Background: Transradial coronary angiography has established itself as safe alternative to transfemoral approach. Today, the artery of approach lies completely on the operator’s choice. The Right Radial Approach (RRA) has been a favorite for most of the interventional cardiologists due to the convenience in operating from the right side. The Left Radial Approach (LRA) has always been a neglected route. LRA does have many advantages over the right, the vascular anatomy being one of them. The aim of our study was to compare the right radial approach of diagnostic coronary angiography with left radial approach. Method: A total of 70 cases of Coronary Angiography (CAG) with normal Allen test and satisfying the inclusion criteria were prospectively observed and studied after randomly assigning them into two equal groups, LRA (Left Radial Approach) n = 35 and RRA (Right Radial Approach) n = 35. Multipurpose TIG (Tiger) catheter was used in both the approaches to catheterize the right as well as left coronary artery. Results: The access time, catheter manipulation time, procedure time, amount of contrast used, hospital stay, intensity of pain experienced, cost of the procedure and quality of coronary angiogram observed were statistically insignificant while the fluoroscopy time was slightly statistically significant which was independent to catheter manipulation time. Conclusions: The neglected Left Radial Approach to coronary angiography is as efficacious, safe and cost effective with reduction in arterial spasm complications when compared to the Right Radial Approach performed by multipurpose Tiger catheter.
The Coronary Angiography (CAG) is one of the minimally invasive diagnostic and therapeutic techniques used in patient with Coronary Heart Disease (CHD). It involves the injection of a special contrast agent into the coronary arteries which is promptly detected by X-rays that further gives a series of image called the angiogram. The angiogram thus obtained provides an inside view of different coronary arteries and their abnormalities which further aids to treatment strategy accordingly. CAG was performed only via the femoral artery in the beginning of its invention but with the development and advancement in the field of Interventional Cardiology, this classic approach has been shifted to radial due to their advantages over the former. Moreover, the advancement in the technology today has made it possible for the miniaturization of the diagnostic catheters and percutaneous transluminal coronary angioplasty equipment too. The radial approach, as an alternative to femoral approach, is becoming popular throughout the world due to this miniaturization [
Therefore, transradial coronary angiography has established itself as safe alternative to transfemoral approach. Today, the artery of approach lies completely on the operator’s choice. The right radial approach has been a favorite for most of the interventional cardiologist due to the convenience in operating from the right side. Moreover, the left radial approach has always been a neglected route. The left radial approach do have many advantages over the right, the vascular anatomy being one of them, which completes the procedure with more ease and quick thereby resembling the procedure same as the femoral approach [
This was a single centered prospective observational study conducted in Interventional Cardiology Department of Jingzhou Central Hospital, Jingzhou, Hubei, China. A total of 75 patients undergoing diagnostic coronary angiography with normal Allen test and satisfying the inclusion criteria were randomly assigned to two approach groups LRA (n = 35) and RRA (n = 35) from 1st April 2015 to 31st December 2015. Variables such as age, sex, risk factors were taken into account and analyzed. Different parameters including access time (radial artery puncture time), catheter manipulation time, procedure time, fluoroscopy time, total contrast agent used, hospital stay, pain experienced by the patients, complications and radial artery abnormalities were recorded and analyzed separately.
The patients included in the study satisfied following criteria:
1) Normal Allen test
2) Indication for CAG
3) Informed consent
1) Abnormal Allen test
2) Previous CAG by radial approach
3) Right heart catheterization
4) Simultaneous renal or aortic angiography
5) Presence of indication for ventricular angiogram
6) Any contraindication for coronary angiography
All patients in the RRA had their wrists hyperextended and the operator standing on right side of the patient while in the LRA the patients had their left forearm laid on their left side. After local subcutaneous anaesthesia with 1% lignocaine, the anterior wall of the radial artery was punctured using an 18 gauge needle. A 0.032" guide wire was introduced through the needle followed by the insertion of 6 Fr. radial sheath. A bolus dose of 2000 IU of heparin was administered intraarterially. For coronary angiography, appropriate size Tiger catheter was used for left radial route and appropriate size Tiger catheter was used for right radial route. The left coronary angiograms were obtained at least four projection views and the right coronary angiograms at least two views.
