Percutaneous coronary intervention characteristics in a center which prioritizes the use of the radial approach

Abstracts

BACKGROUND: The radial approach has demonstrated superior benefits to the femoral approach in reducing vascular complications and bleeding events associated to percutaneous coronary interventions. However, because this is a more complex procedure, it requires a learning curve to get all of the advantages of the technique. The aim of this study was to present the characteristics of the procedures of a center that prioritizes the use of radial approach. METHODS: Prospective registry of patients undergoing percutaneous coronary intervention (PCI) using the radial or ulnar access where angiographic success, technical failure, ischemic adverse events and severe bleeding rates were assessed. A pre-specified analysis of the group undergoing PCI for the right coronary artery was performed, comparing patients using Judkins right catheter (JR) or Amplatz catheters. RESULTS: Between April 2010 and May 2012, 1,117 patients underwent PCI, 1,040 (93.1%) by the radial approach and 50 (4.5%) by the ulnar approach. Sedation was performed in 58.5% of the patients, the crossover rate was 1.2%, and angiographic success was 96.2%. Extra backup catheters were used in 99.1% of PCIs for the left coronary artery, JR in 69.4% and Amplatz in 27.1% of the PCIs for the right coronary artery. When the JR and Amplatz were compared, longer procedure duration, longer fluoroscopy time, larger number of catheters, more frequent lesion predilation and higher number of implanted stents were observed in the group using Amplatz catheters as well as lower angiographic success rates. CONCLUSIONS: The use of radial access in PCI showed a high success rate and a low rate of major cardiac events and bleeding complications. The liberal use of sedation and 6 F introducer sheaths, associated to catheters with stronger backup force, are characteristics of our center, which prioritizes the use of the radial approach.

Radial artery; Angioplasty; Catheters; Hemorrhage

INTRODUÇÃO: O acesso radial tem demonstrado resultados superiores aos do acesso femoral na redução de complicações vasculares e ocorrência de sangramentos associados aos procedimentos coronários percutâneos. Entretanto, por ser procedimento mais elaborado, requer dos operadores curva de aprendizagem para se obter todas as vantagens da técnica. O objetivo deste estudo foi apresentar as características dos procedimentos de um serviço que prioriza a utilização da via radial. MÉTODOS: Registro prospectivo de pacientes submetidos a intervenção coronária percutânea (ICP) pelo acesso radial ou ulnar, em que foram avaliados sucesso angiográfico do procedimento, falência da técnica, taxa de eventos adversos isquêmicos e sangramento grave. Análise pré-especificada do subgrupo que realizou ICP para coronária direita foi realizada, comparando pacientes que utilizaram cateteres Judkins de direita (JR) ou Amplatz. RESULTADOS: Entre abril de 2010 e maio de 2012, 1.117 pacientes realizaram ICP, 1.040 (93,1%) pela via radial e 50 (4,5%), pela ulnar. Sedação foi realizada em 58,5% dos pacientes, a taxa de crossover foi de 1,2% e o sucesso angiográfico, de 96,2%. Cateteres extra backup foram utilizados em 99,1% das ICPs para coronária esquerda, JR em 69,4%, e Amplatz em 27,1% das ICPs para coronária direita. Na comparação entre JR e Amplatz, observou-se maior duração do procedimento, tempo de fluoroscopia, número de cateteres, pré-dilatação da lesão e número de stents implantados no grupo que utilizou cateteres Amplatz, bem como menor sucesso angiográfico. CONCLUSÕES: A utilização do acesso radial na ICP mostrou alto índice de sucesso e baixo índice de eventos cardíacos maiores e de complicações hemorrágicas. O emprego liberal da sedação e de introdutores 6 F associado à escolha de cateteres com maior suporte são características operacionais de nosso centro, que prioriza o uso da técnica radial.

