**7. Conclusions**

Over the last two decades, major improvements have been achieved in pharmacotherapy and device technology making percutaneous coronary interventions safer, despite the increasing complexity of clinical and anatomic conditions treated during these procedures. Numerous trials are now available and show undoubtedly the superiority of the transradial approach with respect to the incidence of vascular access site complications, especially bleeding, and this despite the fact that all transradial procedures are performed immediately after an initial bolus of heparin to prevent radial artery thrombosis. Moreover, transradial percutaneous interventions can be performed with the same success rate as procedures by femoral approach and have shown their capacities to shorten hospitalization duration and offer the possibility for an outpatient strategy. In addition, transradial access has the potential of reducing medical costs and increasing hospital bed utilization without jeopardizing patient safety. The transradial approach also increases peri-procedural patient comfort and is now strongly preferred by patients for subsequent procedures (2,117). All these advantages are maybe a part of the solution to reduce pressure on limited hospital resources facing rising demands. Nevertheless, even if the transradial approach is extremely safe and occlusion of the artery without any clinical consequences, further studies are needed to search for materials minimizing physiological and anatomical changes in the cannulated radial artery. Radial experts underscore the need for other large randomized trials to confirm that radial approach has a favourable impact on the incidence of post procedural ischemic events and cuts mortality as compared to femoral approach. In this case, guidelines relative to percutaneous coronary interventions should be updated and the worldwide practice changed but transradial access is already an essential tool for the interventional cardiologist.

#### **8. Acknowledgments**

The author would like to thank Caroline Lepiece, MD, for her expert assistance in the revision of the manuscript and also Vincent Dangoisse, MD, Patrick Chenu, MD, and Erwin Schroeder,MD , my teachers in interventional cardiology.

#### **9. References**

[1] Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv 2008;1:379-86.

shorter length of stay and fewer vascular access site complications, a more rapid return to

Dedicated radial equipments (such as micropuncture kits and catheters) are still a little bit more expensive than those used for femoral access. However, the RIVAL study reported the use of a lower mean number of diagnostic catheters per procedure with transradial access and similarly the same number of guiding catheters per PCI for the two techniques (2). Economic implications of these observations are not yet quantified, especially during the early adoption of the radial technique, which is often associated with increased catheter

Over the last two decades, major improvements have been achieved in pharmacotherapy and device technology making percutaneous coronary interventions safer, despite the increasing complexity of clinical and anatomic conditions treated during these procedures. Numerous trials are now available and show undoubtedly the superiority of the transradial approach with respect to the incidence of vascular access site complications, especially bleeding, and this despite the fact that all transradial procedures are performed immediately after an initial bolus of heparin to prevent radial artery thrombosis. Moreover, transradial percutaneous interventions can be performed with the same success rate as procedures by femoral approach and have shown their capacities to shorten hospitalization duration and offer the possibility for an outpatient strategy. In addition, transradial access has the potential of reducing medical costs and increasing hospital bed utilization without jeopardizing patient safety. The transradial approach also increases peri-procedural patient comfort and is now strongly preferred by patients for subsequent procedures (2,117). All these advantages are maybe a part of the solution to reduce pressure on limited hospital resources facing rising demands. Nevertheless, even if the transradial approach is extremely safe and occlusion of the artery without any clinical consequences, further studies are needed to search for materials minimizing physiological and anatomical changes in the cannulated radial artery. Radial experts underscore the need for other large randomized trials to confirm that radial approach has a favourable impact on the incidence of post procedural ischemic events and cuts mortality as compared to femoral approach. In this case, guidelines relative to percutaneous coronary interventions should be updated and the worldwide practice changed but transradial access is already an essential tool for the

The author would like to thank Caroline Lepiece, MD, for her expert assistance in the revision of the manuscript and also Vincent Dangoisse, MD, Patrick Chenu, MD, and Erwin

[1] Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and

femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv 2008;1:379-86.

professional activities is insured for working patients.

usage because of frequent inadequate choices.

