Opinion statement
The volume of cardiac diagnostic procedures involving the use of ionizing radiation has increased rapidly in recent years, and the radiation exposure experienced by patients undergoing any medical imaging procedure has recently obtained a growing attention. Transradial (TR) access is being increasingly used worldwide for diagnostic coronary angiography (CA), and percutaneous coronary interventions, since it offers several benefits as compared to transfemoral (TF) access, such as by reducing hemostasis time and vascular complications, increased patient comfort, reduced hospital stay, and lower cost. In contrast, TR CA is thought to be associated with increased radiation exposure parameters compared with the traditional TF access. Although experienced operators may almost counterbalance this shortcoming, the increase in radiation exposure associated with TR approach seems not to be present in most clinical settings.
Similar content being viewed by others
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as:• Of importance and •• Of major importance
Fred A, Mettler J, Bhargavan M, Faulkner K, et al. Radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and comparison with other radiation sources—1950–2007. Radiology. 2009;253:520–31.
Johnson LW, Moore RJ, Balter S. Review of radiation safety in the cardiac catheterization laboratory. Catheter Cardiovasc Diagn. 1992;25:186–94.
Bakalyar DM, Castellani MD, Safian RD. Radiation exposure to patients undergoing diagnostic and interventional cardiac catheterization procedures. Catheter Cardiovasc Diagn. 1997;42:121–5.
Duran A, Hian SK, Miller DL, Le Heron J, Padovani R, Vano E. A summary of recommendations for occupational radiation protection in interventional cardiology. Catheter Cardiovasc Interv. 2013;81:562–7.
Ukisu R, Kushihashi T, Soh I. Skin injuries caused by fluoroscopically guided interventional procedures: case-based review and self-assessment module. AJR Am J Roentgenol. 2009;193:S59–69.
Roguin A, Goldstein J, Bar O, Goldstein JA. Brain and neck tumors among physicians performing interventional procedures. Am J Cardiol. 2013;111:1368–72.
Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004;44:349–56.
Bertrand OF, Rao SV, Pancholy S, et al. Transradial approach for coronary angiography and interventions: results of the first international transradial practice survey. J Am Coll Cardiol Intv. 2010;3:1022–31.
Mitchell MD, Hong JA, Lee BY, Umscheid CA, Bartsch SM, Don CW. Systematic review and cost-benefit analysis of radial artery access for coronary angiography and intervention. Circ Cardiovasc Qual Outcomes. 2012;5:454–62.
Hamon M, Pristipino C, Di Mario C, et al. Consensus document on the radial approach in percutaneous cardiovascular interventions: position paper by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care** and Thrombosis of the European Society of Cardiology. EuroIntervention. 2013;8:1242–51.
Ball WT, Sharieff W, Jolly SS, et al. Characterization of operator learning curve for transradial coronary interventions. Circ Cardiovasc Interv. 2011;4:336–41.
Park EY, Shroff AR, Crisco LV, Vidovich MI. A review of radiation exposures associated with radial cardiac catheterisation. EuroIntervention. 2013;9:745–53.
National Council on Radiation Protection and Measurements (NCRP). Ionizing radiation exposure of the population of the United States. Report No. 93. 1987.
Ciraj-Bjelac O, Rehani M, Minamoto A, Sim KH, Liew HB, Vano E. Radiation-induced eye lens changes and risk for cataract in interventional cardiology. Cardiology. 2012;123:168–71.
Sun Z, AbAziz A, Yusof AK. Radiation-induced noncancer risks in interventional cardiology: optimisation of procedures and staff and patient dose reduction. Biomed Res Int. 2013;2013:976962.
Food and Drug Administration (FDA). Avoidance of serious X-ray-induced skin injuries during fluoroscopically-guided procedures. FDA-Important Informations. 2014.
Zeitler E. Radiation exposure of patients having PTCA N causes/consequences of WHO Report. J Invasive Cardiol. 1997;9:239–42.
Hamada N, Fujimichi Y. Classification of radiation effects for dose limitation purposes: history, current situation and future prospects. J Radiat Res. 2014;55:629–40.
Hendry JH. Radiation biology and radiation protection. Ann ICRP. 2012;41:64–71.
The International Commission on Radiological Protection (ICRP). The 2007 recommendations of the International Commission on Radiological Protection. Ann ICRP 2007; Publication 103.
Christopoulos G, Makke L, Christakopoulos G, et al. Optimizing radiation safety in the cardiac catheterization laboratory: a practical approach. Catheter Cardiovasc Interv. 2016;87:291–301. Methods to increasing safety and reduce radiation exposure in the cathetization laboratory.
Voudris KV, Vidovich MI. Medicolegal implications of radial and femoral access for coronary angiography and intervention in 2016: focus on retroperitoneal hemorrhage. J Transl Intern Med. 2016;4:29–34.
Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. J Am Coll Cardiol Intv. 2008;1:379–86.