Artéria radial; Angioplastia; Cateteres; Hemorragia

ORIGINAL ARTICLE

Percutaneous coronary intervention characteristics in a centre which prioritizes the use of the radial approach

Marden André Tebet^I; Pedro Beraldo de Andrade^II; Ederlon Ferreira Nogueira^III; Vinícius Esteves^IV; Milena Paiva Brasil Matos^V; Mônica Vieira Athanazio de Andrade^VI; Róbson Alves Barbosa^VII; André Labrunie^VIII; Luiz Alberto Mattos^IX

^IPhysician; Interventional cardiologist at Santa Casa de Marília. Marília, SP, Brazil

^IIDoctoral Student. Physician; Interventional cardiologist at Santa Casa de Marília. Marília, SP, Brazil

^IIIPhysician; Interventional cardiologist at Hospital do Coração de Londrina. Londrina, PR, Brazil

^IVPhysician; Interventional cardiologist at Hospital e Maternidade Brasil - Rede D'Or. Santo André, SP, Brazil

^VCardiologist intern at Santa Casa de Marília. Marilia, SP, Brazil

^VINurse; specialist in Cardiovascular Nursing at Santa Casa de Marília. Marília, SP, Brazil

^VIINurse at Santa Casa de Marília. Marília, SP, Brazil

^VIIIPhysician; Interventional cardiologist at Santa Casa de Marília. Marília, SP, Brazil

^IXPhysician; Interventional cardiologist at Instituto Dante Pazzanese de Cardiologia. São Paulo, SP, Brazil

^{Correspondence to}

ABSTRACT

BACKGROUND: The radial approach has demonstrated superior benefits in reducing vascular complications and bleeding events associated with percutaneous coronary interventions (PCIs) when compared with the femoral approach. However, since the radial approach is a more complex procedure, it requires extensive training. The aim of this study was to demonstrate the characteristics of the procedures in a centre that prioritises the use of the radial approach.

METHODS: The angiographic success, technical failure, ischaemic adverse events and severe bleeding rates were assessed in a prospective study of patients undergoing PCI using radial or ulnar access. A pre-specified analysis of the group undergoing PCI for the right coronary artery was performed, comparing patients using Judkins right (JR) catheters or Amplatz catheters.

RESULTS: Between April of 2010 and May of 2012, 1,117 patients underwent PCI, 1,040 (93.1%) by the radial approach, and 50 (4.5%) by the ulnar approach. Sedation was performed in 58.5% of the patients, the crossover rate was 1.2%, and angiographic success was attained in 96.2%. Extra backup catheters were used in 99.1% of PCIs for the left coronary artery: JR in 69.4% and Amplatz in 27.1% of the PCIs for the right coronary artery. When the JR and Amplatz were compared, a longer procedure duration, longer fluoroscopy time, larger number of catheters, more frequent lesion predilation, and a higher number of implanted stents were observed in the group using Amplatz catheters, as well as lower angiographic success rates.

CONCLUSIONS: The use of radial access during PCI produced a high success rate and a low rate of major cardiac events and bleeding complications. The liberal use of sedation and 6-F introducer sheaths, associated with catheters with a stronger backup force, are characteristics of this centre, which prioritises the use of the radial approach.

Descriptors: Radial artery. Angioplasty. Catheters. Hemorrhage.

Percutaneous coronary intervention (PCI) through the radial access route was introduced approximately 20 years ago.¹ Multiple randomised studies have demonstrated superior results compared to the traditional femoral approach, particularly regarding a decrease in vascular complications and in the occurrence of severe bleeding.^2,3

The impact of periprocedural bleeding on clinical outcome, particularly with respect to increased mortality, resulted in a great interest in the radial technique.^4-6 Even in countries such as the United States, which has preferably used femoral access, there has been a progressive increase in the use of the radial approach, although its use today still accounts for less than 10% of all procedures.^7,8

The radial access, in turn, is technically more elaborate, demanding a longer learning period by the surgeons.^9-11 The knowledge of strategies employed in services that prioritise the use of the radial access, particularly regarding the choice of materials, can facilitate the implementation of this technique in new services. The objective of this study was to demonstrate the characteristics of procedures performed through radial access in a centre that prioritises this type of access.¹²

METHODS

Consecutive patients undergoing PCI by radial and ulnar access were included in a prospective study of efficacy and safety. The outcomes of efficacy consisted of procedural success, defined as achieving a stenosis diameter of the target lesion < 20% associated with final Thrombolysis In Myocardial Infarction (TIMI) III flow without the need to change the access route (technique failure); rates of hospital mortality; reinfarction; stroke; and emergency heart surgery. The total procedure duration and fluoroscopy time were obtained from the beginning of arterial puncture until sheath removal. Safety was assessed by the occurrence of severe bleeding and vascular complications related to the puncture site. A pre-specified analysis was performed in the subgroup that underwent PCI for the right coronary artery, comparing patients using Judkins right (JR) and Amplatz catheters.

