Patients prefer transradial access to transfemoral, study finds

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Patients have a strong preference for transradial access, a recent study published in the Journal of Vascular and Interventional Radiology finds. Lead author Lisa Liu, Rush Medical College, Chicago, USA, and colleagues write: “With transradial access, patients experienced less periprocedural pain and shorter recovery times without significant differences in radiation exposure or procedure length.

The study investigators set out to determine patient preference for these two different access sites during hepatocellular carcinoma (HCC) radioembolization procedures after experiencing both. They explain that “The use of transradial access as the preferred approach over transfemoral access in interventional radiology has steadily increased, owing in part to numerous trials by cardiologists demonstrating fewer access-related complications, greater patient satisfaction, and lower cost with transradial access compared with transfemoral access in coronary interventions.”

Thirty patients with HCC under going MAA (macroaggregated albumin) mapping and transarterial radioembolization (TARE) were enrolled to experience one transradial access and one transfemoral access procedure each, with randomisation of which access approach was experienced first. Previous studies have also found a patient preference for transradial access, though, to Liu et al’s knowledge, no earlier study measured potential reasons for patient preference, “such as associated pain, recovery time, or quality of life after the procedure”, the present study authors write. An additional aim of the present study therefore was to “objectively assess the impact of access site on patient comfort and satisfaction.”

The authors cite a retrospective review assessing the safety and feasibility of the trans-radial approach in the first 1,500 non-coronary interventions to use trans-radial access at a single institution published in 2016 by Raghuram Posham (Icahn School of Medicine at Mount Sinai, New York, USA) et al that demonstrated a safety profile of 98.2% technical success rate and <3% complications, most of which were defined as minor complications.

This prospective, randomised, single-institution, controlled crossover trial of 30 patients (28 men; mean patient age of 66 years) reported that 22 (73.3%) patients indicated preference for radial access. Four (13.3%) patients indicated preference for femoral access, and four (13.3%) indicated no preference. Liu and colleagues deem this a “strong preference for transradial access”, drawing attention to the fact that more than five times as many patients prefer transradial to transfemoral access.

The authors also note that no acute minor or major adverse events were identified on physical examination at the day of procedure at a 30-day follow-up appointment. They write: “No access-site bruising and/or haematoma, radial artery occlusion, or any other minor or major complications were documented.” Fourteen patients self-reported superficial bruising following radial procedures in surveys given out during follow-up; for patients commenting on trans-femoral access, 17 patients reported bruising (46.7% vs. 53.3% for transradial and transfemoral access, respectively; p=0.4074). All 14 patients who reported bruising following transradial access were amongst the 17 to also report bruising following transfemoral access. Amongst the total patient cohort, 10 were taking anti-coagulants: seven of these patients reported bruising after transradial access, and nine after transfemoral access.

To greater elucidate the association between the self-reported bruising rate for transradial versus transfemoral access and the use of anticoagulants, the study authors call for future studies on the incidence of bruising after transradial versus transfemoral access to “control for anticoagulation and antiplatelet medication use.”

Surveys assessing pain and quality of life were administered after each MAA mapping and TARE procedure. Patients were contacted via e-mail, phone, or in person to complete a survey on demographics, occurrence of self-reported bruising, and numerical pain rating scale. This scale ranged from no pain at 1 to worst pain at 10 in four different contexts: during the procedure overall, during the procedure at the access site, after the procedure in the recovery room, and after the procedure at home. Patients also completed a modified 12-item Short Form Health Survey to assess quality of life.

Patients experiencing transradial access recorded, on average, significantly lower overall pain during the procedure, significantly lower pain at the access site during the procedure, and significantly lower pain after the procedure in the recovery room compared with transfemoral access (p=0.0046, p=0.0004, p=0.0357, respectively). No significant difference was observed for average pain reported after discharge at home between transradial and transfemoral procedures (p=0.4235). Liu and colleagues write that “These results suggest that the reduced pain and increased comfort associated with transradial access are short-term benefits limited to the perioperative time period during the procedure and immediately after in the recovery room before discharge.”

Furthermore, the authors report no significant differences between quality of life scores after transradial access versus transfemoral access.

Average fluoroscopy time—a measure of radiation exposure—and total recovery time were also not significantly different between the two access types (p=0.1442 and p=0.1496, respectively). For TARE procedures, the authors note that “radial access cases [both MAA mapping and TARE] were associated with significantly shorter recovery times on average compared with femoral access cases (108 minutes for transradial access, 153 minutes for transfemoral acess; p=0.0193).”

Summarising their results, Liu et al write: “Overall, patients reported significantly less pain with transradial access compared with transfemoral access during the procedure and afterward in the recovery room. Additionally, transradial access was associated with shorter recovery times for both MAA mapping procedures and TARE procedures, with a significant difference observed for TARE procedures.” Liu and colleagues postulate that “the lack of corresponding significance for MAA mapping procedures may be attributed to having overall shorter recovery times compared with TARE (118.9 minutes vs. 130.7 minutes), and perhaps a significant result may have been reached in the MAA mapping group with a larger sample size.

“Additionally,” they add, “the significant difference in recovery time achieved in the TARE group should be considered with caution, as patients receiving trans-femoral access underwent a conservative two-hour bedbound protocol after AngioSeal (Terumo) deployment rather than the recently US Food and Drug Administration (FDA)–approved 20-minute early ambulation protocol.”

Commenting on the significance of this finding, the study investigators comment: “The findings of this study support considering radial access as a default patient-centred approach to radioembolization procedures for patients eligible for both radial and femoral access approaches.”

A positive response from interventional radiologists

Commenting on these results on Twitter, Naveed Rajper, an interventional cardiologist based in New York, USA, wrote: “Trials are not necessary to prove this. Radial first is tried and tested. Let us cross-pollinate advancements like this between procedural specialties, be open to change, and focus on even bigger things.”

Responding to this remark, Aaron Fischman, an interventional radiologist also from New York, USA, and an author on this study, said, “You would be surprised the conversations we have at interventional radiology meetings about this concept. There are some things that have to be proven in a rigorous way to move the needle. Patient preference specific to interventional oncology is an important step in that direction.”

Darren Klass, another advocate for the transradial approach, and an interventional radiologist in Vancouver, Canada, agrees with Fischman, writing online in direct response to the latter ’s comment: “Agree. Patient preference is one. Nursing intensity post-procedure, complications, discharge time, radiation dose to patient and operator, done or in midst of publication for interventional radiology, yet we still face the apathetic objectors.”

Generally commenting on the study, Klass said on social media that this publication is “cementing what radial first operators all experience.”

The study authors do acknowledge some concerns with transradial access. One “potential concern” of transradial access for noncoronary interventions “is longer procedure times and subsequent greater patient radiation exposure owing to the greater anatomic distance from access site to treatment site.” However, they note that trials from interventional cardiology have not found significant differences in fluoroscopy time.

Liu et al also note that the subjectivity of surveys and of pain scales as research tools acts as a limitation to the present study. In addition, they acknowledge that as four of the 30 patients in the trial had experienced a prior intervention using radial or femoral access, there was the possibility of introducing a preconceived bias into their results. However, they write that “the effect of this limitation is expected to be minimal considering the small percentage of patients with prior transradial access or transfemoral access [experience], and no pattern of bias was observed in analysis of this subset of patients and their choice of access preference.”

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