**6. Transradial approach: The perspectives**

#### **6.1 Outpatient strategy is feasible with transradial approach**

Ad-hoc percutaneous coronary interventions, performed immediately after diagnostic angiography, have been shown to have equivalent short and long term safety when compared to elective interventions (101-105). In current clinical practice, ad-hoc PCI represents the majority of elective coronary interventions in most countries. PCI programs with same day discharge are therefore conceivable.

In accordance with the known benefits of transradial interventions, including less bleeding complications, better quality of care and earlier ambulation after the procedure, it was natural to test the feasibility and safety of an ambulatory discharge strategy in selected patients undergoing transradial coronary procedures. Numerous international studies are now available and even if not always randomized, they have validated this strategy after uncomplicated transradial percutaneous coronary interventions (106-112). No more access site complications are observed and the majority of events occurring 24 hours after discharge would not have been avoided by traditional next-day discharge. Bertrand et al. have also shown in a selected high risk population of patients (two thirds of patients presented with unstable angina and approximately 20% presented with high-risk acute coronary syndrome prior to the procedure) that same-day home discharge after uncomplicated transradial coronary stenting and administration of a bolus of abciximab is not clinically inferior to the standard overnight hospitalization with a bolus of abciximab followed by a 12-hour infusion. The primary composite end point of this study was the 30 day incidence of any of the following events: death, myocardial infarction, urgent revascularization, major bleeding, repeat hospitalization, access site complications, and severe thrombocytopenia. The incidence of the primary end point was 20.4% in the sameday discharge group and 18.2% in the overnight hospitalization group (P=0.017 for noninferiority).No death occurred and the rate of major bleeding in both groups was extremely low at 0.8% and 0.2%, respectively (106).

Interestingly, similar feasibility and safety data are far less numerous to date for femoral approach, even if the same strategy may likewise be amenable by this access. Previous trials

have demonstrated a higher incidence of local vascular complications either with or without the use of a vascular closure device and despite an optimal post-PCI recumbency depending on the vascular access management strategy chosen by the operator. Moreover, patients undergoing a transfemoral access, even if receiving closure devices, more frequently need to be reassured regarding early ambulation compared to those with a transradial approach and an unrestricted post-catheterization ambulation (109).

#### **6.2 Reductions of hospitalizations stays and costs**

18 Coronary Interventions

limited experience in transradial approach and results have not been corrected for probable

Finally, even if differences in terms of radiation dose beneath the lead apron are minimal between these approaches, their clinical impact in the long term is not known and operators

Concerning many points, the debate is not closed and future randomized trials, if correctly powered to demonstrated differences in primary outcomes between the two vascular approaches and designed to avoid confounding factors, will be useful to confirm these findings. However, all the previous authors agree with the fact that clinicians may choose radial access for percutaneous coronary interventions because of its similar performances

Ad-hoc percutaneous coronary interventions, performed immediately after diagnostic angiography, have been shown to have equivalent short and long term safety when compared to elective interventions (101-105). In current clinical practice, ad-hoc PCI represents the majority of elective coronary interventions in most countries. PCI programs

In accordance with the known benefits of transradial interventions, including less bleeding complications, better quality of care and earlier ambulation after the procedure, it was natural to test the feasibility and safety of an ambulatory discharge strategy in selected patients undergoing transradial coronary procedures. Numerous international studies are now available and even if not always randomized, they have validated this strategy after uncomplicated transradial percutaneous coronary interventions (106-112). No more access site complications are observed and the majority of events occurring 24 hours after discharge would not have been avoided by traditional next-day discharge. Bertrand et al. have also shown in a selected high risk population of patients (two thirds of patients presented with unstable angina and approximately 20% presented with high-risk acute coronary syndrome prior to the procedure) that same-day home discharge after uncomplicated transradial coronary stenting and administration of a bolus of abciximab is not clinically inferior to the standard overnight hospitalization with a bolus of abciximab followed by a 12-hour infusion. The primary composite end point of this study was the 30 day incidence of any of the following events: death, myocardial infarction, urgent revascularization, major bleeding, repeat hospitalization, access site complications, and severe thrombocytopenia. The incidence of the primary end point was 20.4% in the sameday discharge group and 18.2% in the overnight hospitalization group (P=0.017 for noninferiority).No death occurred and the rate of major bleeding in both groups was extremely

Interestingly, similar feasibility and safety data are far less numerous to date for femoral approach, even if the same strategy may likewise be amenable by this access. Previous trials

should always apply all efforts to reduce the radiation dose in their daily practice.

improvements with greater expertise.

and above all, its reduced vascular complications.

**6. Transradial approach: The perspectives** 

with same day discharge are therefore conceivable.

low at 0.8% and 0.2%, respectively (106).

**6.1 Outpatient strategy is feasible with transradial approach** 

**5.4 Conclusions** 

Several dedicated costs analyses have shown a significant reduction in hospital costs with transradial access compared to other arterial access sites .The economic benefits of the transradial approach are mainly derived from its known advantages: a reduced incidence of vascular access site complications and immediate ambulation after the procedure (45).

