Study population

From August 2022 to February 2023, all patients who underwent elective scheduled coronary angiography and PCI in our institution with failed radial access were included in this retrospective cross-section study. The exclusion criteria were: ST segment elevation myocardial infarction (STEMI) patients underwent primary PCI (PPCI), patients who were in a cardiogenic shock requiring both inotropic support and intra-aortic balloon pump (IABP), and severely ill patients with a mechanical ventillatory support.

Finally, three hundred patients were finally enrolled and classified into two groups; 150 patients in a brachial access group and 150 patients in a femoral access group. In addition to demographic data, procedural characteristics, hospital stay, and complications were reported in both groups to assess safety and efficacy of the brachial access in relation to the femoral one. The study was carried out in adherence to the principles of the Declaration of Helsinki on Biomedical Research Involving Human Subjects. The institutional Ethics Committee approved the study protocol (ZU-IRB#10502). All study participants gave written informed consent before the procedure.

Clinical data collection

Baseline demographic and clinical characteristics of all enrolled patients were obtained from hospital records and the cardiovascular risk factors were identified. The diagnosis of diabetes mellitus was confirmed in all patients receiving active treatment or defined as an abnormal glycated hemoglobin (> 6.5%), abnormal fasting blood glucose level (> 126 mg/dl) or abnormal 2 h postprandial level (> 200 mg/dl). Hypertensive patients were those receiving antihypertensive therapy or those with systolic blood pressure (SBP) > 140 mmHg and/or a diastolic blood pressure (DBP) > 90 mmHg. Dyslipidemia was defined if total cholesterol > 200 mg/dL or low-density lipoprotein cholesterol (LDL-C) > 100 mg/dL or when the patient was previously on lipid-lowering medication in accordance with Adult Treatment Panel III Guidelines [11]. Family history of CAD was defined as the presence of CAD in first-degree relatives before the age of 55 years for men and 65 years for women. Patients using tobacco products or those quit smoking within the past month were considered as smokers [12]. History of stroke, coronary artery bypass grafting (CABG), and peripheral vascular diseases were also included in clinical data collection.

Blood samples and laboratory analysis

Venous blood samples were obtained from all patients prior to coronary angiography. The following parameters were obtained from all included patients: complete blood count (CBC), renal function tests (serum creatinine level and estimated glomerular filtration rate; eGFR), cardiac enzymes (Troponin I and creatine kinase-MB; CK-MB), and lipid profile.

Electrocardiogram (ECG) analysis and Echocardiography protocol

A resting 12-lead ECG was obtained at a speed of 25 mm/s and a voltage of 10 mm/mV for all patients at admission. Transthoracic echocardiography (TTE) was done before coronary angiography by an experienced blinded cardiologist according to the current practice guidelines [13] using a commercially available device (Siemens ACUSON X300) with a 1.8 MHz phased array transducer to assess the diastolic function and LVEF by the modified Simpson’s rule.

Coronary angiography and PCI protocol

Coronary angiography and PCI were performed by experienced operators according to standard protocols using Siemens (Axiom Sensis XP, Berlin, Germany) device at our catheterization laboratory via trans-brachial or trans-femoral approach using dedicated diagnostic and guiding catheters. Access, procedural and fluoroscopy times were recorded. All patients were examined carefully immediately after the procedure and before discharge to assess any complications. Complications were further classified into minor complications (conservative treatment only) and major complications (requiring surgical intervention).

Brachial artery access (Fig. 1)Fig. 1

Steps of trans-brachial approach. a, b Proper sterile preparation of the antecubital fossa with a povidone iodine solution. c Subdermal injection of 2% xylocaine solution above the elbow crease. d The brachial artery punctureutilising either the single puncture approach or the modified Seldinger method. e, f Advancement of a 30 cm guidewire. g–i insertion of an arterial sheath over the wireand confirmed by fluoroscopy. j, k RCA and LMCA engagement via trans-brachial approach. l Removal of the arterial sheath followed by direct digital compression to the brachial artery for 10 min to achieve hemostasis. m Maintain the arm in such position for 4–6 h

Patients with unsuccessful radial access (both in the left and right radial arteries) and operators who lacked trans-ulnar approach experience or who lacked motivation to gain femoral access were the selection criteria for the brachial approach. In all cases, there was no failed femoral approach after failure to get the radial access as the femoral artery puncture had never been attempted. In case of congenital anomalies or extreme tortuosity of the arterial system resulting in failed radial approach, the brachial approach was abandoned in favour of the femoral one.

