Abstract

The adoption of transradial coronary angiography and coronary intervention is growing because of emerging data on its potential advantages over the femoral approach. As the adoption of radial procedures increases, it is important to understand the remaining challenges of both the technique and its implementation. In this review, we discuss four important issues related to transradial procedures—radial access site bleeding, radial artery injury and occlusion, radiation exposure, and implementation of a successful transradial primary percutaneous coronary intervention (PCI) programme. Although the radial artery is superficial and haemostasis can be achieved readily, access site bleeding can occur that, if left unchecked, can lead to forearm haematoma and, rarely, to compartment syndrome. Radial artery injury and occlusion are consequences of radial access, and randomized trials show that use of smaller diameter sheaths, adequate anticoagulation, and post-procedure ‘patent’ haemostasis reduce the risk of occlusion. The published literature demonstrates an association between transradial procedures and increased radiation exposure; therefore, reduction of radiation dosing during transradial procedures should be a priority for operators and catheterization laboratories. The potential reduction in mortality seen with transradial primary PCI must be balanced against the clinical imperative of timely reperfusion. Operators and catheterization laboratories should not begin a transradial primary PCI programme until sufficient radial experience has been gained in the elective setting. In addition, a protocol for femoral bailout should be considered to maintain door-to-reperfusion metrics.

Introduction

First described several decades ago,1 transradial angiography and intervention has evolved into a viable alternative to the traditional femoral approach, and may be preferred in specific clinical settings. The specific advantages of the radial approach over the femoral approach have been reviewed extensively,2 which include a lower risk of major vascular complications, major bleeding, reduced post-procedure length of stay, reduced resource use, and possibly lower mortality in high-risk patients such as those with ST-segment elevation myocardial infarction (STEMI).3

As the potential advantages of transradial procedures emerge and the adoption continues to increase throughout the world, it is important to outline the remaining unresolved issues related to the technique. The purpose of this review was to examine four specific topics related to transradial procedures: radial access site bleeding, radial artery injury and occlusion, increased radiation exposure, and implementation of a transradial primary percutaneous coronary intervention (PCI) programme that balances the reduction in vascular complications with the clinical imperative of timely reperfusion. The first three are challenges posed by the radial procedure technique, while the fourth is a challenge posed by the implementation of radial procedure.

Radial artery access site bleeding

Although the small calibre of the radial artery affords a safer vascular access route, there are specific complications that can occur either during a transradial procedure or after one. These include rare events such as radial artery perforation, evulsion, and pseudoaneurysm formation, as well as more common complications such as non-occlusive radial artery injury and radial artery occlusion. In addition, local bleeding complications can occur that, if left untreated, can lead to large forearm haematomas and, rarely, to compartment syndrome. Radial artery complications have been reviewed elsewhere4; therefore, this review will focus on bleeding complications related to the radial artery access site and radial artery injury and occlusion.

Owing to the superficial location of the radial artery, which facilitates haemostasis, bleeding from the radial access site is uncommon. In the RadIalVsfemoAL access for coronary intervention (RIVAL) trial that randomized 7021 patients with acute coronary syndrome undergoing coronary angiography or intervention to radial or femoral access, no patients developed bleeding at the radial access site as against 18 patients who developed bleeding at the femoral access site.5 Other studies have shown rates of radial access site bleeding up to 3–5%.6,7 The factors associated with bleeding after transradial PCI include creatinine clearance <60 mL/min, procedure duration, and sheath size. Similar to bleeding events that occur after transfemoral PCI, bleeding events that occur after transradial PCI are also associated with long-term major adverse cardiac events.8 One type of radial access site bleeding that can lead to significant morbidity is a forearm haematoma, which, if left unchecked, can lead to compartment syndrome of the arm. This is an exceedingly rare complication, occurring only in 0.004% in one case series.9 Forearm haematoma is caused by bleeding from the radial artery access site into the tissues of the forearm. The key to treatment is early recognition and compression. Figure 1 displays a haematoma grading system and the corresponding treatment strategies developed in the context of the Early Discharge After Transradial Stenting of Coronary Arteries (EASY) trial. The female sex has been shown to be an independent predictor of developing forearm haematoma after transradial PCI.10

Figure 1

The EASY trial haematoma grading scale with corresponding treatment strategies.

Figure 1

The EASY trial haematoma grading scale with corresponding treatment strategies.

