Cardiac CatheterizationCardiac Catheterization

Cardiac Catheterization: Comparison between Trans-Radial and Trans-Femoral Approach In Cardiac catheterization
Prepared by : Mohammed Al-Rahahleh, Alaa Saad, Tahani Khalil, ,.2018
Reviewed by : Dr.MarwaFaculty Of Nursing
Alzaytoonah University

Table Of Content
Literature Review …………………………………………………8
The purpose of this literature review paper is to study the comparison of the safety and harms between trans radial and trans femoral approach during coronary arteries angiography procedures. Coronary artery disease (CAD) can lead to a symptomatic vascular blockage.. Traditionally the femoral approach was the preferably used method in interventional cardiology for diagnostics and therapy of coronary artery disease. It has been perceived as being easy and facilitating quick access with relatively low risk. Trans femoral is considered as a classical approach over transradial due to the unlimited repetition of puncturing, easy access, less radiation time, and less contrast. In the last two decades, transradial approach emerged as mostly being used for the interventional and diagnostic approach in cardiology(Sinha, Mishra, &Afdaali, 2016) .And also, The transradial approach in interventional cardiology is safe with lower incidence of hemorrhage , effective, accessible, allows early ambulation for the patient post procedure, cost effectiveness ,decreased the hospital mortality and morbidity rate and feasible as compared to the trans femoral approach. However, longer procedural duration and radiation exposure are still concerns regarding trans radial approach (Kedev , Kalpak ,&Dharma.,2014),Guide placement is more challenging and requires learning a different technique with a steep learning curve (Hess 2014),and Vessel spasm is more common (Kim 2011).
Cardiac catheterization (heart cath) is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes. Subsets of this technique are mainly coronary catheterization, involving the catheterization of the coronary arteries, and catheterization of cardiac chambers and valves of the cardiac system (Shabir Bhimji,2016).

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Indications for diagnostic use of coronary catheterization
Patients without cardiac symptoms or high-risk markers for a heart problem should not have a coronary catheterization to screen for problems.

Marc ,2011.Said that the Indications for cardiac catheterization include :Heart Attack (includes ST elevation MI, Non-ST Elevation MI, Unstable Angina),Abnormal Stress Test,New-onset unexplained heart failure, Survival of sudden cardiac death or dangerous cardiac arrhythmia, Persistent chest pain despite optimal medical therapy, and Workup of suspected Prinzmetal Angina (coronary vasospasm).In addition to that , Marc.,2011. Explained that the Investigative techniques used with coronary catheterization are :To measure intra- cardiac and intravascular blood pressures, To take tissue samples for biopsy, To inject various agents for measuring blood flow in the heart; also to detect and quantify the presence of an intra-cardiac shunt, To inject contrast agents in order to study the shape of the heart vessels and chambers and how they and to Change as the heart beats. In the same paper Marc S., said that in Cardiac catheterization and coronary angiography are usually very safe. However, as with all procedures, there are some risks including :Being allergic to the contrast dye – this is uncommon, but you should discuss any allergies that you have with your cardiologist (heart specialist) before having the procedure, Bleeding under the skin where the catheter was inserted – this should stop after a few days, but you should contact your GP if you’re concerned about it, and Avery small risk of
more serious complications, including damage to the artery in the arm or leg where the catheter was inserted, heart attack, stroke, kidney damage and, very rarely, death
Cardiovascular diseases (CVDs) are the number one cause of death globally. In 2012, an estimated 7.4 million deaths were due to coronary heart disease (WHO 2015). CVDs were the direct cause of more than four million deaths in Europe around the year 2000, accounting for 43% of all deaths at all ages in men and 55% in women. Coronary artery disease (CAD) accounts for half of this mortality burden and depends mostly on the occurrence of acute coronary syndromes (Bosch 2013). Patients with CAD usually present with pain or discomfort in the center of the chest that may radiate to the arms, left shoulder, elbows, jaw or back. In addition, the person may experience shortness of breath (WHO 2015).

When cardiovascular disease (CAD) has led to a (partial) vascular blockage, this can be detected with Coronary Angiograph (CAG) and treated with PCI. The main advantages of using catheterization approach are a rapid recovery with early ambulation, less postoperative complications, less hospital cost and less chance of scars formation. Thus, it increases the patient comfort (Kedev , Kalpak ,; Dharma,2014) Additionally, angioplasty is now considered as a gold standard procedure for the treatment of acute myocardial infarction .

