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Published on: August 8, 2025
Precision approach for transradial access during PCI: a state-of-the-art review
Tanawat Attachaipanich1, Muzamil Khawaja2, Hafeez Ul Hassan Virk3
1Department of Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas city, MO, United States.
Insights
The transradial approach (TRA) is preferred for cardiac procedures due to fewer complications. Refinements improve success, but optimal anticoagulation and alternative access sites need further study.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Access
Background:
- The transradial approach (TRA) is now the standard for coronary angiography and percutaneous coronary intervention (PCI).
- TRA offers significant benefits over the transfemoral approach, including reduced bleeding, vascular complications, and mortality in acute coronary syndromes (ACS).
Purpose of the Study:
- To review technical refinements and strategies to optimize TRA success.
- To discuss alternative access sites like distal radial (dTRA) and ulnar approaches.
- To examine optimal anticoagulation strategies and management of TRA-related complications.
Main Methods:
- Review of current literature on TRA techniques, including puncture methods and vasodilator use.
- Analysis of alternative access strategies (dTRA, ulnar) and their associated benefits and limitations.
- Discussion of anticoagulation protocols and complication management in the context of TRA.
Main Results:
- Technical refinements like ultrasound guidance and radial cocktails improve TRA success and reduce radial artery spasm (RAS).
- Distal radial (dTRA) and ulnar approaches may lower radial artery occlusion (RAO) rates and preserve conduit arteries but require more experience.
- Optimal anticoagulation strategies for TRA are still debated, as the bleeding risk is already low.
Conclusions:
- TRA is a safe and effective vascular access method for cardiac procedures, with ongoing refinements enhancing its utility.
- While dTRA and ulnar approaches show promise, further research and operator experience are needed.
- Preventing and managing complications like hematoma, RAS, and RAO remains crucial for successful TRA outcomes.
Abstract:
The transradial approach (TRA) has become the preferred vascular access for coronary angiography and percutaneous coronary intervention (PCI), offering reductions in bleeding and vascular complications compared with the transfemoral approach, and lower mortality in patients with acute coronary syndromes (ACS). Technical refinements have further enhanced procedural success with TRA. Variations in puncture technique (ultrasound-guidance, through-and-through vs. single-wall technique) and the use of vasodilator "radial cocktails" can improve access success and reduce the risk of radial artery spasm (RAS), while adequate anticoagulation, appropriate sheath sizing, and optimized radial band removal techniques help to reduce radial artery occlusion (RAO). Alternative access strategies such as distal radial (dTRA) and ulnar approaches offer advantages including lower RAO rates and preservation of the proximal radial artery for future conduit use, though these techniques are limited by higher crossover rates, longer cannulation times, and the need for additional operator experience. Optimal intraprocedural anticoagulation in the TRA era remains uncertain, as the bleeding advantage of alternatives to unfractionated heparin may be attenuated given the inherently lower access-site bleeding risk. Procedural complications, including hematoma, RAS, RAO warrant prevention and prompt recognition. Future research should refine anticoagulation strategies, personalize access-site selection, and further evaluate dTRA and ulnar approaches as operator experience matures.
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