1) Because of language problem it was difficult to collect data.
2) Because of limited number of literature and research studies on left versus right approach we could not consider more explanations and clinical aspects from various research sources.
3) Because of the operators convenience usually operating from right approach we could not get sufficient number of case to compare the study in a large aspect.
4) Because of our single centered prospective evaluation of 9 month of study, our findings may be clinically significant and reliable for only our hospital setup, which may or may not be true for another hospital setup.
The data for this study was collected for a period of 9 months, by the principal researcher during the procedure and was recorded into a structure questionnaire.
Permission to do the study was sought from Jingzhou Central Hospital, Department of Cardiology. Confidentiality and personal privacy was respected in all levels of the study. Collected data will not be used for any other purpose.
The statistical analysis was carried out using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, version 16.0 for Windows). All quantitative variables were estimated using measures of central location (mean, median) and measures of dispersion (standard deviation). Normality of data was checked by measures of Kolmogorov Smirnov tests of normality. For normally distributed data means were compared using student’s t-test for two groups. For skewed data Mann-Whitney test was applied. Qualitative or categorical variables were described as frequencies and proportions. Proportions were compared using Chi square or Fisher’s exact test whichever was applicable. All statistical tests were two-sided and performed at a significance level of α = 0.05.
The mean age of the patients in left radial approach group (LRA) was 48.28 with an age group of 29 - 75 years whereas in the right radial approach group (RRA) were in the age group 32 - 78 years with a mean of 48.25 years (P = 0.991).
Amongst 35 patients in LRA group, 26 (74%) were males and 9 (26%) were females with Male: Female ratio of 2.88:1,
Diabetes Mellitus (DM) was the predominant risk factor occurring in 22 patients in RRA group and 18 patients in LRA group. Hypertension (HTN), Obesity and Smoking were the other risk factors respectively (
The time required for securing access (access time-AT) to the radial artery ranged from 15 - 60 seconds in the LRA while it ranged from 20 - 70 seconds in RRA, (P = 0.542),
The mean catheter manipulation time (CMT) in LRA was 64.00 seconds while it was 63.09 seconds in the RRA, (P = 0.686).
It was observed that the mean fluoroscopy time was more in LRA when compared to RRA approach and was slightly statistically significant (LRA-5.72 minutes vs RRA-4.25 minutes, P = 0.041).
However, when the procedure time (PT) was taken into account, it was seen that it did not differ significantly between the two groups (LRA-14.26 minutes vs RRA-13.58 minutes, P = 0.194).
The amount of contrast used (CU) during the angiography procedure was also similar while comparing both the groups (LRA-40.71 mL vs RRA-38.39 mL, P = 0.217).
Tiger catheter was used to catheterize the coronary arteries in both the approach groups. The number of catheters used for angiography also did not differ significantly between the two groups in our study.
Left Radial Approach | Right Radial Approach | Total | P-value | |||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
n | Min | Max | Mn | Md | n | Min | Max | Mn | Md | n | Min | Max | Mn | Md | ||
AT | 35 | 15.00 | 60.00 | 32.51 | 31.00 | 35 | 20.00 | 70.00 | 34.28 | 31.00 | 70 | 15.00 | 70.00 | 33.40 | 31.00 | 0.542 |