During this procedure, a small inflatable balloon on a wired catheter is guided under X-ray imaging from the puncture site, through arterial blood vessels until the potential blockage in the epicardial coronary artery is reached (Bertrand 2010). By PCI the vascular obstruction or occlusion will be removed by inflating the balloon to open the coronary artery lumen and by inserting stents to prevent the vessel from re-occlusion. The choice for vascular access by CAG and/or PCI is the first technical consideration of cardiovascular procedures and can influence its
overall success (Bertrand ,2010; Schwalm ,2012). In interventional cardiology, multiple access sites can be distinguished for CAG and/or PCI. The brachial artery (TBA) was the standard access-site, followed by the femoral artery (TFA) access which achieved the default status in the late 1970s (Bertrand , 2010; Kiemeneij , 1997).
The uses of trans-femoral approach to cardiac catheterization has dominated the explosive growth of invasive cardiology in the past decades (Venkitachalam 2009). Continual evolution of device technology and antithrombotic regimen has resulted in the application of PCI to a wider population of patients. As current PCI procedural success rates are high and cardiac events relatively rare, evolution of PCI practice has led to an emphasis on minimizing pre- and post-procedural vascular complications (Agostoni , 2004; Rao , 2012). Bleeding complications after PCI are most commonly related to the vascular access site and associated with an increased risk of post-PCI morbidity and mortality (Rao , 2010). In the Netherlands, Dr. Kiemeneij and colleagues applied the first trans-radial (TRA) angioplasty in the early 1990s, and currently there is a resurgence of interest in upper limb trans-radial CAG (Bertrand et al., 2012; Kiemeneij., 1997). Despite early enthusiasm for TRA, technical and material limitations confined the use of trans-radial PCI and restrained TRA to become a standard procedure (Agostoni , 2004; Rao , 2010). During the last decade, the refinement and miniaturization of stents permitted the use of guiding catheters with smaller diameters that were better suited for use through the relatively small radial artery (Safirstein, 2013). A consistent body of evidence, including the outcomes of the ACCESS and the RIVAL study, has suggested that radial access for CAG is a safe and effective alternative for the femoral route (Jolly , 2011; Kiemeneij, 1997). The vascular access site selection has ever since evolved with an increasing worldwide use of the TRA instead of the TFA, especially in Europe and Asia, were
48% and 42% of procedures are performed with the TRA respectively (Bertrand ,2010; Erbel ; Wijns, 2014). In contrast, in the United States the TRA is used approximately in one out of six PCI procedures and it is growing steadily (Safirstein, 2013).
We use a Search strategy for identification of studies MEDLINE, CENTRAL, and EBESCO were searched for eligible studies between 2000 to April 2018.. Prior systematic reviews and other studies references were hand-searched to include all relevant studies.

And we found that :
Mitul ; Kadakia, 2015 conducted a study in the American College of Cardiology Foundation, The researchers collets the data elements from diagnostic catheterization and PCI at 1,453 participating centers .Data entered in system , The study population included adult (age;18) ,the patients divided on the basis of access site. After that , the researchers performed a comparing in hospital bleeding , vascular complications ,and morality outcomes among transfemoral and transradial approach patients . The result showed that transradial approach was used in 14.2% cases .In analyses, Transradial was associated with less bleeding than the transfemoral access.

Before 2008, the transfemoral approach was considered as the main route of arterial access for cardiac catheterization in the United States. However, transradial cardiac catheterization in the United States is growing with time due to the significant risk of transfemoral associated major and minor vascular complications related to transfemoral approach. The American College of Cardiology defines vascular complications as minor or major. Minor vascular complications were defined as any of the following: hematoma ; 10 cm, fistulae, or pseudo aneurysm
(Applegate RJ, Grabarczyk MA,; Little WC, 2002). However, the major vascular complications were defined as death caused by major vascular bleeding leading to ; 3 g fall in hemoglobin level due to retroperitoneal bleeding or administration of blood transfusions or vascular repair, vessel occlusion, or loss of pulse (Tewari S, Sharma N,; Kapoor A, 2013).