**7. Conclusions** 

interventional cardiologist.

**8. Acknowledgments** 

**9. References** 

Schroeder,MD , my teachers in interventional cardiology.


Transradial Approach

for Coronary Interventions: The New Gold Standard for Vascular Access? 23

[34] Stella PR, Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R.

[35] Nikolsky E, Mehran R, Halkin A, et al. Vascular complications associated with

[36] Chevalier B, Lancelin B, Koning R, et al. Effect of a closure device on complication rates

[37] Mann T, Cowper PA, Peterson ED, et al. Transradial coronary stenting: comparison

[38] Louvard Y, Ludwig J, Lefevre T, et al. Transradial approach for coronary angioplasty in

[39] Morice MC, Dumas P, Lefevre T, Loubeyre C, Louvard Y, Piechaud JF. Systematic use

[40] Sciahbasi A, Fischetti D, Picciolo A, et al. Transradial access compared with femoral

[41] Dangas G, Mehran R, Kokolis S, et al. Vascular complications after percutaneous

[42] Dauerman HL, Applegate RJ, Cohen DJ. Vascular closure devices: the second decade. J

[43] Meyerson SL, Feldman T, Desai TR, Leef J, Schwartz LB, McKinsey JF. Angiographic

[44] Arora N, Matheny ME, Sepke C, Resnic FS. A propensity analysis of the risk of vascular

[45] Caputo RP. Transradial Arterial Access: Economic Considerations. J Invasive Cardiol.

[46] Fitts J, Ver Lee P, Hofmaster P, Malenka D. Fluoroscopy-guided femoral artery

[47] Grier D, Hartnell G. Percutaneous femoral artery puncture: practice and anatomy. Br J

[50] Hamon M, Mc Fadden E. Trans-radial approach for cardiovascular interventions: ESM,

[51] Patel T. Patel's Atlas of Transradial Intervention: The Basics: Seascript Company, 2007.

[48] Safian RD, Freed M. The manual of interventional cardiology: Physicians' Press, 2001. [49] Barbeau GR, Arsenault F, Dugas L, Simard S, Lariviere MM. Evaluation of the

with the Allen's test in 1010 patients. Am Heart J 2004;147:489-93.

arteriotomy closure devices. J Am Coll Cardiol 2001;38:638-41.

coronary angioplasty. Cathet Cardiovasc Diagn 1997;40:156-8.

procedures: a meta-analysis. J Am Coll Cardiol 2004;44:1200-9.

Cardiovasc Interv 2003;58:285-91.

Cardiovasc Interv 2002;55:206-11.

Am Coll Cardiol 2007;50:1617-26.

closure devices. Am Heart J 2007;153:606-11.

Interv 2000;49:150-6.

2009;137:199-205.

Surg 2002;36:137-44.

2009;21:18-20.

2008;21:273-8.

2003.

Radiol 1990;63:602-4.

Incidence and outcome of radial artery occlusion following transradial artery

arteriotomy closure devices in patients undergoing percutaneous coronary

in high-local-risk patients: results of a randomized multicenter trial. Catheter

with femoral access closed with an arterial suture device. Catheter Cardiovasc

the setting of acute myocardial infarction: a dual-center registry. Catheter

of transradial approach or suture of the femoral artery after angioplasty: attempt at achieving zero access site complications. Catheter Cardiovasc Interv 2000;51:417-21.

puncture closure devices in percutaneous coronary procedures. Int J Cardiol

coronary interventions following hemostasis with manual compression versus

access site complications in the era of arterial closure devices. Vasc Endovascular

complications after cardiac catheterization procedures with the use of vascular

puncture reduces the risk of PCI-related vascular complications. J Interv Cardiol

ulnopalmar arterial arches with pulse oximetry and plethysmography: comparison


[18] An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. The GUSTO investigators. N Engl J Med 1993;329:673-82. [19] Chesebro JH, Knatterud G, Roberts R, et al. Thrombolysis in Myocardial Infarction