CMT | 35 | 53.00 | 76.00 | 64.00 | 63.00 | 33 | 45.00 | 80.00 | 63.09 | 66.00 | 68 | 45.00 | 80.00 | 63.55 | 64.50 | 0.686 |
FT | 35 | 1.55 | 14.56 | 5.72 | 4.62 | 33 | 1.27 | 11.21 | 4.25 | 3.80 | 68 | 1.27 | 14.56 | 5.01 | 4.30 | 0.041 |
PT | 35 | 12.12 | 24.39 | 14.26 | 14.17 | 33 | 11.13 | 21.21 | 13.58 | 13.16 | 68 | 11.13 | 24.39 | 13.93 | 13.41 | 0.194 |
CU | 35 | 30.00 | 50.00 | 40.71 | 40.00 | 33 | 20.00 | 50.00 | 38.39 | 38.00 | 68 | 20.00 | 50.00 | 39.58 | 40.00 | 0.217 |
BCT | 35 | 2.00 | 3.00 | 2.41 | 2.00 | 33 | 2.00 | 3.00 | 2.38 | 2.00 | 68 | 2.00 | 3.00 | 2.40 | 2.00 | 0.801 |
DT | 35 | 6.00 | 12.00 | 7.71 | 6.00 | 33 | 6.00 | 12.00 | 7.09 | 6.00 | 68 | 6.00 | 12.00 | 7.41 | 6.00 | 0.156 |
PE | 35 | 1.00 | 4.00 | 2.00 | 2.00 | 33 | 0.00 | 5.00 | 2.27 | 2.00 | 68 | 0.00 | 5.00 | 2.13 | 2.00 | 0.336 |
*AT-Access Time (in seconds), CMT-Catheter Manipulation time (in seconds), FT-Fluoroscopy Time (in minutes), PT-Procedure Time (in minutes), CU-Contrast Used (in mL), BCT-Bed Confinement Time (in hours), DT-Discharge Time (in hours), PE-Pain Endured (in scale of 0 - 10). *n = no. of patients, Min-Minimum, Max-Maximum, Mn-Mean, Md-Median.
The quality of angiograms (QA) was measured on a scale of 1 to 3 for the left coronary artery as well as right coronary artery which did not differ significantly between the two groups (LRA-3 vs RRA-3).
The average bed confinement time (BCT) was 2.41 hours in LRA while it was 2.38 hours in RRA. Patients in LRA were discharged after a mean of 7.71 hours while those in RRA were discharged after a mean of 7.09 hours. The bed confinement time and discharge time also did not differ significantly between the two groups (P = 0.801, P = 0.156 respectively).
All the patients in both the approach groups were asked to grade their pain endured (PE) on a scale of 0 - 10. The grades were not statistically significant between the 2 groups (LRA-2.00 vs RRA-2.27, P = 0.336).
The mean cost (C) of the angiography was 1300 RMB in each approach groups which did not differ statistically.
The common complication encountered was radial artery spasm (2 in LRA vs 3 in RRA; P = 0.642),
Left Radial Approach | Right Radial Approach | P-value | |
---|---|---|---|
Complications | |||
Radial Artery Spasm | 2 | 3 | 0.642 |
Crossover | 0 | 2 | 0.357 |
Radial Artery Anomalies | |||
Tortuosity | 2 | 4 | 0.414 |
H-bRO | 1 | 0 | 0.317 |
Hypoplasia | 1 | 0 | 0.317 |
RA & BA Stenosis | |||
RA > 50% stenosis | 9 | 7 | 0.617 |
BA > 50% stenosis | 2 | 4 | 0.414 |
RA < 50% stenosis | 3 | 2 | 0.654 |
BA < 50% stenosis | 1 | 1 | 1 |
RA > 50% stenosis | 1 | 3 | 0.317 |
BA > 50% stenosis | |||
RA > 50% stenosis | 0 | 1 | 0.317 |
BA < 50% stenosis | |||
RA < 50% stenosis | 0 | 0 | 0 |
BA > 50% stenosis | |||
RA < 50% stenosis | 0 | 0 | 0 |
BA < 50% stenosis | |||
Catheterization Findings | |||
0 vessel Involved | 8 | 13 | 0.294 |
1 vessel Involved | 12 | 7 | |
2 vessel Involved | 6 | 9 | |
3 vessel Involved | 9 | 6 |
*H-bRO-High-bifurcating Radial Origin, RA-Radial Artery, BA-Brachial Artery.
There were total numbers of 2 crossovers in our study both due to radial artery spasm which were only in the RRA, one to ipsilateral ulnar and other to the femoral. The difference between the crossover in our study was not statistically significant, (P = 0.357).
The common radial artery anomalies encountered were high-bifurcating radial origin, tortuosity and hypoplasia (P = 0.317, P = 0.414, P = 0.317). Therefore, no radial artery anomaly was statistically significant between the 2 groups. We did not come across any case of retroesophageal subclavian artery anomaly.