Radial artery injury and occlusion

A common complication of radial access is radial artery injury and occlusion. Injury to the radial artery by placement of the introducer sheath likely involves inflammation and thrombus formation. Compared with arteries that have not been previously accessed for catheterization, catheterized radial arteries show significantly more intimal hyperplasia, periarterial tissue or fat necrosis, and adventitial inflammation.11 Optical coherence tomography of an access radial artery shows intimal tears and thickening, medial dissections, and thrombi, all of which are more common in radial arteries that have been repeatedly accessed.12 Some studies have reported that radial access may also temporarily impair arterial function,13 although studies are not consistent in this regard.14,15

These pathological and physiological changes in the radial artery after arterial access may ultimately lead to radial artery occlusion. The reported incidence of occlusion in the literature varies widely (0.8–30%)16 and depends on many factors including the method used to document occlusion, the diameter of the arterial sheath relative to the arterial diameter, the degree of procedural anticoagulation, and the post-procedural haemostasis technique. Approximately 25–50% of early radial occlusions re-canalize at 30 days.17 While hand ischaemia after extended duration of in-dwelling radial artery pressure-monitoring catheters in critically ill patients has been reported,18,19 radial artery occlusion after transradial cardiac catheterization is most often asymptomatic.20 This is not universally true, however, and occlusion leading to hand ischaemia after transradial cardiac catheterization has recently been documented in three case reports,21–23 two of which were successfully treated with antegrade angioplasty and one of which resulted in amputation of the index finger. Although all the three cases shared the common finding of radial occlusion, other potential causes such as distal embolization have led to digital ischaemia. Frequent flushing of arterial sheaths may reduce the risk of embolization, although this has not been studied systematically. Other case series have reported ‘symptomatic’ radial occlusions primarily manifest as pain at the access site or in the forearm,16,24 without hand ischaemia. While it is not clear whether the occlusion was responsible for the symptoms, a short course of anticoagulation with either low-molecular-weight heparin or fondaparinux was associated with greater radial artery re-canalization at follow-up.

One important issue is whether the presence of collateral flow to the hand, documented by either the Allen's or the more objective test using pulse oximetry and plethysmography,25 can identify patients at risk of hand ischaemia with radial artery occlusion. According to an international survey, 23.4% of respondents reported not routinely assessing for dual circulation of the hand prior to transradial procedures.26 While seemingly objective, there is no clear evidence that the results of these tests are correlated with the outcomes after occlusion occurs. One study indicated that, among patients with abnormal Allen's test, 30 min of radial occlusion resulted in significantly lower blood flow to the thumb and significantly higher thumb capillary lactate levels, but no clinical outcomes were reported.27 Moreover, these patients had some increase in blood flow to the thumb during compression, and the known extensive collateralization of the hand vasculature might have led to greater increases in flow if the duration of compression had been longer. In one of the case reports of digital ischaemia referenced earlier, the pre-procedure test for dual hand circulation using plethysmography was normal,21 providing a clinical example of how testing for dual hand circulation may not necessarily prevent ischaemic sequelae of radial occlusion. Moreover, the radial artery has been used as an arterial graft for coronary artery bypass surgery without compromising digital flow or hand function.28

Although most occlusions are asymptomatic, its reduction should still be a priority for radial operators for the simple reason that hand ischaemia may occur in rare cases and limits repeat access through the ipsilateral artery. Unfortunately, the majority of operators do not routinely assess for radial patency after transradial procedures.26 Strategies to minimize the risk of radial artery occlusion are summarized in Table 1. A randomized trial comparing 6-French and 5-French sheaths for transradial procedures found that the use of 5-French sheaths resulted in lower rates of radial occlusion (1.1 vs. 5.9%, P= 0.05),29 a finding subsequently confirmed in an observational study.16 For procedures where large bore guide catheters are required, sheathless techniques can be used, as this reduces the size of the arteriotomy,30 but radial occlusion rates are not reduced unless other strategies described in Table 2 are used.31 Randomized trials have shown that adequate anticoagulation (e.g. at least 5000 units of unfractionated heparin) and use of so-called ‘patent’ or non-occlusive haemostasis (Figure 2)—applying enough pressure to the radial access site to achieve haemostasis but maintaining antegrade flow in the radial artery—significantly reduce the risk of radial occlusion.32,33 Other novel measures include post-procedure ulnar compression to re-canalize an occluded radial artery6 and the use of drug-eluting sheaths34 to prevent arterial injury. As measures with proven ability to reduce the risk of radial artery occlusion are available, it may be useful for active radial programmes to monitor their patients for post-procedure occlusion prior to discharge as well as at 30 days in order to identify higher than expected rates that may warrant a change in practice.

