radial approaches should be considered separately, because they are so different. For example, the right radial approach is often considered more challenging. This is because there are more arterial tortuosities in the dominant arm, more tortuosities in the anonymous trunk versus the left subclavian artery, and a different pathway for catheters to reach the aortic root relative to left-sided routes [4]. Despite these difficulties, a number of operators still prefer it. One main reason relates to the physician's comfort, since they need not bend over the patient either during arterial puncture or during the subsequent procedure, a fact that may become critical in case of obesity of the patient. In addition, using the right side may expose the operator to a lower radiation dose. The preference for right versus left access is supported by evidence indicating that left and right radial approaches exhibit similar feasibility and success rates during interventional procedures. This being said, some of these studies suggest that there may be a difference in radiation exposure and in procedure duration between the two techniques. ⁎ Tel.: +39 0633062481; fax: +39 0633062516. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2014.03.094 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
In this issue, De Rosa et al. greatly expand a previous meta-analysis already published in the International Journal of Cardiology [5], adding more recent randomized studies, as well as non-randomized studies into their analysis. They show that, in spite of similar procedural success rate and total procedural time, the left radial approach is associated with a statistically-significant reduction in radiation exposure and administered contrast media than the right radial approach in 7603 procedures. This is of unclear clinical importance. Indeed, the average 43 s difference in the patient's radiation exposure and the 4 ml reduction in contrast media are not likely to impact outcomes. In observational trials, these differences are more marked than in randomized trials, but still insufficient to render them clinically significant. Nonetheless, the main message of this meta-analysis is that the right radial approach is, on average, technically more demanding than achieving access via the left, apparently in an independent way from operator's proficiency. The small observed difference may also be considered a statistical anomaly secondary to inhomogeneous populations, different procedures and different operators. Likely, there are situations that may magnify the clinical significance of the differences in radiation exposure and contrast use between right and left radial approaches. Consequently, future research should be directed towards clarifying which patients benefit most from a left versus right radial approach, and vice versa. This implies that the disadvantages of a right radial approach, despite being clinically negligible on average, might become critical in particular conditions; for example, when operators are insufficiently trained or still on their learning curve. This point also highlights that, in research on non-pharmacological interventions in which outcomes are operator-dependent, special caution must be taken, both when interpreting results and earlier when designing the study, taking into account a number of neglected variables like individual operator and centre proficiency. Unfortunately, the majority of studies on which De Rosa et al.'s meta-analysis is based lack any quantification of operator or team proficiency in either left or right radial approach. This should be a requirement of all contemporary radial approach studies, so that their internal validity can be determined. Another point that needs to be addressed in future studies is the safety of left versus right radial access in terms of cerebral embolization [6], which has been insufficiently studied in the available researches. Finally, an overall higher degree of patient exposure during a procedure does not necessarily translate into greater exposure for the operator. Indeed, if the operator can be more easily shielded with a right radial approach because of his or her position relative to the patient, the final result could render the higher radiation dose irrelevant [7].
348
Editorial
radiation is suggested in the learning phase with the right radial approach. As such, a radial approach should be considered primary routine access when indications are present and operators have sufficient training, paying particular attention to achieving optimal proficiency in both left and right access approaches, possibly following EAPCI/ESC recommendations for the learning curve for each side of access (Fig. 1), so as to overcome any differences inherent between the two sides.
References
Fig. 1. Proposed framework for learning steps and competency levels for TRI. (Reprinted from EuroIntervention Vol 8 / number 11, Hamon M, Pristipino C, Di Mario C, et al, Consensus document on the radial approach in percutaneous cardiovascular interventions: position paper by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care and Thrombosis of the European Society of Cardiology. Page 1447, Copyright (2013), with permission from Europa Digital & Publishing.)
Again, specific studies must be directed towards clarifying such a question. Taking all these data and considerations together, it is possible to corroborate the recently-issued ESC EAPCI consensus document on radial approaches [1], suggesting no preference for one access route over the other at this stage; though more attention to
[1] Hamon M, Pristipino C, Di Mario C, et al. Consensus document on the radial approach in percutaneous cardiovascular interventions: position paper by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care and Thrombosis of the European Society of Cardiology. EuroIntervention 2013;8:1242–51. [2] Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;44:349–56. [3] Pristipino C, Roncella A, Trani C, et al. Prospective Registry of Vascular Access in Interventions in Lazio region (PREVAIL) study group. Identifying factors that predict the choice and success rate of radial artery catheterisation in contemporary real world cardiology practice: a sub-analysis of the PREVAIL study data. EuroIntervention 2010;6:240–6. [4] Norgaz T, Gorgulu S, Dagdelen S. A randomized study comparing the effectiveness of right and left radial approach for coronary angiography. Catheter Cardiovasc Interv 2012;80:260–4. [5] Biondi-Zoccai G, Sciahbasi A, Bodí V, et al. Right versus left radial artery access for coronary procedures: an international collaborative systematic review and meta-analysis including 5 randomized trials and 3210 patients. Int J Cardiol 2013;166:621–6. [6] Pristipino C, Hamon M. Letter by Pristipino and Hamon regarding article, “cerebral microembolism during coronary angiography: a randomized comparison between femoral and radial arterial access”. Stroke 2011;42:e418. [7] Pristipino C. Radial artery catheterization and radiological exposure. Eur Heart J 2008;29:2316–7.