A lower rate of access site complications also means decreased length of stay and costs compared with those observed in case of an adverse event (1,113,114). A vascular complication inevitably drives additional charges related to its careful medical evaluation using different diagnostic vascular imaging techniques and because of treatments required. Red blood cell or platelet transfusions (preceded by numerous laboratory tests), thrombin injections or operating room charges for surgical repair rapidly increase hospitalization costs. These adverse outcomes inevitably prolong hospitalization but indirect costs linked with an increased nursing and staff workload must also be considered even if they are more difficult to appreciate. Several authors have evaluated the negative economic impact of vascular access complications and the incremental costs ranged from \$ 4000 for minor complications up to \$ 14 000 for major events (114-116). Cooper et al. have showed, in a single center randomized study, that transradial access for diagnostic cardiac catheterization led to significant reductions in hospital costs when compared to femoral access (\$ 2010 versus \$2299 respectively, p< 0.001). Lower bed costs, mainly, taking into account nursing workload, but also pharmacy explain the median cost reduction of 289 \$ per procedure (117). In the same way, Roussanov et al. have shown that a femoral access with or without the use of a closure device also failed to reduce total hospitalization costs as compare to radial access even in case of similar recovery times (radial =369.5 \$ ± 74.6, femoral= 446.9 \$ ± 60.2 and femoral with closure device 553.4 \$ ± 81.0; p < 0.001) (118).

Immediate ambulation, in addition to showing radial approach safety, provides additional cost reductions through different mechanisms. First, transradial approach provides shorter length of stay .A systematic review and meta-analysis of randomized trials showed that radial access reduced hospital stay by a mean of 0.4 days [95% CI 0.2-0.5], p=0.0001) which also means an expedited room turn-over (24).Secondly, as reported by Amoroso et al, nursing workload can be significantly reduced inside (86 min versus 174 min for femoral access) as well as outside the catheterization laboratory (386 min versus 720 min for femoral access) when the radial way is systematically used for a catheterization procedure (119).An increased catheterization laboratory throughput can also be expected with radial access because less time is spent for sheath removal. Third, it has been shown that same day home discharge after an uncomplicated transradial percutaneous intervention results in a 50% relative reduction in post-PCI medical costs. In the EASY trial, at 30-day follow-up, the mean cumulative medical cost per outpatient was \$1,117 ± \$1,554 versus \$2,258 ± \$1,328 for overnight-stay patients (Canadian dollars). The mean difference of \$1,141[95% CI: \$962 to \$1,320] was mainly due to the extra night for overnight hospital stay (120). Finally, with

Transradial Approach

for Coronary Interventions: The New Gold Standard for Vascular Access? 21

[2] Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography

[4] Resnic FS, Arora N, Matheny M, Reynolds MR. A cost-minimization analysis of the

[5] Geisler T, Gawaz M, Steinhubl SR, Bhatt DL, Storey RF, Flather M. Current strategies in

[6] Gunasekaran S, Cherukupalli R. Radial artery perforation and its management during

[7] Mannucci PM, Franchini M. Mechanism of hemostasis defects and management of bleeding in patients with acute coronary syndromes. Eur J Intern Med 2010;21:254-9. [8] Ndrepepa G, Keta D, Byrne RA, et al. Impact of body mass index on clinical outcome in

[9] Ndrepepa G, Keta D, Schulz S, et al. Characterization of patients with bleeding

[10] Wijns W, Kolh P, Danchin N, et al. Guidelines on myocardial revascularization. Eur

[11] Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach

[12] Doyle BJ, Rihal CS, Gastineau DA, Holmes DR, Jr. Bleeding, blood transfusion, and

[13] Eikelboom JW, Mehta SR, Anand SS, Xie C, Fox KA, Yusuf S. Adverse impact of

[14] Moscucci M, Fox KA, Cannon CP, et al. Predictors of major bleeding in acute coronary

[15] Ndrepepa G, Berger PB, Mehilli J, et al. Periprocedural bleeding and 1-year outcome

as a component of a quadruple end point. J Am Coll Cardiol 2008;51:690-7. [16] Osten MD, Ivanov J, Eichhofer J, et al. Impact of renal insufficiency on angiographic,

[17] Rao SV, O'Grady K, Pieper KS, et al. Impact of bleeding severity on clinical outcomes among patients with acute coronary syndromes. Am J Cardiol 2005;96:1200-6.

contemporary practice. J Am Coll Cardiol 2009;53:2019-27.

randomised, parallel group, multicentre trial. Lancet 2011;377:1409-20. [3] Kinnaird TD, Stabile E, Mintz GS, et al. Incidence, predictors, and prognostic

interventions. Am J Cardiol 2003;92:930-5.

Am J Cardiol 2007;99:766-70.

Pharmacol Ther 2010;127:95-107.

PCI. J Invasive Cardiol 2009;21:E24-6.

intervention. Heart Vessels 2010;25:27-34.

intervention. Heart Vessels 2010;25:294-8.

intervention. Am J Cardiol 2008;101:780-5.

Heart J 2010;31:2501-55.

2006;114:774-82.

2003;24:1815-23.

and intervention in patients with acute coronary syndromes (RIVAL): a

implications of bleeding and blood transfusion following percutaneous coronary

angio-seal vascular closure device following percutaneous coronary intervention.

antiplatelet therapy--does identification of risk and adjustment of therapy contribute to more effective, personalized medicine in cardiovascular disease?

patients with acute coronary syndromes treated with percutaneous coronary

complications who are at increased risk of death after percutaneous coronary

for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;44:349-56.

increased mortality after percutaneous coronary intervention: implications for

bleeding on prognosis in patients with acute coronary syndromes. Circulation

syndromes: the Global Registry of Acute Coronary Events (GRACE). Eur Heart J

after percutaneous coronary interventions: appropriateness of including bleeding

procedural, and in-hospital outcomes following percutaneous coronary

shorter length of stay and fewer vascular access site complications, a more rapid return to professional activities is insured for working patients.

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 usage because of frequent inadequate choices.