[20] Stone GW, McLaurin BT, Cox DA, et al. Bivalirudin for patients with acute coronary

[21] Doyle BJ, Ting HH, Bell MR, et al. Major femoral bleeding complications after

[22] Chase AJ, Fretz EB, Warburton WP, et al. Association of the arterial access site at

[23] Cox N, Resnic FS, Popma JJ, Simon DI, Eisenhauer AC, Rogers C. Comparison of the

[24] Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for

[25] Hirano Y, Ikuta S, Uehara H, et al. Diagnosis of vascular complications at the puncture

[26] Koreny M, Riedmuller E, Nikfardjam M, Siostrzonek P, Mullner M. Arterial puncture

catheterization: systematic review and meta-analysis. Jama 2004;291:350-7. [27] Louvard Y, Benamer H, Garot P, et al. Comparison of transradial and transfemoral

[28] Waksman R, King SB, 3rd, Douglas JS, et al. Predictors of groin complications after balloon and new-device coronary intervention. Am J Cardiol 1995;75:886-9. [29] Corriere MA, Guzman RJ. True and false aneurysms of the femoral artery. Semin Vasc

[30] Graham AN, Wilson CM, Hood JM, Barros D'Sa AA. Risk of rupture of

[31] Kazmers A, Meeker C, Nofz K, et al. Nonoperative therapy for postcatheterization

[32] Sherev DA, Shaw RE, Brent BN. Angiographic predictors of femoral access site

[33] Tavris DR, Gallauresi BA, Dey S, Brindis R, Mitchel K. Risk of local adverse events by

complications: implication for planned percutaneous coronary intervention.

gender following cardiac catheterization. Pharmacoepidemiol Drug Saf

postangiographic femoral false aneurysm. Br J Surg 1992;79:1022-5.

femoral artery pseudoaneurysms. Am Surg 1997;63:199-204.

site after cardiac catheterization. J Cardiol 2004;43:259-65.

OCTOPLUS study). Am J Cardiol 2004;94:1177-80.

Catheter Cardiovasc Interv 2005;65:196-202.

discharge. Circulation 1987;76:142-54.

JACC Cardiovasc Interv 2008;1:202-9.

Arm or Leg). Heart 2008;94:1019-25.

2004;94:1174-7.

Heart J 2009;157:132-40.

Surg 2005;18:216-23.

2007;16:125-31.

syndromes. N Engl J Med 2006;355:2203-16.

(TIMI) Trial, Phase I: A comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital

percutaneous coronary intervention: incidence, predictors, and impact on longterm survival among 17,901 patients treated at the Mayo Clinic from 1994 to 2005.

angioplasty with transfusion and mortality: the M.O.R.T.A.L study (Mortality benefit Of Reduced Transfusion after percutaneous coronary intervention via the

risk of vascular complications associated with femoral and radial access coronary catheterization procedures in obese versus nonobese patients. Am J Cardiol

coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am

closing devices compared with standard manual compression after cardiac

approaches for coronary angiography and angioplasty in octogenarians (the


Transradial Approach

75.

5.

2010;76:654-8.

Cardiovasc Interv 2002;56:188-95.

Invasive Cardiol 1996;8 Suppl D:40D-44D.

hand function. J Invasive Cardiol 2000;12:605-9.

Cardiovasc Interv 2007;70:185-9.

2003;41:1109-14.

Catheter Cardiovasc Interv 2008;72:335-40.

catheterization. Am J Cardiol 2011;107:1698-701.

procedure. Catheter Cardiovasc Interv 2003;58:301-4.

