Radialer Zugang bei Koronarinterventionen

Abstract

There is ongoing discussion about the optimal access site for PCI and stent implantation. The transradial access (TRA) is being increasingly used over the past years. Recent studies in patients with acute coronary syndrome (RIVAL study) and in patients with STEMI (RIFLE-STEACS study), revealed a reduced access site-related bleeding and a better cardiovascular outcome in patients with TRA compared to patients with transfemoral access (TFA). This was especially true in high risk patients and in experienced interventionalists in centres with high radial volume. Within this manuscript we will describe the pros and cons of the TRA versus the TF approach as well as current evidence from the literature. In conclusion the TRA should be the favourite and first choice approach for almost all of our patients.

Kernaussagen

• In der interventionellen Kardiologie spielt der Radialiszugang in den letzten Jahren eine immer wichtigere Rolle.

• Bei Patienten mit akutem Koronarsyndrom und STEMI (RIVAL-Studie) oder STEMI (RIFLE-STEACS-Studie) waren die zugangsbedingten Blutungskomplikationen und die kardiovaskuläre Morbidität und Mortalität niedriger als bei transfemoral behandelten Patienten. Insbesondere traf diese Beobachtung auf Patienten mit erhöhtem Risiko zu.

• Die Erfolgs- und Komplikationsrate der Radialisuntersuchung hängt von der Expertise des Untersuchers und dem Volumen der transradialen Untersuchungen/Interventionen/Jahr ab. Das Konsensusdokument einiger Fachgesellschaften fordert einen Curriculum zur transradialen Untersuchung. Um eine Expertise zu bekommen und zu erhalten, sollten mindestens 50 % der Katheteruntersuchungen und Koronarinterventionen pro Jahr transradial durchgeführt werden, mindestens aber 80 Prozeduren pro Untersucher und Jahr.

• Zu den Komplikationen nach Radialisuntersuchung gehört in bis zu 10 % der Verschluss der A. radialis. Wahrscheinlich ist er noch häufiger, weil er aufgrund der dualen Blutversorgung der Hand über den Arcus palmaris oft asymptomatisch verläuft. Insbesondere die Wahl der Schleusen- und Kathetergröße sowie die postinterventionelle Kompression und Hämostase sind dabei entscheidende Faktoren. Wichtig ist, dass während der Kompression ein Restfluss im Gefäß erhalten bleibt. Die Kompressionsdauer sollte 2 – 4 Stunden nicht überschreiten.

• Die Dauer der Durchleuchtung und der Prozedur selbst können bei der Radialisuntersuchung länger sein als bei einem transfemoralen Zugang, wobei auch diese Parameter deutlich von der Expertise des Untersuchers abhängen.

• Insgesamt hat der Radialiszugang in der interventionellen Kardiologie einen hohen Stellenwert und sollte als Routinezugang eingesetzt werden, insbesondere bei Patienten mit akutem Koronarsyndrom oder STEMI.

• Literatur

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