Table 1

Strategies to reduce the risk of radial artery occlusion

Proven to reduce risk May reduce risk Not shown to reduce risk 
Adequate anticoagulationa Hydrophilic sheaths Short vs. long arterial sheaths 
Non-occlusive (‘patent’) haemostasis Reducing radial artery spasm Sheathless technique 
Smaller diameter arterial sheaths Minimizing the duration of post-procedure radial artery compression  
Minimizing number of times same radial artery is accessed   
Proven to reduce risk May reduce risk Not shown to reduce risk 
Adequate anticoagulationa Hydrophilic sheaths Short vs. long arterial sheaths 
Non-occlusive (‘patent’) haemostasis Reducing radial artery spasm Sheathless technique 
Smaller diameter arterial sheaths Minimizing the duration of post-procedure radial artery compression  
Minimizing number of times same radial artery is accessed   

aUnfractionated heparin 70 µ/kg up to 5000 units, bivalirudin, enoxaparin 60 mg via arterial sheath.

Table 2

Comparison of radiation exposure between transradial and transfemoral procedures for patients

Patient exposure
 
Study Fluoroscopy time (min)—diagnostic cases
 
Fluoroscopy time (min)—PCI cases
 
Dose-area product (Gy*cm2)—diagnostic cases
 
Dose-area product (Gy*cm2)—PCI cases
 
Radial Femoral Radial Femoral Radial Femoral Radial Femoral 
Mann et al.38   19.2a 15.8     
Kiemeneij et al.55   13 ± 11 11 ± 10     
Louvard et al.56 3.8 ± 2.2b 3.1 ± 1.7       
Saito et al.57   15.1 ± 7.6 16.1 ± 7.9     
Louvard et al.58   6.0 ± 4.4 4.5 ± 3.7     
Reddy et al.59   5.9 ± 1.1 6.8 ± 1.5     
Cantor et al.60   11.3 (7.6–15) 9 (7.2–16.5) 15.1 ± 8.4 13.1 ± 8.5 46.3 ± 28.7 51 ± 29.4 
Achenbach et al.61   5.6 ± 5.9 4.7 ± 3.9   3737 ± 2367 3199 ± 1879 
Lange and von Boetticher39 2.8 ± 2.1 1.7 ± 1.4 11.4 ± 8.4 10.4 ± 6.8 15.1 ± 8.4 13.1 ± 8.5 46.3 ± 28.7 51 ± 29.4 
Yigit et al.62 3.9 ± 1.7 3.9 ± 1.71       
Brasselet et al.63   13 ± 9 8 ± 6     
Brueck et al.64   9.0 (3.9–10.7) 5.8 (1.7–7.5)   41.9 (22.6–52.2) 38.2 (20.4–48.5) 
Chodor et al.65   10.9 ± 5.6 11.2 ± 7.0     
Chodor et al.66   7.5 ± 3.0 6.9 ± 3.0     
Mercuri et al.67 5.4 ± 8.3 3.82 ± 5.57       
Jolly et al.3   9.3 (5.8–15) 8.0 (4.5–13.0)     
Patient exposure
 
Study Fluoroscopy time (min)—diagnostic cases
 
Fluoroscopy time (min)—PCI cases
 
Dose-area product (Gy*cm2)—diagnostic cases
 
Dose-area product (Gy*cm2)—PCI cases
 
Radial Femoral Radial Femoral Radial Femoral Radial Femoral 
Mann et al.38   19.2a 15.8     
Kiemeneij et al.55   13 ± 11 11 ± 10     
Louvard et al.56 3.8 ± 2.2b 3.1 ± 1.7       
Saito et al.57   15.1 ± 7.6 16.1 ± 7.9     
Louvard et al.58   6.0 ± 4.4 4.5 ± 3.7     
Reddy et al.59   5.9 ± 1.1 6.8 ± 1.5     
Cantor et al.60   11.3 (7.6–15) 9 (7.2–16.5) 15.1 ± 8.4 13.1 ± 8.5 46.3 ± 28.7 51 ± 29.4 
Achenbach et al.61   5.6 ± 5.9 4.7 ± 3.9   3737 ± 2367 3199 ± 1879 
Lange and von Boetticher39 2.8 ± 2.1 1.7 ± 1.4 11.4 ± 8.4 10.4 ± 6.8 15.1 ± 8.4 13.1 ± 8.5 46.3 ± 28.7 51 ± 29.4 
Yigit et al.62 3.9 ± 1.7 3.9 ± 1.71       
Brasselet et al.63   13 ± 9 8 ± 6     
Brueck et al.64   9.0 (3.9–10.7) 5.8 (1.7–7.5)   41.9 (22.6–52.2) 38.2 (20.4–48.5) 
Chodor et al.65   10.9 ± 5.6 11.2 ± 7.0     
Chodor et al.66   7.5 ± 3.0 6.9 ± 3.0     
Mercuri et al.67 5.4 ± 8.3 3.82 ± 5.57       
Jolly et al.3   9.3 (5.8–15) 8.0 (4.5–13.0)     