Diagn 1997;41:124-30.

for Coronary Interventions: The New Gold Standard for Vascular Access? 25

[67] Cha KS, Kim MH. Feasibility and safety of concomitant left internal mammary

[68] Benit E, Missault L, Eeman T, et al. Brachial, radial, or femoral approach for elective

[69] Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. A randomized

[70] Mann JT, 3rd, Cubeddu MG, Schneider JE, Arrowood M. Right Radial Access for PTCA:

[71] Plante S, Cantor WJ, Goldman L, et al. Comparison of bivalirudin versus heparin on

[72] Wu SS, Galani RJ, Bahro A, Moore JA, Burket MW, Cooper CJ. 8 french transradial

[73] Saito S, Ikei H, Hosokawa G, Tanaka S. Influence of the ratio between radial artery

[74] Sakai H, Ikeda S, Harada T, et al. Limitations of successive transradial approach in the same arm: the Japanese experience. Catheter Cardiovasc Interv 2001;54:204-8. [75] Pancholy SB. Comparison of the effect of intra-arterial versus intravenous heparin on

[76] Sanmartin M, Gomez M, Rumoroso JR, et al. Interruption of blood flow during

[77] Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of radial artery occlusion-

[78] Bernat I, Bertrand OF, Rokyta R, et al. Efficacy and safety of transient ulnar artery

[79] Yoo BS, Lee SH, Ko JY, et al. Procedural outcomes of repeated transradial coronary

[80] Edmundson A, Mann T. Nonocclusive radial artery injury resulting from transradial coronary interventions: radial artery IVUS. J Invasive Cardiol 2005;17:528-31. [81] Wakeyama T, Ogawa H, Iida H, et al. Intima-media thickening of the radial artery after

[82] Sanmartin M, Goicolea J, Ocaranza R, Cuevas D, Calvo F. Vasoreactivity of the radial artery after transradial catheterization. J Invasive Cardiol 2004;16:635-8.

coronary intervention. Catheter Cardiovasc Interv 1999;46:173-8.

arteriography at the setting of the right transradial coronary angiography. Catheter

Palmaz-Schatz stent implantation: a randomized comparison. Cathet Cardiovasc

comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol 1997;29:1269-

A Prospective Study Demonstrates Reduced Complications and Hospital Charges. J

radial artery occlusion after transradial catheterization. Catheter Cardiovasc Interv

coronary interventions: clinical outcome and late effects on the radial artery and

inner diameter and sheath outer diameter on radial artery flow after transradial

radial artery occlusion after transradial catheterization. Am J Cardiol 2009;104:1083-

compression and radial artery occlusion after transradial catheterization. Catheter

patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization.

compression to recanalize acute radial artery occlusion after transradial

transradial intervention. An intravascular ultrasound study. J Am Coll Cardiol


[52] Sciahbasi A, Romagnoli E, Trani C, et al. Evaluation of the "learning curve" for left and

[53] Guédès A, Dangoisse V, Gabriel L, et al. Low rate of conversion to transfemoral

[54] Dahm JB, Vogelgesang D, Hummel A, Staudt A, Volzke H, Felix SB. A randomized trial

[55] Kiemeneij F, Fraser D, Slagboom T, Laarman G, van der Wieken R. Hydrophilic coating

[56] Rathore S, Stables RH, Pauriah M, et al. Impact of length and hydrophilic coating of the

[57] Saito S, Tanaka S, Hiroe Y, et al. Comparative study on transradial approach vs.

[58] Chodor P, Krupa H, Kurek T, et al. RADIal versus femoral approach for percutaneous

[60] Hamon M, Sabatier R, Zhao Q, Niculescu R, Valette B, Grollier G. Mini-invasive

uncoated sheaths. Catheter Cardiovasc Interv 2003;59:161-4.

a randomized study. JACC Cardiovasc Interv 2010;3:475-83.

2011;108:185-8.

Invasive Cardiol 2010;22:391-7.

Cardiovasc Interv 2002;57:172-6.

Interv 2003;59:26-33.

Cardiol 2011.

2008;72:357-64.