The most common femoral approach vascular complications are; the access site bleeding, hematoma, arteriovenous (AV) fistula, retroperitoneal bleeding, and pseudo-aneurysm. In the United States, the proportion of transradial percutaneous coronary intervention (PCI) increased gradually, from 1.2% in 2007 to 16.1% in 2012 and a total of 6.3% of total procedures from 2007 to 2012(Fa’ak F, Shabaneh B, Younis G,2016). The complication for this procedure includes bleeding which may sometimes require transfusion to treat the bleeding complication. However, the many studies appoint strongly towards the -evidence that these post-procedural bleeding especially retroperitoneal bleeding is associated with a bad prognosis and the blood transfusion after the procedure is also associated with poor prognosis (Rao, Eikelboom,& Granger,2007) . Studies have suggested that transradial approach may reduce hospital mortality among patients with STEMI. The study has shown that 294,769 patients undergone PCI for ST-segment elevation myocardial infarction STEMI in between 2007 and 2011. Data shows less bleeding complications and lower hospital morbidity and mortality rate by transradial approach (Baklanov, Kaltenbach,& Marso, 2013). Radial approach is considered better for coronary stenting than femoral in patients with the acute coronary syndrome. Access site bleeding complications are less and shorter hospital stay results in decrease morbidity and mortality (Mann, Cubeddu,&Bowen, 1998). A significant benefit of transradial catheterization is faster, more comfortable recovery. A cohort study included 334 end stage liver failure patients, have shown that transradial approach decreased the risk of bleeding, lower
vascular complications and pseudo aneurysm as compared to the classical approach in patients with end-stage liver disease (Feng, Gupta, &Terrazas, 2014). In some instances, the patients with ST-elevation myocardial infarction STEMI may require antithrombotic therapy and have the high risk of bleeding. However, the studies have shown that transradial approach is safe and efficient for coronary angiography in these patients (Jolly, Amlani, &Hamon, 2009). A study conducted by Sciahbasi AT showed the frequency of bleeding and mortality due to transradial approach and has been demonstrated in an extensive study in PCI (Sciahbasi, Pristipino, & Ambrosio,2009). Similar observational study on thousand non-ST-segment elevations myocardial infarction NSTEMI patients has been demonstrated in transradial treated cases (Chase, Fretz, &Warburton, 2008).

While A randomized comparison study conducted by, Tesfaldet &Micha,2013. For 128 patients referred for cardiac angiography via radial access was associated with a higher mean contrast volume , and longer procedure time .

We conclude that although the trans femoral is being an old traditional approach, the transradial is the more modern approach. The most imperative question is that, are both of these approaches useful?. The evidence implies that both of these methods have been useful and fruitfully used in the past and the present. However, like any procedure, these two methods have their complications as well several studies suggest that the modern approach overweight’s in benefits with the comparison to the classical approach. Complete transition from femoral approach to a radial approach is safe and successful in many cardiovascular procedures. The
findings of the recent studies have shown that the transradial approach in cardiac catheterization is safe, cost-effective, and feasible with similar results to those of the transfemoral approach. However, duration and radiation exposure are higher in the transradial access. As the time passes, more research is being conducted and obviously more studies will be published in the future that will be able to target to find how to lessen the duration and the radiation exposure in transradial approach. Thus, the future studies will broaden our knowledge about the further possible benefits and complications of both the approaches.

The radial access site for coronary angiography is an appealing approach that eliminates the local vascular complications and significantly shortens the hospital stay. Despite these advantages, radial vascular access is still more challenging. The significant crossover from the radial to femoral approach can be improved as experience with the technique grows. The femoral approach is the standard access site for coronary angiography. However, interventional cardiologists should acquire the experience to cannulate the radial artery as an alternative in specific situations.

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Jang JS, Jin HY, Seo JS, et al.: The transradial versus the transfemoral approach for primary percutaneous coronary intervention in patients with acute myocardial infarction: a systematic review and meta-analysis. EAPCI. 2012, 8:501–510.

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Kedev S, Kalpak O, Dharma S, et al.: Complete transitioning to the radial approach for primary percutaneous coronary intervention: a real-world single-center registry of 1808 consecutive patients with acute ST-elevation myocardial infarction. J Invasive Cardiol. 2014, 26:475–482.
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