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Cardiology fellows proved competent in learning the radial access technique during coronary procedures, and fellowship programs should routinely include radial training, researchers suggested.

From the first half of the academic year through the second half, researchers found no difference in fluoroscopy or procedure time when fellows employed the radial approach during diagnostic coronary angiography, and there was a "slight but significant" reduction in contrast use, reported Jason Rogers, MD, and colleagues from the University of California Davis Medical Center in Sacramento.

Regarding radial access for percutaneous coronary intervention (PCI), no differences occurred between the two halves of the year in fluoroscopy time, procedure time, or contrast use, they wrote in the March issue of the American Heart Journal.

The trainees were simultaneously learning the transfemoral approach and again, researchers found no differences in any of the three metrics between the first 6 months and the last 6 months with respect to coronary angiography or PCI.

In the study's introduction, researchers noted that the radial approach has several advantages over the femoral approach such as fewer bleeding and vascular complications, as well as faster recovery.

However, disadvantages include increased procedural time and more radiation exposure, which can be exacerbated by its steeper learning curve compared with femoral access.

Such disadvantages "have limited the widespread acceptance of transradial procedures in both clinical practice and cardiovascular training programs in the United States," the investigators wrote.

They added that most studies to date examining competency in the transradial technique have concentrated on interventionalists already experienced in the femoral approach.

Rogers and colleagues compared procedural and clinical outcomes between radial and femoral access "at a cardiovascular training program, where trainees are exposed to the radial and femoral approaches concurrently."

The retrospective, nonrandomized study included 141 radial and 261 femoral cases that took place between July 2010 and June 2011. Right radial artery access occurred in 90% of coronary angiography cases and 85% of PCI cases.

The cardiovascular fellows acted as primary operators on all cases. The program consisted of 12 general cardiology fellows and two interventional. The faculty who supervised the fellows were very experienced in femoral access, but only modestly so in transradial.

Rogers and colleagues compared outcomes from the first 6 months with the last 6 months.

The mean age of diagnostic angiography patients was 61, two-thirds were men, about a quarter had prior PCI, 46% presented with unstable angina/non-ST-segment elevation myocardial infarction (non-STEMI), and there were significantly more diabetics in the radial group (41% versus 30%, P=0.03).

The mean age of PCI patients was about 62, nearly 70% were men, 40% had diabetes, and 62% presented with unstable angina/non-STEMI.

Researchers removed certain cases from the final count because they would "significantly bias the operators toward a femoral or radial approach" such as STEMI, previous coronary artery bypass grafting, or procedures with concomitant right heart catheterization." They also excluded chronic total occlusions because they require higher fluoroscopy time.

Rogers and colleagues compared the differences in coronary angiography over the course of the year and the differences in PCI over the course of the year.

They also compared radial with femoral access over the course of the year. For coronary angiography cases, they found:

• No difference in contrast volume use between radial and femoral access
• A significant difference in fluoroscopy time for radial in the second half of the year (P=0.059 versus P=0.0001)
• A significant difference in procedure time for radial in the second half of the year (P=0.404 versus P=0.0015)

The same comparison for PCI showed no differences between radial and femoral in any of the same three indices over the course of the year:

• Contrast volume: P=0.51 versus P=0.69
• Fluoroscopy time: P=0.34 versus P=0.21
• Procedure time: P=0.67 versus P=0.20

No matter which access route the cardiology fellows chose, they used lesion-assessing tools such as fractional flow reserve, optical coherence tomography, and intravascular ultrasound equally. They also found similar lesion characteristics and lesion locations with each access route.

Complication rates were very low for all groups and none of the differences between radial and femoral access during coronary angiography or PCI rose to significance.

There were five major bleeding cases with transfemoral coronary angiography and four instances of major vascular complications compared with no major bleeding and one case of vascular complication in the transradial coronary angiography group (P=0.1 and P=0.5, respectively).

There were three instances of major vascular complications and four cases of major bleeding complications with femoral PCI versus none with radial PCI (P=0.68 and P=0.27, respectively).

Finally, there was very little crossover, with four of the radial diagnostic coronary angiography cases crossing over to the femoral approach, and one case going from femoral to a radial approach (P=0.03). For PCI, three of the radial approach cases required crossover to a femoral approach, but none of the femoral cases had to switch to a radial approach.

Cardiovascular fellows demonstrated radial access competency over the course of the year as evidenced by the little or no difference in fluoroscopy time, procedural time, and contrast use during coronary angiography and PCI, researchers concluded.

"Cardiology fellowship training programs looking to adopt transradial procedures as part of their repertoire can do so safely without increased harm to the patient," they added.

Limitations included the lack of randomization and the small sample. They also did not assess differences between right and left radial approaches. Finally, results may not be generalizable to patients with more complex lesions.

From the American Heart Association:

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