Heart J 2011;161:172-9.

right radial approach during percutaneous coronary procedures. Am J Cardiol

approach when attempting both radial arteries for coronary angiography and percutaneous coronary intervention: a study of 1,826 consecutive procedures. J

of 5 vs. 6 French transradial percutaneous coronary interventions. Catheter

aids radial sheath withdrawal and reduces patient discomfort following transradial coronary intervention: a randomized double-blind comparison of coated and

introducer sheath on radial artery spasm during transradial coronary intervention:

transfemoral approach in primary stent implantation for patients with acute myocardial infarction: results of the test for myocardial infarction by prospective unicenter randomization for access sites (TEMPURA) trial. Catheter Cardiovasc

coronary interventions in patients with Acute Myocardial Infarction (RADIAMI): A prospective, randomized, single-center clinical trial. Cardiol J 2009;16:332-40. [59] Egred M. Feasibility and Safety of 7-Fr Radial Approach for Complex PCI. J Interv

strategy in acute coronary syndromes: direct coronary stenting using 5 Fr guiding catheters and transradial approach. Catheter Cardiovasc Interv 2002;55:340-3. [61] Ochiai M, Isshiki T, Toyoizumi H, et al. Efficacy of transradial primary stenting in patients with acute myocardial infarction. Am J Cardiol 1999;83:966-8, A10. [62] Rathore S, Hakeem A, Pauriah M, Roberts E, Beaumont A, Morris JL. A comparison of

the transradial and the transfemoral approach in chronic total occlusion percutaneous coronary intervention. Catheter Cardiovasc Interv 2009;73:883-7. [63] Rathore S, Roberts E, Hakeem AR, Pauriah M, Beaumont A, Morris JL. The feasibility of

percutaneous transradial coronary intervention for saphenous vein graft lesions

intervention using large bore sheathless guide catheter. Catheter Cardiovasc Interv

procedural times during percutaneous coronary procedures: TALENT study. Am

and comparison with transfemoral route. J Interv Cardiol 2009;22:336-40. [64] Mamas MA, Eichhofer J, Hendry C, et al. Use of the Heartrail II catheter as a distal stent delivery device; an extended case series. EuroIntervention 2009;5:265-71. [65] Mamas MA, Fath-Ordoubadi F, Fraser DG. Atraumatic complex transradial

[66] Sciahbasi A, Romagnoli E, Burzotta F, et al. Transradial approach (left vs right) and


Transradial Approach

for Coronary Interventions: The New Gold Standard for Vascular Access? 27

[100] Sciahbasi A, Romagnoli E, Trani C, et al. Operator radiation exposure during

[102] Feldman DN, Minutello RM, Gade CL, Wong SC. Outcomes following immediate (ad

[104] Krone RJ, Shaw RE, Klein LW, Blankenship JC, Weintraub WS. Ad hoc percutaneous

[105] Shubrooks SJ, Jr., Malenka DJ, Piper WD, et al. Safety and efficacy of percutaneous

[106] Bertrand OF, De Larochelliere R, Rodes-Cabau J, et al. A randomized study comparing

[107] Gilchrist IC, Nickolaus MJ, Momplaisir T. Same-day transradial outpatient stenting

[108] Heyde GS, Koch KT, de Winter RJ, et al. Randomized trial comparing same-day

[109] Jabara R, Gadesam R, Pendyala L, et al. Ambulatory discharge after transradial

[110] Silber S, Albertsson P, Aviles FF, et al. Guidelines for percutaneous coronary

[111] Slagboom T, Kiemeneij F, Laarman GJ, van der Wieken R. Outpatient coronary angioplasty: feasible and safe. Catheter Cardiovasc Interv 2005;64:421-7. [112] Slagboom T, Kiemeneij F, Laarman GJ, van der Wieken R, Odekerken D. Actual

[113] Cohen DJ, Lincoff AM, Lavelle TA, et al. Economic evaluation of bivalirudin with

European Society of Cardiology. Eur Heart J 2005;26:804-47.