aValue shown is without a portable floor shield; value with the floor shield is 18.

bData shown are for the right radial approach; the left radial value is 4.2 ± 1.7.

Figure 2

Patent haemostasis: after reduction of RA compression pressure, the plethysmographic curve on oximeter display shows antegrade radial artery flow with manual compression of the ulnar artery (reproduced from Bernat et al. IntervAkut Kardiol;2010:9(3):130–134; reproduced with permission).

Figure 2

Patent haemostasis: after reduction of RA compression pressure, the plethysmographic curve on oximeter display shows antegrade radial artery flow with manual compression of the ulnar artery (reproduced from Bernat et al. IntervAkut Kardiol;2010:9(3):130–134; reproduced with permission).

Increased radiation exposure compared with femoral approach

For percutaneous cardiac procedures, there are significant dose variations in radiation that depend on the X-ray exposure parameters, the individual patient's anatomy, the complexity of the procedure, and the experience of the interventional cardiologist. Although there are several measures of radiation exposure such as air kerma or dose-area-product, the most commonly reported indirect parameter of radiation exposure is fluoroscopy time. At the patient level, the dose-area-product correlates linearly with fluoroscopy time, whereas at the operator level, there is less correlation.35 Recommended annual exposures for interventional cardiologists have been previously published.36

Table 2 lists the fluoroscopy times and radiation doses for patients from randomized trials comparing radial and femoral approaches to angiography or PCI. For diagnostic angiography, almost all studies reported an additional ∼1–2 min fluoroscopy time with the radial approach; for PCI, a similar increase in fluoroscopy time was found in the majority of studies, but a few studies reported lower fluoroscopy time with the radial approach. Some studies reported the dose-area-product and, based on this metric, there were less radiation doses to patients undergoing femoral procedures, but the overall exposure remained well below the recommended levels.37 As shown in Table 3, there have been only two randomized studies comparing operators’ exposure between radial and femoral approaches.38,39 Without specific additional radiation protection, the radial approach was associated with a 100% increase in effective doses; however in one study, the use of a movable floor shield significantly reduced the level of operator exposure below that seen with the femoral approach.38 Another relevant issue is the comparison of operator radiation exposure with the right vs. the left radial approach. In one study that randomized patients undergoing angiography or PCI to the right or the left radial approach, Sciahbasi et al.40 found similar thyroid, trunk, and shoulder exposure, but higher wrist exposure, with the right radial approach. Given that the maximum annual dose recommendation for hands or feet is 500 mSv, this increase with the right radial approach is well below that published standard.

Table 3

Comparison of radiation exposure between transradial and transfemoral procedures operators

Operator exposure
 
Study Effective dose (µSv)—diagnostic cases
 
Effective dose (µSv)—PCI cases
 
Radial Femoral Radial Femoral 
Mann*38 N/A N/A 135 µSv 88 µSv 
Lange39 64 µSv ± 55 32 µSv ± 39 166 µSv ± 188 110 µSv ± 115 
Operator exposure
 
Study Effective dose (µSv)—diagnostic cases
 
Effective dose (µSv)—PCI cases
 
Radial Femoral Radial Femoral 
Mann*38 N/A N/A 135 µSv 88 µSv 
Lange39 64 µSv ± 55 32 µSv ± 39 166 µSv ± 188 110 µSv ± 115 

*Study included only patients undergoing PTCA. Values shown reflect doses without a moveable floor radiation shield. Use of the shield reduced the exposure: Radial 1.0 µSv/case vs. Femoral 2.7 µSv/case, P < 0.01.

