Zusammenfassung
Die A. radialis als Zugangsweg zur Koronarangiograhie wurde vor mehr als 15 Jahren insbesondere zur Reduktion blutungs- bzw. immobilisationsbedingter Komplikationen erstmals benutzt. Wenngleich bereits frühzeitig vergleichbare prozedurale und klinische Resultate gezeigt werden konnten, konnte der radiale Zugang sich zunächst nur regional sehr unterschiedlich (u. a. Kanada, Frankreich, Italien) als Standardzugang etablieren.
Nachdem inzwischen auch signifikant bessere kardiale Resultate beim transradialen Zugang dokumentiert werden konnten, scheint sich der radiale Zugangsweg nicht nur wegen des höheren Patientenkomforts, geringerer Personalbelastung und Hospitalisierungskosten nunmehr auch in Deutschland als Standardzugang zu etablieren.
Das relativ kleine Gefäßkaliber in einem im Vergleich zur Femoralispunktion komplikationsärmeren Umfeld bringt aber neben dem Hauptvorteil, den signifikant niedrigeren Blutungskomplikationen, schwierigere Punktionsbedingungen und das Problem von Gefäßspasmen und postinterventionellen Gefäßobliterationen mit sich, v. a bei den Patienten, bei denen die hierfür typischen Prädiktoren Rauchen, weibliches Geschlecht und kleine Gefäßkaliber, vorliegen. Neben dem Gebrauch kleinerer Katheter (4/5 F) konnte diesbezüglich auch ein Zusammenhang mit adjuvanter Heparingabe (> 3000 IE) sowie periprozeduraler spasmolytischer Pharmakotherapie (u. a. Nitro, Verapamil) nachgewiesen werden.
Geringfügig höhere Durchleuchtungszeiten fanden sich auch in unserem Patientenklientel und sind vermutlich der zwingend unter Durchleuchtung zu erfolgenden retrograden Passage der großen thorakalen Gefäße anzulasten. Wegen der potenziell besseren Abschirmungsmöglichkeiten vor Streustrahlen muss dies aber nicht automatisch zu einer höheren Strahlenbelastung für den Untersucher führen.
Abstract
Radial artery access for coronary interventions was initially introduced as a useful vascular access site for reducing vascular complications (e.g. bleeding) and to enhance patient comfort, reduce hospital staff workload and costs. Although earlier data indicated comparable procedural success rates but longer procedural and fluoroscopy times with radial as compared to femoral access, recent data from prospective multicenter studies and large meta-analyses even revealed significantly better immediate and long-term outcomes in contemporary, real world clinical settings of percutaneous cardiovascular procedures including acute coronary syndrome (ACS) and acute myocardial infarction (AMI). From this perspective, the better cardiac outcome after transradial percutaneous coronary interventions may be explained by the lower necessity of cessation of anticoagulation and antiplatelet therapy due to significantly less bleeding complications after radial access.
Bleeding complications occur only very rarely with this technique but procedural success of transradial access is occasionally limited by anatomical circumstances or radial spasms and postinterventional occlusions, which seems to be strongly related to the mandatory adjuvant pharmacological therapy (e.g. 3,000 U heparin, verapamil and nitroglycerine) and the anatomical variations, which can possibly be reduced by the use of smaller catheters.
The most likely reason for sometimes longer fluoroscopy times (even for very experienced interventionalists) could be explained by the mandatory use of fluoroscopy while retrogradely passing the great thoracic vessels but this does not necessarily mean higher radiation exposure to the interventionists due to the potentially better possibilities of effective protection measures against backscatter radiation.
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Dahm, J., Wolpers, H., Becker, J. et al. Radialiszugang zur Koronarintervention. Kardiologe 6, 412–422 (2012). https://doi.org/10.1007/s12181-012-0444-5
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DOI: https://doi.org/10.1007/s12181-012-0444-5