2001 New York State Angioplasty Registry). Am J Cardiol 2007;99:446-9. [103] Good CW, Blankenship JC, Scott TD, Skelding KA, Berger PB, Wood GC. Feasibility

TALENT dosimetric substudy. Circ Cardiovasc Interv 2011;4:226-31. [101] Chung WJ, Fang HY, Tsai TH, et al. Transradial approach percutaneous coronary

interventions in an out-patient clinic. Int Heart J 2010;51:371-6.

Invasive Cardiol 2009;21:194-200.

2006;68:696-703.

306.

J 2008;156:1141-6.

2001;53:204-8.

Am J Cardiol 2000;86:41-5.

Circulation 2006;114:2636-43.

Catheter Cardiovasc Interv 2002;56:10-3.

percutaneous coronary procedures through the left or right radial approach: the

hoc) versus staged percutaneous coronary interventions (report from the 2000 to

and safety of ad hoc percutaneous coronary intervention in the modern era. J

coronary interventions in patients with stable coronary artery disease--a study of prevalence, safety, and variation in use from the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR). Catheter Cardiovasc Interv

coronary interventions performed immediately after diagnostic catheterization in northern new england and comparison with similar procedures performed later.

same-day home discharge and abciximab bolus only to overnight hospitalization and abciximab bolus and infusion after transradial coronary stent implantation.

with a 6-hr course of glycoprotein IIb/IIIa receptor blockade: a feasibility study.

discharge with overnight hospital stay after percutaneous coronary intervention: results of the Elective PCI in Outpatient Study (EPOS). Circulation 2007;115:2299-

coronary intervention: Preliminary US single-center experience (Same-day TransRadial Intervention and Discharge Evaluation, the STRIDE Study). Am Heart

interventions. The Task Force for Percutaneous Coronary Interventions of the

outpatient PTCA: results of the OUTCLAS pilot study. Catheter Cardiovasc Interv

provisional glycoprotein IIB/IIIA inhibition versus heparin with routine


[83] Bazemore E, Mann JT, 3rd. Problems and complications of the transradial approach for

[84] Tizon-Marcos H, Barbeau GR. Incidence of compartment syndrome of the arm in a

[85] Louvard Y, Lefevre T. Loops and transradial approach in coronary diagnosis and

[86] Rathore S, Morris JL. The radial approach: is this the route to take? J Interv Cardiol

[87] Dieter RS, Akef A, Wolff M. Eversion endarterectomy complicating radial artery access for left heart catheterization. Catheter Cardiovasc Interv 2003;58:478-80. [88] Park KW, Chung JW, Chang SA, Kim KI, Chung WY, Chae IH. Two cases of

[89] Papadimos TJ, Hofmann JP. Radial artery thrombosis, palmar arch systolic blood

[90] Goldman S, Sethi GK, Holman W, et al. Radial artery grafts vs saphenous vein grafts in coronary artery bypass surgery: a randomized trial. Jama 2011;305:167-74. [91] Kamiya H, Ushijima T, Kanamori T, et al. Use of the radial artery graft after transradial catheterization: is it suitable as a bypass conduit? Ann Thorac Surg 2003;76:1505-9. [92] Rao SV, Cohen MG, Kandzari DE, Bertrand OF, Gilchrist IC. The transradial approach

[93] Manoukian SV, Feit F, Mehran R, et al. Impact of major bleeding on 30-day mortality

[94] Montalescot G, Ongen Z, Guindy R, et al. Predictors of outcome in patients undergoing

[95] Sciahbasi A, Pristipino C, Ambrosio G, et al. Arterial access-site-related outcomes of

[96] Vorobcsuk A, Konyi A, Aradi D, et al. Transradial versus transfemoral percutaneous

[97] Jurga J, Nyman J, Tornvall P, et al. Cerebral microembolism during coronary

[98] Lund C, Nes RB, Ugelstad TP, et al. Cerebral emboli during left heart catheterization

[99] Brasselet C, Blanpain T, Tassan-Mangina S, et al. Comparison of operator radiation

may cause acute brain injury. Eur Heart J 2005;26:1269-75.