Brachial access is being performed more frequently with similar benefits compared to radial and ulnar arterial accesses; especially in case of not successfully getting radial artery access, but the vascular and neurological complications become hurdles to interventional cardiologists. Specifically, failed radial approach was related to unsuccessful radial access attempts due to its limitations including small diameter, spasm, tortuosity, anatomic variants, and asymptomatic occlusion. In addition, other limitations include an occluded radial artery restricting future cardiac catheterization, bypass grafts, and dialysis fistulae [14,15,16].

Depending on the pulse condition, the puncture side (left or right) was selected. It had never been necessary to use the Sones or brachial cut-down techniques. The antecubital fossa was draped in a sterile fashion after proper sterile preparation with a povidone iodine solution. After that, 2% xylocaine solution was injected sub-dermal above the elbow crease where the brachial pulsation was best palpated. The modified Seldinger technique or the single puncture technique was used to prick the brachial artery followed by advancing a 30 cm guidewire with a sheath over it. In case of coronary angioplasty, heparin (10,000 i.u) was given, otherwise only 5000 i.u was given in diagnostic procedures. Catheters and wires were used according to operator preference.

The arterial sheath was removed after the procedure and the brachial artery was then directly compressed for at least 10 min to establish hemostasis. After that, further local compression using an elastic bandage was applied to the brachial artery and the elbow immobilized by an arm board. The arm was kept in such position for 4 to 6 h.

Femoral artery access

The selection criteria for femoral approach were patients with failed arm approach, and according to operators’ preference. Right femoral approach was used as a default approach. However, left side could be used in case of (a) weak right femoral pulse secondary to peripheral arterial disease, or (b) haemodialysis with insertion of double lumen catheter in the right femoral region. Both right and left sides were used in chronic total occlusion intervention.

The groin was draped after sterile preparation with a povidone-iodine solution. Under local anesthesia, percutaneous puncture of the femoral artery was done with an 18-G needle using either direct anterior puncture or modified Seldinger techniques. After that, a short 0.0359J-wire was passed with a sheath over it. For iliac negotiation, hydrophilic guidewires were employed and the operator's preferred catheter was used. Heparin dosage was administered in accordance with the type of procedure; 10,000 IU of heparin were administered during coronary angioplasty.

The arterial sheath was removed 4 to 6 h after the procedure. Manual digital pressure over the femoral artery was applied for 15 min to achieve hemostasis and then further local compression was applied by a sand bag and an elastic band for four hours. The patients were instructed to spend the entire process in bed and not to ambulate for 8 h. Doppler evaluation to both brachial and femoral arteries was done the day after the procedure.

Efficacy and safety

In this study, the procedural characteristics were reported in both brachial and femoral accesses to assess the efficacy of brachial approach as an alternative arterial access. The procedural characteristics included procedure type including coronary angiography, simple PCI, chronic total occlusion PCI (CTO PCI), left main coronary artery PCI (LMCA PCI), bifurcation PCI, and intracoronary imaging in addition to sheat size (5, 6, and 7 french), amount of contrast, and access, procedural, fluoroscopic times. Also, hospital stay in days was also reported in both brachial and femoral accesses. All these data were documented in brachial access group to assess its efficacy in relation to femoral access group.

Regarding safety, access complications were categorized as major and minor. Major complications included moderate/severe bleeding at puncture or non-puncture sites associated with a significant hemoglobin drop and required blood transfusion, permanent neurological deficit in addition to vascular complications as thrombotic occlusion, abscess, fistula, and pseudo-aneurysm. Minor complications included minor bleeding not requiring blood transfusion, transient neurological deficit, and local hematoma not requiring surgery. All patients were re-evaluated both before discharge and during outpatient appointments.

Statistical analyses

Data distribution was assessed according to the Kolgormonov-Smirnov test. Categorical data were compared using the chi-square test or Fisher exact test. Continuous variables were compared using an unpaired Student’s t-test or Mann–Whitney U-test. Data were expressed as mean ± standard deviation. All tests were two-sided, and a p-value of < 0.05 represented statistically significant differences. All analyses were performed using SPSS version 20 (SPSS Inc., USA).