On the basis of these data, the radial approach does appear to be associated with a slightly higher fluoroscopy time and radiation exposure for patients compared with the femoral approach, and the left radial appears to afford some protection for operators compared with the right radial approach. The increases appear to be concentrated primarily in diagnostic cases rather than PCIs, which implies that diagnostic radial cases require more fluoroscopy, ostensibly to navigate tortuous arm or chest vasculature, but once the guide catheter is seated in the coronary ostium, the PCI proceeds as if it were being performed via the femoral approach. As the adoption of transradial procedures increases worldwide, it will be crucial to optimize radiation protection measures. This involves use of the ‘ALARA’ (‘as low as reasonably achievable’) principle during radial cases, which may include low frame rate fluoroscopy and avoiding routine fluoroscopic tracking of the catheter and/or guidewire as it passes through the arm, use of appropriate shielding, and potentially the use of novel protective arm boards or drapes.

Implementation of a transradial primary PCI programme

Patients with STEMI represent the highest risk patients undergoing PCI. The rates of short-term death or recurrent myocardial infarction (MI) are higher among STEMI patients compared with patients without STEMI, as are the rates of bleeding.41,42 The goal of primary PCI for STEMI is to rapidly establish patency of the infarct-related artery.43 Strategies that achieve timely reperfusion and minimize bleeding risk are associated with reduced mortality.42 In this context, radial access is an attractive alternative to femoral access; however, the bleeding reduction afforded by the radial approach must be balanced against the potential risk of delayed reperfusion.

The association between radial approach and outcomes in STEMI patients has been studied in both randomized trials and observational studies. The RIVAL trial included1958 patients with STEMI, and showed a significant reduction in the rate of 30-day death, MI, stroke, or major bleeding, as well as 30-day mortality, major adverse cardiac events (death, MI, or stroke), and major vascular access site complications among patients assigned to the radial approach.3 While these data should be interpreted with caution because of the subgroup nature of the analysis, they are consistent with prior randomized and observational studies that have also suggested a reduction in mortality with transradial, as opposed to transfemoral, primary PCI44,45 (Table 4).

Table 4

Comparisons of major bleeding, door-to-balloon times, overall procedure times, and mortality for transradial vs. transfemoral primary PCI for STEMI (transfemoral as reference) from two meta-analyses with and without the RIVAL trial data

Outcomes in STEMI patients not including RIVAL data44
 
Outcome Radial 
Major bleeding [odds ratio (95% CI)] 0.30 (0.16–0.55) 
Door-to-balloon time, min [mean difference (95% CI)] −0.58 (−1.56, 0.39) (favours radial) 
Overall mortality [odds ratio (95% CI)] 0.54 (0.33–0.86) 
Outcomes in STEMI patients including RIVAL data45 
Major bleeding [odds ratio (95% CI)] 0.63 (0.35–1.12) 
Overall procedure time, min [mean difference (95% CI)] 1.76 (0.59–2.92) (favours femoral) 
Overall mortality [odds ratio (95% CI)] 0.53 (0.33–0.84) 
Outcomes in STEMI patients not including RIVAL data44
 
Outcome Radial 
Major bleeding [odds ratio (95% CI)] 0.30 (0.16–0.55) 
Door-to-balloon time, min [mean difference (95% CI)] −0.58 (−1.56, 0.39) (favours radial) 
Overall mortality [odds ratio (95% CI)] 0.54 (0.33–0.86) 
Outcomes in STEMI patients including RIVAL data45 
Major bleeding [odds ratio (95% CI)] 0.63 (0.35–1.12) 
Overall procedure time, min [mean difference (95% CI)] 1.76 (0.59–2.92) (favours femoral) 
Overall mortality [odds ratio (95% CI)] 0.53 (0.33–0.84) 

The mechanisms underlying this association are unclear but may be related to reduction in bleeding or vascular complications. STEMI patients are at higher risk of bleeding compared with patients who do not present with STEMI,42 and the bleeding reduction afforded by radial access may therefore have a greater impact on STEMI outcomes. This is contradicted by the fact that while major vascular access site complications were lower among patients assigned to radial access in the RIVAL trial, there was no difference in major bleeding rates.3 Other potential explanations for the reduction in mortality seen among STEMI patients in the RIVAL trial include selection bias (more stable STEMI patients were enroled on the study, while patients who were unstable or shocked were not approached), or the possibility that transradial primary PCI may be a marker for centres that have other processes of care associated with better outcomes. This may explain the association between radial centre volume and better outcomes that was seen when outcomes were stratified by centre volume. Additionally, given that the STEMI analysis from the RIVAL trial is a subgroup of an overall neutral clinical trial, the possibility of confounding cannot be excluded.

