Complex transradial coronary intervention: Adapting transradial techniques to more complex lesions and higher-risk patients

Jacob Misenheimer, MD Interventional Cardiologist Assistant Professor, Medicine

In recent years, transradial cardiac catheterization and intervention has been growing in prevalence and popularity due to lower bleeding risk, to early patient mobilization, and even to cost savings. Many operators, however, are reluctant to adopt transradial interventional techniques out of concerns regarding the steep learning curve to develop the necessary technical skills. This is especially true in regards to patients with complex anatomy, such as calcified or bifurcation lesions, and in high-risk patients, including patients suffering from acute ST segment elevation myocardial infarction.

A recent meta-analysis published in the Journal of the American College of Cardiology: Cardiovascular Interventions by Ferrante and colleagues has demonstrated that transradial coronary intervention is associated not only with reduced risks of bleeding and vascular access site complications but also with lower mortality as compared to transfemoral intervention. These benefits were found to be consistent across all patient subsets, including stable patients and patients presenting with acute coronary syndromes. Most interestingly, subgroup analysis revealed the mortality benefit to be the greatest in patients presenting with acute ST segment elevation myocardial infarction, and these benefits all came without increased risk of postprocedural myocardial infarction or stroke.

Although these findings are striking, it is notable that all of the studies analyzed were performed in high-volume transradial centers by operators skilled in transradial coronary interventions. For this reason, the Society for Cardiovascular Angiography and Interventions (SCAI) recommends a stepwise approach for developing transradial skills. Operators and labs should first develop competence performing simple diagnostic and interventional procedures on patients with favorable upper limb and coronary anatomy and then become proficient performing elective and urgent interventions on patients with more challenging anatomy, including subclavian loops, radial loops and complex coronary anatomy. Finally, after attaining competence in these types of cases, operators can move on to performing multivessel interventions, chronic total occlusion interventions and interventions, during acute myocardial infarction via the transradial approach.

At Augusta University, our lab is well-experienced in transradial coronary interventions, allowing our patients to benefit from the advantages of the approach, even if they present with acute myocardial infarction or have complex coronary anatomy. Utilizing state-of-the-art, sheathless guide catheters, both traditional rotational atherectomy devices, and newer, smaller-bore, orbital atherectomy devices, even calcified lesions (Figure 1) and high-risk bifurcation lesions, including left main lesions (Figure 2), can be intervened upon safely with a transradial approach. Most importantly, patients who present with acute ST segment elevation myocardial infarction, who derive the greatest benefit from a transradial approach, can be intervened upon safely and expediently with excellent results (Figure 3).