In accordance with the classification of the Bleeding Academic Research Consortium,¹³ severe bleeding was defined as type 3 (3a, bleeding with a decrease in haemoglobin > 3 g/dL and < 5 g/dL or transfusion of packed red blood cells; 3b, bleeding with a decrease in haemoglobin > 5 g/dL, cardiac tamponade, bleeding requiring surgical intervention or bleeding requiring intravenous vasoactive drugs; 3c, intracranial haemorrhage or subcategories confirmed by autopsy, imaging examination, lumbar puncture or intraocular bleeding with vision impairment); or Type 5 (5a, likely fatal bleeding; 5b definitive fatal bleeding). The haematomas were graded according to the classification of the Early Discharge after Transradial Stenting of Coronary Arteries (EASY) study:¹⁴ type I, < 5 cm in diameter; type II, < 10 cm diameter; type III, > 10 cm without reaching the elbow; type IV, haematoma extending beyond the elbow; type V, any haematoma with ischaemic injury to the hand. Complications related to the puncture site, in addition to haematomas, included arteriovenous fistula, pseudoaneurysm, asymptomatic arterial occlusion, need for surgical vascular repair and site infection.

Through the hyperextension of the wrist and infiltration of 1 to 2 mL of 2% xylocaine, the radial artery was punctured at 1 cm proximal to the styloid process, using a needle with a 20-22 gauge Jelco^® polyethylene catheter (Smiths Medical - Kent, England) and the Seldinger technique. After puncture, a 0.021-inch guidewire was introduced, followed by a small skin incision with a scalpel blade number 11 and the insertion of a short sheath (< 11 cm) 5-7 F. A solution containing 5,000 IU heparin sulphate and 10 mg of isosorbide mononitrate was administered through the sheath extender. At the end of the procedure, the sheath was immediately removed, and haemostasis was obtained with a pressure dressing using a porous elastic adhesive bandage (Tensoplast^®, BSN Medical - Hamburg, Germany) or selective compressor band (TR Band^TM, Terumo Medical - Tokyo, Japan). Clinical examination of the puncture site and evaluation of the radial pulse were performed at the time of hospital discharge.

Sedation was achieved with midazolam (3 ml-15 mg), fentanyl (3 ml-150 μg), and saline (4 ml). The initial dose used was 1 mL of the solution, which was repeated as needed.

Statistical Analysis

Categorical variables were expressed as frequencies and percentages and compared using the chi-squared test. Continuous variables were expressed as the mean and standard deviation and compared using Student's t-test or Fisher's exact test. Values were considered statistically significant at P < 0.05.

RESULTS

Between April of 2010 and May of 2012, PCIs were performed in 1,117 patients, of which 1,090 (97.6%) were performed through radial and ulnar access; radial access was used in 1,040 (93.1%) cases and ulnar in 50 (4.5%) cases.

The demographic characteristics of the patients are indicated in Table 1. The mean age was 62.4 ± 11.6 years, 31.8% were females and 32% were diabetic. The predominant indication was acute coronary syndrome (72%), in which 38.3% were classified as unstable angina or acute myocardial infarction (AMI) without ST-segment elevation and 33.7% as AMI with ST-segment elevation.

The characteristics of the procedures are indicated in Table 2. Elective PCI was performed in 55.2% of cases, ad hoc PCI in 23.3% and primary PCI in 20.8%. The rate of failure in obtaining radial and/or ulnar access or the need to change the access route for procedure completion was 1.2% (12 failures by the radial access and one by the ulnar). The most frequent causes of technique failure were right brachial artery occlusion after previous coronary angiography by Sones technique (five cases); inadequate support for the PCI (three cases); excessive tortuosity of the radial artery after its emergence from the brachial artery, preventing the progression of the guidewire and/or catheter (two cases); hypoplastic radial artery and/or spasm when attempting to perform puncture and cannulation (two cases); and failure to advance the sheath, most likely due to ulnar artery dissection by the guidewire (one case). The femoral artery was chosen as the alternative route in seven patients, the contralateral radial artery was chosen in five patients and the ipsilateral ulnar artery in one patient.

