By transradial interventions we mean that
angiographies and angioplasties are performed through the radial artery.
Traditionally angiographies are performed through the transfemoral route but after the first transradial Angiography by Campeau in 1989 and the first transradial angioplasty by Dr Kiemeneij in 1992, the popularity of this approach has grown significantly worldwide.
We developed our transradial programme six years back after we lost two patients in one month secondary to vascular complications following successful transfemoral intervention. After passing through the initial learning curve we have by now performed over 20000 transradial procedures and 98.5% of all procedures done in our cath lab are through the radial route. Our series on transradial interventions is one of the largest series in the world and our centre is becoming an international referral centre for people who are interested in learning the transradial technique.
Transradial route has several distinct advantages over the transfemoral route
- There is zero per cent rate of vascular complications such as bleeding, haematoma, pseudoaneurysm formation as compared to 1.5% to 5.5% rate with the transfemoral route. This is because the radial artery is a superficial artery and can be compressed easily. These vascular complications have even lead to death of the patient after successful intervention through the transfemoral route.
- This is a patient friendly procedure. We call transradial Angiography as “Walk in and walk out angiography” as patients walks in and walks out of the cath lab. Transradial approach (TRA) ensures immediate mobilisation after the procedure with no need of urinary catheter, urine pot and bed pans which is usually the case with transfemoral approach, as patient has to lie down immobile for at least 6 hours after the procedure. At our centre patients walk around, enjoy meals and watches televison after the procedure in a Radial Lounge which has been specially designed for them.
- Early discharge of the patient is facilitated by TRA. After angiography we usually discharge the patients within 3 hours and after angioplasties within 12-16 hours. With advancement in hardware for angioplasties we discharge some patients within 6 hours of angioplasty making it a day care procedure.
- In the era of primary angioplasties and rescue angioplasties wherein the patient has alreadly received thrombolytics such as streptokinase and is loaded with antiplatelets such as aspirin, clopidogrel, abciximab (Reopro) during angioplasty, TRA has a sharp edge over the transfemoral approach. There is no risk of bleeding complications with TRA as compared to TFA even in such an acute setting wherein a vascular complication can be life threatening.
However, we would like to emphasize that the transradial approach requires a learning curve which every interventionalist has to go through. There are certain issues regarding radial artery spasm, radial artery anomalies, radial artery loops and subclavian artery loops which one learns to overcome with experience.
There are certain myths which prevail regarding the transradial route which we would like to clarify.
It is said that the radial artery cannot be used as a conduit during bypass surgery after transradial interventions. But surgeons usually take the left radial artery (non dominant arm) as a conduit and we perform transradial interventions through the right radial artey. Recent studies have shown that radial artery grafts are not superior to saphenous venous grafts in bypass surgery, so we feel there is no need to deprive the patient of this elegant route for interventions
Secondly it is said that high risk cases and complex interventions cannot be performed through the transradial route an opinion with which we differ. At our centre we perform all primary angioplasties in setting of acute MI through the transradial route. We perform all complex interventions such as left main artery stenting, chronic total occlusions and by pass grafts interventions through the TRA.
Thirdly it is said that TRA is not a suitable route for peripheral interventions. We have developed the programme for peripheral interventions through the transradial route. This includes renal artery stenting, Iliac artery stenting, femoral artery stenting, subclavian artery stenting, carotid artery stenting and intracranial artery stenting such as vertebral artery, basilar artery, and middle cerebral artery. Our series on peripheral interventions through the transradial approach is one of the largest in the world.
We would like to conclude by saying that the transradial approach is an elegant and an extremely patient friendly approach from which patients should not be deprived. Instead of promoting transradial approach as an alternative route for interventions we would like to promote it as the preferred route for interventions.
ETHNIC GROUPS AND DIFFERENCES IN HYPERTENSION
Hypertension in young white people seems to be high renin (type 1) hypertension and best responds to treatment with angiotensin converting enzyme inhibitors and b blockers (AB drugs). Hypertension in young black people, however, seems to be low renin (type 2) hypertension and responds better to calcium channel blockers and diuretics (CD drugs).
BMJ, 2006; 332, 833.