PCI. Results of the RIVIERA study. Int J Cardiol 2008;129:379-87.

large series of transradial approach for coronary procedures. J Interv Cardiol

mediastinal hematoma after cardiac catheterization: A rare but real complication of

velocities, and chronic regional pain syndrome 1 following transradial cardiac

to percutaneous coronary intervention: historical perspective, current concepts, and

and clinical outcomes in patients with acute coronary syndromes: an analysis from

patients undergoing invasive coronary procedures for acute coronary syndromes (from the ComPaRison of Early Invasive and Conservative Treatment in Patients With Non-ST-ElevatiOn Acute Coronary Syndromes [PRESTO-ACS] Vascular

coronary intervention in acute myocardial infarction Systematic overview and

angiography: a randomized comparison between femoral and radial arterial access.

exposure with optimized radiation protection devices during coronary angiograms and ad hoc percutaneous coronary interventions by radial and femoral routes. Eur

coronary interventions: a review. J Invasive Cardiol 2005;17:156-9.

intervention. Catheter Cardiovasc Interv 2000;51:250-2.

the transradial approach. Int J Cardiol 2008;130:e89-92.

future directions. J Am Coll Cardiol 2010;55:2187-95.

the ACUITY Trial. J Am Coll Cardiol 2007;49:1362-8.

Substudy). Am J Cardiol 2009;103:796-800.

meta-analysis. Am Heart J 2009;158:814-21.

Stroke 2011;42:1475-7.

Heart J 2007.

catheterization. Catheter Cardiovasc Interv 2002;57:537-40.

2008;21:380-4.

2008;21:375-9.


**2** 

*Canada* 

**Percutaneous Coronary Intervention and** 

Coronary artery disease remains highly prevalent in contemporary society and over 1000000 revascularisation procedures by percutaneous coronary intervention (PCI) are performed annually worldwide. PCI has seen significant improvement in clinical outcomes with the current generation of drug eluting stents. The role of PCI in multivessel coronary disease has been expanded with current trial evidence indicating equipoise between PCI and

Increasingly, coronary artery by-pass surgery (CABG) or PCI is being considered as an equivalent revascularisation strategy within the same patient population. Given the options available to clinicians and patients it is important to have robust tools to accurately compare the risk and benefits of selected strategies when making management decisions. Whilst these tools have been available to the cardiac surgeons for some time (Granton & Cheng, 2008), an

The CANADA Score is a risk prediction model for determining 30 day mortality risk in patients undergoing elective, urgent and emergent PCI. Its development and validation will be discussed with reference to the established cardiac surgical risk calculators currently available.

Risk prediction models are statistical models produced from patient databases using a combination of individual risk predication markers and are used by clinicians and patients for making treatment decisions. Model inaccuracy and ineffectiveness can therefore have negative implications on risk measurement and subsequent patient decisions and outcomes. The accuracy of the model is typically summarised in terms of the model's discrimination and calibration (Janes et al, 2008). The applicability of a risk model to a patient population is

Discrimination is the ability of the model to correctly classify outcomes (Nathanson & Higgins, 2008). The statistical measures of area under the curve (AUC) or concordance index (C-index) are commonly used to describe how well patients are classified within the model.

equivalent tool for the interventional cardiologist has only recently been published.

**1. Introduction** 

**2. Risk prediction models** 

determined by validation.

**2.1 Discrimination** 

coronary artery by-pass surgery in selected groups.

**30-Day Mortality: The CANADA Score** 

Rohan Poulter and Jaap Hamburger

*University of British Columbia* 

glycoprotein IIB/IIIA inhibition for percutaneous coronary intervention: results from the REPLACE-2 trial. J Am Coll Cardiol 2004;44:1792-800.