6-F sheaths were used in 92.8% of cases, with an average of 1.2 ± 0.5 catheters per patient. The de novo lesions were treated in 95.8% of cases, and the number of stents used was 1.2 ± 0.5 stents per patient. Drug-eluting stents were implanted in 14.3% of patients, and lesions were pre-and post-dilated in 45.2% and 62.7% of cases, respectively. Glycoprotein IIb/IIIa inhibitors were used in 19.8% of the procedures, representing two thirds of the cases with primary PCI. Sedation was used in more than half (58.5%) of the patients. Angiographic success was obtained in 96.2% of the PCIs.

Table 3 illustrates the in-hospital outcomes of efficacy and safety. A severe bleeding episode was recorded in 5 (0.5%) patients, all classified as type 3 (3a in three patients and 3c in two patients). Haematomas were discovered in 1.1% of cases.

In PCIs to the left coronary artery, backup catheters were used in virtually all procedures (99.1%). JR catheters were used in 69.4% of cases in the treatment of the right coronary artery and Amplatz catheters in 27.1% (Table 4). The comparison between the groups treated with JR and Amplatz catheters indicated similar demographic characteristics, except for a higher prevalence of smoking (47.4% vs. 35.6%, P = 0.04) in the group treated with the JR catheter and older age (60.6 ± 10.7 years vs. 64.1 ± 10.7, P < 0.005), arterial hypertension (70.3% vs. 82.7%; P = 0.01) and previous CABG (4.1% vs. 9.6%, P < 0.04) in the group treated with Amplatz catheters. The total duration of the procedure (32.9 ± 17.2 minutes vs. 42.8 ± 19.7 minutes, P < 0.0001), fluoroscopy time (9 ± 6.2 minutes vs. 13.5 ± 9.3, P < 0.0001), number of catheters used (1.2 ± 0.5 vs. 1.6 ± 0.9; P < 0.0001), lesion pre-dilation (39.5% vs. 65.4%; P < 0.0001), and the number of stents per patient (1.3 ± 0.6 vs. 1.5 ± 0.6; P < 0.04) were higher in the group treated with Amplatz catheters. Angiographic success was greater (98.1% vs. 93.3%; P < 0.04) in the group treated with the JR catheter (Table 5). The rates of adverse cardiac events (4.6% vs. 2.7%; P = 0.76) and severe bleeding (0.5% vs. 0.0%; P > 0.99) did not differ between the groups.

DISCUSSION

The current practice in a centre that prioritises the use of the radial (and ulnar) access when performing invasive coronary procedures is reported. The presence of acute coronary syndrome in the majority of the patients (72%), with some returning to their home hospitals after the procedure, was one of the major factors for the rapid adoption of this technique as the preferred treatment in the majority of cases. In this clinical group, there is a potential benefit by reducing ischaemic outcomes due to the decreased occurrence of known determinants of poor prognosis: vascular complications at the arterial puncture site, episodes of severe bleeding, and need for transfusion.^3,15

The low rate of crossover and high success rate of the procedure demonstrated in the present study have a direct correlation with the frequency of the access use. Pristipino et al.¹⁶ demonstrated in their Prospective REgistry of Vascular Access in Interventions in Lazio region (PREVAIL) an inverse correlation between the frequency of the use of radial access by the surgeon and the need for crossover of the access route. The correlation was as high as 33% among those who use radial access in at least 25% of the cases, decreasing to 3% among those whose percentage is higher than 85%.

The ulnar access is viable, safe, and effective in patients who cannot undergo the examination through the radial access, with success and complication rates related to the puncture site similar to those reported for the radial access.¹⁷ This access has had increasing popularity, especially among the users of the transradial technique¹⁸ (the so-called 'radialists' and 'evangelists').¹⁹

Bertrand et al.²⁰ evaluated the contemporary use of the transradial practice by 1,107 interventional cardiologists from several centres around the world through an electronic questionnaire. The right radial access was used during 90% of procedures, and 25% of physicians reported not previously evaluating dual circulation of the hand. In cases where radial access failure occurred in centres that use this route during more than 50% of PCIs, 41% of physicians used the contralateral radial, and 47.1%, the femoral access. Sedation before the examination was used in 41.7%, and vasodilators were administered to more than 80% of cases. The use of the 6-F sheath was the standard, with a backup catheter used in more than 65% of the PCIs to the left coronary artery and the JR catheter in approximately 70% of PCIs to the right coronary artery. These results are consistent with those obtained in the present study, where backup catheters were used in almost all procedures to left coronary artery and JR catheters in approximately 70% of cases of PCI to right coronary artery. Over 90% of these cases, especially in primary PCIs, used 6-F sheaths, approximately 50% with direct stenting, a more liberal use of sedation (58.5%), and the use of glycoprotein IIb / IIIa inhibitors.