Feldman DN, Swaminathan RV, Kaltenbach LA, et al. Adoption of radial access and comparison of outcomes to femoral access in percutaneous coronary intervention: an updated report from the National Cardiovascular Data Registry (2007–2012). Circulation. 2013;127:2295–306. Frequency of radial access use and complications in the US based on NCDR records.
Mann T, Cubeddu G, Bowen J, et al. Stenting in acute coronary syndromes: a comparison of radial versus femoral access sites. J Am Coll Cardiol. 1998;32:572–6.
Louvard Y, Lefevre T, Allain A, Morice M. Coronary angiography through the radial or the femoral approach: the CARAFE Study. Catheter Cardiovasc Interv. 2001;52:181–7.
Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the ACCESS Study. J Am Coll Cardiol. 1997;29:1269–75.
Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;377:1409–20.
Amin AP, House JA, Safley DM, et al. Costs of transradial percutaneous coronary intervention. J Am Coll Cardiol Intv. 2013;6:827–34.
Mehta SR, Jolly SS, Cairns J, et al. Effects of radial versus femoral artery access in patients with acute coronary syndromes with or without ST-segment elevation. J Am Coll Cardiol. 2012;60:2490–9.
Porto I, Bolognese L, Dudek D, et al. Impact of access site on bleeding and ischemic events in patients with non-ST-segment elevation myocardial infarction treated with prasugrel: the ACCOAST Access Substudy. J Am Coll Cardiol Intv. 2016;9:897–907.
Valgimigli M, Gagnor A, Calabro P, et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet. 2015;385:2465–76. MATRIX study showing mortality benefit in patients with ACS undergoing TR coronary angiography and PCI.
Pandie S, Mehta SR, Cantor WJ, et al. Radial versus femoral access for coronary angiography/intervention in women with acute coronary syndromes: insights from the RIVAL Trial (Radial Vs femorAL access for coronary intervention). J Am Coll Cardiol Intv. 2015;8:505–12.
Cusma JT, Bell MR, Wondrow MA, Taubel JP, Holmes Jr DR. Real-time measurement of radiation exposure to patients during diagnostic coronary angiography and percutaneous interventional procedures. J Am Coll Cardiol. 1999;33:427–35.
Eisenberg MJ, Afilalo J, Lawler PR, Abrahamowicz M, Richard H, Pilote L. Cancer risk related to low-dose ionizing radiation from cardiac imaging in patients after acute myocardial infarction. Can Med Assoc J. 2011;183:430–6.
Brueck M, Bandorski D, Kramer W, Wieczorek M, Holtgen R, Tillmanns H. A randomized comparison of transradial versus transfemoral approach for coronary angiography and angioplasty. J Am Coll Cardiol Intv. 2009;2:1047–54.
Brasselet C, Blanpain T, Tassan-Mangina S, et al. Comparison of operator radiation exposure with optimized radiation protection devices during coronary angiograms and ad hoc percutaneous coronary interventions by radial and femoral routes. Eur Heart J. 2008;29:63–70.
Mercuri M, Xie C, Levy M, Valettas N, Natarajan MK. Predictors of increased radiation dose during percutaneous coronary intervention. Am J Cardiol. 2009;104:1241–4.
Mercuri M, Mehta S, Xie C, Valettas N, Velianou JL, Natarajan MK. Radial artery access as a predictor of increased radiation exposure during a diagnostic cardiac catheterization procedure. J Am Coll Cardiol Intv. 2011;4:347–52.
Neill J, Douglas H, Richardson G, et al. Comparison of radiation dose and the effect of operator experience in femoral and radial arterial access for coronary procedures. Am J Cardiol. 2010;106:936–40.
Lo TS, Ratib K, Chong AY, Bhatia G, Gunning M, Nolan J. Impact of access site selection and operator expertise on radiation exposure; a controlled prospective study. Am Heart J. 2012;164:455–61.
Delewi R, Hoebers LP, Ramunddal T, et al. Clinical and procedural characteristics associated with higher radiation exposure during percutaneous coronary interventions and coronary angiography. Circ Cardiovasc Interv. 2013;6:501–6.
Shah B, Bangalore S, Feit F, et al. Radiation exposure during coronary angiography via transradial or transfemoral approaches when performed by experienced operators. Am Heart J. 2013;165:286–92.
Caputo RP, Tremmel JA, Rao S, et al. Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI. Catheter Cardiovasc Interv. 2011;78:823–39.
Rigattieri S, Sciahbasi A, Drefahl S, et al. Transradial access and radiation exposure in diagnostic and interventional coronary procedures. J Invasive Cardiol. 2014;26:469–74.
Bundhoo S, Nallur-Shivu G, Ossei-Gerning N, Zaman A, Kinnaird TD, Anderson RA. Switching from transfemoral to transradial access for PCI: a single-center learning curve over 5 years. J Invasive Cardiol. 2014;26:535–41.