A total of 7 patients in the RRA demonstrated significant stenosis (>50% stenosis) of radial artery while the same number in LRA was 9. Similarly, slightly mor e patients had significant brachial artery stenosis (>50% stenosis) in the RRA (4) as compared to LRA (2). However, they were not different statistically. None of the groups attained statistical significance between the RRA and LRA implying that the stenoses of radial artery were evenly distributed across both the groups.
Coronary angiogram done had a range of vessel involvement ranging from no vessel to involvement of all the three coronary arteries by atherosclerosis. In the LRA, the largest number of patients had single vessel involvement by atherosclerosis (34%). In the RRA, more patients had no vessel involvement by atherosclerosis on coronary angiogram (37%). There was no difference between the 2 groups with respect to number of vessels involved (P = 0.294).
This study was undertaken to compare the right radial approach with left radial approach and prove that left radial approach is as efficacious as the right approach in diagnostic coronary angiography with respect to access time, catheter manipulation time, procedure time, contrast, hospital stay, discharge time, pain endured during and after the procedure. The use of TIG catheter to catheterize the arteries lowers the incidence of arterial spasm.
The access time in our study was not found to be significant which was similar to the study of Kawashima O et al. [
The catheter manipulation time was found to be similar in both the approaches in our study unlike Kawashima O et al. [
The fluoroscopy time was slightly significant (P = 0.041) and was greater in the LRA which was independent to catheter manipulation time. Santas E et al. [
Though the fluoroscopy time was found to be dissimilar between both the groups our procedure time was not statistically significant (P = 0.194) which is in support of Santas E et al. [
The amount of contrast and number of catheters used during the procedure was also statistically insignificant in our study when compared to both the groups which was similar to the finding of Kawashima O et al. [
Since we used identical type (Tiger) and numbers of catheter for both the LRA and RRA groups, the cost of the procedure did not differ significantly. Moreover, the amount of contrast used was similar which also contributed to the similar cost of the procedure in both the groups. The duration of hospital stay was also found to be similar which is in support of Louvard Y et al. [
There were total numbers of 2 crossovers in our study both due to radial artery spasm which were only in the RRA group, one to ipsilateral ulnar and other to the femoral. The difference between the crossover in our study was not statistically significant (P = 0.357) which was similar to Binita Shah et al. [
The quality of angiogram and pain experienced by the patients during the procedure was also similar as well as statistically insignificant in both the groups.
We experienced 4 radial artery anomalies in the RRA group all of which were Tortuosity with the same number in LRA group, 2 Tortuosity, 1 High-birfurcating Radial Origin and 1 Hypoplasia. Vasecchi O et al. [
The coronary angiogram findings of our study revealed single vessel disease in 19 patients, double vessel disease in 15 patients, triple vessel disease in 15 patients and 21 patients without significant (>50%) stenosis. The number of vessels involved had no statistical relationship with the left or right radial approach. Saito S et al. [
Radial artery spasm were found to be the only complication in our study which was more in RRA in comparison to LRA but were not statistically significant (P = 0.642). Dominici M et al. [
Moreover, the unique advantage of the multipurpose Tiger catheter to easily cannulate both right and left coronary artery presents an advantage to the operator and provides patient comfort decreasing the various complications during transradial coronary angiography.
Coronary angiography performed via left radial approach is as efficacious, efficient and safe as right radial approach when performed by Tiger catheter with respect to the access time, catheter manipulation, procedure time, amount of contrast used, hospital stay, intensity of pain experienced and quality of coronary angiograms observed. Arterial spasm, which is one of the common complications encountered during angiography, is not found to be significant with the use of Tiger catheter in either group.
The authors would like to thank the doctors, nurses, radiology technicians as well as our patients and their guardians without whose co-operation this study would not be possible.
Pasupati Rajoria,Chenghong Xu,Yunfeng Zhang,Wenjun Guan,Hua Yang,Keping Yang, (2016) Left Radial Approach versus Right Radial Approach of Coronary Angiography in the Diagnosis of Coronary Heart Disease. World Journal of Cardiovascular Diseases,06,265-274. doi: 10.4236/wjcd.2016.68030