The sedative pharmacological solution used in this study combines the sleep-inducing and relaxing effects of midazolam with fentanyl analgesia, important factors in the prevention of radial spasm. The low use of 7-F catheters (< 1%) is noteworthy, even in the presence of bifurcation lesions, in which the provisional stenting technique is most commonly used in this hospital. This technique is easily performed with 6-F sheaths and lowprofile materials available in Brazil. Even when it is necessary to implant two stents, it is not necessary to change the catheter in most cases, when techniques such as T, TAP, or step crush are used.

The choice of guide catheters is one of the determinants of the successful implementation of training and learning programs for the transradial approach. Dedicated catheters are recommended,²¹ although the utilisation of catheters used during femoral route PCIs may facilitate the implementation and dissemination of the transradial approach without adding cost and time during the initial learning phase. Dedicated catheters can be used after the learning curve has been overcome.

Ikari et al.²² evaluated the strength of support of guide catheters in simulations of femoral and radial PCIs to the left coronary artery in an arterial tree model. Three factors were associated with a greater support: the diameter of the catheter guide (the greatest diameter provided the greatest support); the angle (theta) of the catheter located on the opposite side of the aorta (one position lower than the catheter was preferable as the point of contact in the aorta, as the angle approached values close to 90 degrees, producing greater support); and the contact area with the aorta (the largest contact generated greater support to a limited extent). The study also demonstrated that, when using a left Judkins catheter, the support through the femoral access was 1.6 times greater when compared with the radial access. When the backup catheter was used, there was slightly greater support with the femoral approach (8%) with similar angles, but with a larger contact area compared with the radial access. There were no comparisons between the left Judkins catheters for femoral access and backup catheters through radial access; however, the maximum resistance values were very similar. In a later study conducted by the same group,²³ there was a comparison between the JR catheters and left Amplatz with PCIs to the right coronary catheter, indicating the superiority of the Amplatz in both radial and femoral approaches. This finding can be explained by a different mechanism from that regarding the use of catheters in the left coronary artery. The main factor that increased support to the guide catheter of the right coronary artery was the site of primary support of the catheter. For the right radial approach and the JR catheter, this site was the brachiocephalic trunk; for the left Amplatz catheter, this site was the reverse side of the aorta.

In the present study, the analysis of the subgroup submitted to PCI of the right coronary artery indicated patients with a higher-risk clinical profile, longer procedure and fluoroscopy times, higher number of catheters used, greater need for pre-dilation, increased number of stents per patient, and a lower angiographic success in patients who used the Amplatz catheter. This suggests that the choice of these catheters should be reserved for more complex cases, such as lesions that are more distal; the presence of tortuosity, calcification, and bifurcation lesions; and the presence of posterior and superior origins of the right coronary ostium.

Limitations

Given that this study was observational, it has limitations, such as the nonrandomised nature of the subgroup analysis, its performance at only one centre, and the absence of late clinical followup.

CONCLUSIONS

The use of radial access during PCIs produced a high success rate and a low incidence of major cardiac events and bleeding complications. The liberal use of sedation and 6 F sheaths associated with the choice of catheters with higher support are operational characteristics of this centre, which prioritises the use of the transradial approach.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.