Becher T, Behnes M, Unsal M et al. Radiation exposure and contrast agent use related to radial versus femoral arterial access during percutaneous coronary intervention (PCI)—results of the FERARI Study. Cardiovasc Revasc Med : including molecular interventions 2016. doi:10.1016/j.carrev.2016.05.008.
Jolly SS, Cairns J, Niemela K, et al. Effect of radial versus femoral access on radiation dose and the importance of procedural volume: a substudy of the multicenter randomized RIVAL trial. J Am Coll Cardiol Intv. 2013;6:258–66.
Simard T, Hibbert B, Natarajan MK, et al. Impact of center experience on patient radiation exposure during transradial coronary angiography and percutaneous intervention: a patient-level, international, collaborative, multi-center analysis. J Am Heart Assoc. 2016;5:e003333. Multicenter randomized study underlying the importance of operator’s learning curve in radiation exposure. When a center’s procedure access balances, the resultant radiation exposure is equivalent.
Michael TT, Alomar M, Papayannis A, et al. A randomized comparison of the transradial and transfemoral approaches for coronary artery bypass graft angiography and intervention: the RADIAL-CABG Trial (RADIAL Versus Femoral Access for Coronary Artery Bypass Graft Angiography and Intervention). J Am Coll Cardiol Intv. 2013;6:1138–44.
Hibbert B, Simard T, Wilson KR, et al. Transradial versus transfemoral artery approach for coronary angiography and percutaneous coronary intervention in the extremely obese. J Am Coll Cardiol Intv. 2012;5:819–26.
Sciahbasi A, Calabro P, Sarandrea A, et al. Randomized comparison of operator radiation exposure comparing transradial and transfemoral approach for percutaneous coronary procedures: rationale and design of the minimizing adverse haemorrhagic events by TRansradial access site and systemic implementation of angioX—RAdiation Dose Study (RAD-MATRIX). Cardiovasc Revasc Med. 2014;15:209–13. RAD-MATRIX: randomized multicenter study designed to compare the clinical outcome of patients with acute coronary syndromes treated invasively according to the access site.
Sciahbasi A, Romagnoli E, Burzotta F, et al. Transradial approach (left vs right) and procedural times during percutaneous coronary procedures: TALENT Study. Am Heart J. 2011;161:172–9.
Hu H, Fu Q, Chen W, Wang D, Hua X, Chen B. A prospective randomized comparison of left and right radial approach for percutaneous coronary angiography in Asian populations. Clin Interv Aging. 2014;9:963–8.
Dominici M, Diletti R, Milici C, et al. Left radial versus right radial approach for coronary artery catheterization: a prospective comparison. J Interv Cardiol. 2012;25:203–9.
Guo X, Ding J, Qi Y, et al. Left radial access is preferable to right radial access for the diagnostic or interventional coronary procedures: a meta-analysis involving 22 randomized clinical trials and 10287 patients. PLoS One. 2013;8:e78499.
Kado H, Patel AM, Suryadevara S, et al. Operator radiation exposure and physical discomfort during a right versus left radial approach for coronary interventions: a randomized evaluation. J Am Coll Cardiol Intv. 2014;7:810–6.
Xia SL, Zhang XB, Zhou JS, Gao X. Comparative efficacy and safety of the left versus right radial approach for percutaneous coronary procedures: a meta-analysis including 6870 patients. Braz J Med Biol Res=Rev Bras Pesqui Med Biol/Soc Bras Biofis. 2015;48:743–50.
Shah RM, Patel D, Abbate A, Cowley MJ, Jovin IS. Comparison of transradial coronary procedures via right radial versus left radial artery approach: a meta-analysis. Catheter Cardiovasc Interv. 2016. doi:10.1002/ccd.26519. Meta-analysis comparing right versus left radial approach—left radial approach was associated with significant reductions in fluoroscopy time and contrast volume.
Pancholy SB, Joshi P, Shah S, Rao SV, Bertrand OF, Patel TM. Effect of vascular access site choice on radiation exposure during coronary angiography: the REVERE Trial (Randomized Evaluation of Vascular Entry Site and Radiation Exposure). J Am Coll Cardiol Intv. 2015;8:1189–96.
Acknowledgments
The authors would like to thank Dr. Marc A. Silver for his helpful and constructive comments that greatly contributed to improving the final version of the paper.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Konstantinos V. Voudris, Martha Habibi, Panagiotis Karyofillis, and Mladen I. Vidovich each declare no potential conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of the Topical Collection on Coronary Artery Disease
Rights and permissions
About this article
Cite this article
Voudris, K.V., Habibi, M., Karyofillis, P. et al. Radiation Exposures Associated With Radial and Femoral Coronary Interventions. Curr Treat Options Cardio Med 18, 73 (2016). https://doi.org/10.1007/s11936-016-0499-x
Published:
DOI: https://doi.org/10.1007/s11936-016-0499-x