Radial Access for Acute Coronary Syndromes

Over the last decades much has been done in the treatment of the patients with acute coronary syndromes. An early invasive treatment as well as combined and tailored antithrombotic therapy have contributed to increase the survival and reduce recurrence and adverse events. Potent antithrombotic and antiplatelet medication before, during and after the invasive procedure increase on the other hand the risk of potentially serious bleedings. Bleeding is associated with worse short term and long term outcome. The adverse effect of bleeding could even overcome the beneficial effect of early and invasive strategy and aggressive antithrombotic regimen. Therefore a potential target to further enhance the outcome of new strategies might be reducing intra- and postprocedural bleeding in patients undergoing PCI for acute coronary syndromes. A common site of bleeding is the femoral artery puncture site. Transradial coronary angiography and intervention was first introduced and described many years ago. The first angiography by brachial route was performed by Dr. Jason Sones in the 1958 and Dr. Ferdinand Kimeneji has first made wide use of radial access for PCI in the early 1990’s. Because of the technical difficulties and stiff catheters at that time this technique did not find large success and remained available in limited centers. Parallel to the technical refinements and medical progress, the use of radial artery as the preferred access site for coronary interventions during acute coronary syndromes has gained importance. Some large scale randomized trials have pointed out the significant potential of this technic to reduce the access site bleeding as well as the mortality. A comprehensive meta-Analysis of randomized trials comparing femoral vs radial access has been recently published and found that using radial artery as routine access site for PCI reduces all cause mortality by 21%, MACE by 16% and the risk of major bleeding and vascular complications following PCI by 47% and 77% respectively. As a consequence the 2017 ESC Guidelines for the treatment of ACS have changed the radial artery as preferred access site from II to Ia indication. It has to be pointed out that this specific technique has a demanding learning curve and the experience of the operator may play a determinant role in the success and results of the intervention.