REFERENCES

Received on: 6/25/2012

Accepted on: 9/3/2012

• 1. Kiemeneij F, Laarman GJ. Percutaneous transradial artery approach for coronary stent implantation. Cathet Cardiovasc Diagn. 1993;30(2):173-8.
• 2. Chase AJ, Fretz EB, Warburton WP, Klinke WP, Carere RG, Pi D, et al. Association of the arterial access site at angioplasty with transfusion and mortality: the M.O.R.T.A.L study (Mortality benefit Of Reduced Transfusion after percutaneous coronary intervention via the Arm or Leg). Heart. 2008;94(8): 1019-25.
• 3. Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J. 2009;157(1):132-40.
• 4. Mann T, Cubeddu G, Bowen J, Schneider JE, Arrowood M, Newman WN, et al. Stenting in acute coronary syndromes: a comparison of radial versus femoral access sites. J Am Coll Cardiol. 1998;32(3):572-6.
• 5. Manoukian SV, Feit F, Mehran R, Voeltz MD, Ebrahimi R, Hamon M, et al. Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes: an analysis from the ACUITY Trial. J Am Coll Cardiol. 2007;49(12):1362-8.
• 6. Bertrand OF, Larose E, Rodes-Cabau J, Gleeton O, Taillon I, Roy L, et al. Incidence, predictors, and clinical impact of bleeding after transradial coronary stenting and maximal antiplatelet therapy. Am Heart J. 2009;157(1):164-9.
• 7. Rao SV, Ou F, Wang TY, Roe MT, Brindis R, Rumsfeld JS, 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(4):379-86.
• 8. Andrade PB, Tebet MA, Andrade MV, Labrunie A, Mattos LA. Radial approach in percutaneous coronary interventions: current status in Brazil. Arq Bras Cardiol. 2011;96(4):312-6.
• 9. Louvard Y, Pezzano M, Scheers L, Koukoui F, Marien C, Benaim R, et al. Coronary angiography by a radial artery approach: feasibility, learning curve. One operator's experience. Arch Mal Coeur Vaiss. 1998;91(2):209-15.
• 10. Goldberg SL, Renslo R, Sinow R, French WJ. Learning curve in the use of the radial artery as vascular access in the performance of percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn. 1998;44(2):147-52.
• 11. Labrunie A, Tebet MA, Andrade PB, Andrade MVA, Conterno LO, Mattos LAP, et al. Coronariografia via transradial: curva de aprendizagem, avaliada por estudo multicêntrico. Rev Bras Cardiol Invasiva. 2009;17(1):82-7.
• 12. Tebet MA, Andrade PB, Andrade MVA, Mattos LAP, Labrunie A. Reutilização do acesso transradial na realização de procedimentos coronários diagnósticos. Rev Bras Cardiol Invasiva. 2010;18(1):37-43.
• 13. Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation. 2011;123(23):2736-47.
• 14. Bertrand OF, De Larochellière R, Cabau JR, Proulx G, Gleeton O, Nguyen CM, et al. A randomized study comparing same-day home discharge and abciximab bolus only to overnight hospitalization and abciximab bolus and infusion after transradial coronary stent implantation. Circulation. 2006;114(24): 2636-43.
• 15. Jolly S, Yusuf S, Cairns J, Niemela K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;377(9775):1409-20.
• 16. Pristipino C, Trani C, Nazzaro MS, Berni A, Patti G, Patrizi R, et al. Major improvement of percutaneous cardiovascular procedures outcomes with radial artery catheterization: results from the PREVAIL study. Heart. 2009;95(6):476-82.
• 17. Aptecar E, Pernes JM, Chabane-Chaouch M, Bussy N, Catarino G, Shahmir A, et al. Transulnar versus transradial artery approach for coronary angioplasty: the PCVI-CUBA study. Catheter Cardiovasc Interv. 2006;67(5):711-20.
• 18. Andrade PB, Tebet MA, Andrade MV, Mattos LA, Labrunie A. Registro prospectivo de avaliação da segurança e eficácia da técnica ulnar na realização de procedimentos coronários. Rev Bras Cardiol Invasiva. 2008;16(3):312-6.
• 19. Saito S. Transradial approach-from the evangelist's view. Catheter Cardiovasc Interv. 2001;53(2):269-70.
• 20. Bertrand OF, Rao SV, Pancholy S, Jolly SS, Rodés-Cabau J, Larose E, et al. Transradial approach for coronary angiography and interventions: results of the first international transradial practice survey. JACC Cardiovasc Interv. 2010;3(10): 1022-31.
• 21. Youssef AA, Hsieh YK, Cheng CI, We CJ. A single transradial guiding catheter for right and left coronary angiography and intervention. EuroIntervention. 2008;3(4):475-81.
• 22. Ikari Y, Nagaoka M, Kim JY, Morino Y, Tanabe T. The physics of guiding catheters for the left coronary artery in transfemoral and transradial interventions. J Invasive Cardiol. 2005; 17(12):636-41.
• 23. Ikari Y, Masuda N, Matsukage T, Ogata N, Nakazawa G, Tanabe T, et al. Backup force of guiding catheters for the right coronary artery in transfemoral and transradial interventions. J Invasive Cardiol. 2009;21(11):570-4.

Publication Dates

• Publication in this collection
  08 Nov 2012
• Date of issue
  2012

History

• Received
  25 June 2012
• Accepted
  03 Sept 2012