Registries show that the radial approach is used less often in STEMI patients than in patients without STEMI,46,47 which may, in part, reflect the concern over the ability to open the infarct artery in a timely fashion. Unfortunately, the reporting of door-to-balloon time metrics has been inconsistent across studies comparing radial and femoral primary PCI. In a meta-analysis of 12 studies of 3324 patients, there was no significant difference in the door-to-balloon time between transradial or transfemoral primary PCI.44 Smaller single centre studies have also found either no difference in door-to-balloon times48 or shorter times with transradial primary.49 An updated meta-analysis of 10 randomized trials comparing radial and femoral access in STEMI patients, including the RIVAL trial, showed that the radial approach was associated with a non-significant increase of 1.76 min [95% confidence interval (CI) 0.59–2.92] in overall procedure time compared with the femoral approach.45 These metrics are available from the RIVAL trial but have not yet been reported (S. Mehta, personal communication).

It is important to note that the aforementioned studies involved very experienced operators. In particular, the RIVAL trial had minimum radial procedural volume requirements in order to participate as an investigator.3 There is a clear relationship between operator experience and procedural metrics such as procedure duration and success.50 Since reperfusion delays during transradial primary PCI may involve a combination of delays in patient preparation, arterial access, or engaging the coronary artery with the guide catheter, an experienced radial operator and catheterization laboratory staff are the integral components of implementing a transradial primary PCI programme. A fundamental question is how best to define an ‘experienced’ operator. While radial procedural volume is an attractive metric to define proficiency, a more important measure may be the operator's radial procedure success or rate of access site crossover (‘bailout’ to femoral access). Access site crossover, which occurs much more frequently from radial to femoral rather than the converse, is significantly lower among experienced radial centres.3 The pooled data on transradial vs. transfemoral PCI in STEMI as well as data from the RIVAL study show a radial-to-femoral crossover rate of ∼7%.3,44 Therefore, a reasonable recommendation is that operators should not start performing transradial primary PCI until their procedure success rates are comparable between their elective radial and femoral PCI procedures and their radial-to-femoral crossover rate is ≤7%. An a priori left radial approach in older patients may also reduce reperfusion times because of less subclavian tortuosity and faster guide catheter placement.51,52 In addition, a successful programme should also have specific benchmarks for when femoral bailout is indicated based on delays in obtaining radial arterial access, engaging the coronary arteries, or establishing coronary patency, although formal recommendations do not currently exist.

A unifying theme

A common underlying aspect of minimizing radiation exposure with the radial approach and successfully implementing a transradial primary PCI programme is experience in the radial approach. The concept of radial ‘learning curve’ has been documented with studies showing a decrease in procedure failure, contrast use, and fluoroscopy time as an operator's radial volume increases.50,53 For operators who are early in their radial experience, an a priori left radial approach is associated with a significant reduction in fluoroscopy time compared with the right radial approach.54 On the other hand, for experienced operators, there appears to be no significant difference between right and left radial approaches. With respect to procedure success, Ball et al.53 found that among operators inexperienced in the radial approach, the rate of procedure success after 50 transradial PCI procedures increased significantly and approached the rate seen with experienced radial operators (those with annual radial PCI volumes >300). As noted earlier, this is most relevant in the setting of transradial primary PCI where procedure success must be achieved in a timely fashion. While this study points to 50 procedures as the inflection point where an ‘experienced’ operator might be defined, it is likely that procedural metrics continue to improve in a linear fashion as an individual's number of transradial procedures increases. Additionally, the number of procedures required to achieve procedural success similar to that of the femoral approach likely varies among operators.

Conclusions

The adoption of transradial angiography and intervention is driven in part by clinical data showing a lower risk of complications over the femoral approach. As the enthusiasm for radial procedures increases, it is important to understand the challenges that remain. Radial access site bleeding, radial artery injury and occlusion, increased radiation exposure, and implementation of successful transradial primary PCI programmes are important considerations for both novice radial operators and those who are experienced. Future studies involving transradial procedures should focus on strategies to minimize radial artery injury and occlusion, discover methods to reduce fluoroscopy times and radiation exposure, and outline best practices for the application of transradial primary PCI.

Conflict of interest: S.V.R. received consultant honoraria from Terumo Medical.

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