Do you recommend avoiding radial artery access for cardiac catheterization to preserve potential future dialysis access sites in patients with advanced CKD?

With Radial arterial catheterization ( RA-CA), structural damage to the artery manifests as intimal tears and medial dissection along the length of the vessel. Further, even though 2-30% of the arteries will thrombose, about 50% of these will recanalize at 1 month. In spite of this, endothelial function such as flow-mediated vasodilation is impaired. Intimal hyperplasia & adventitial inflammation occur as well which reduce arterial lumen. These are worse when the distal radial artery is punctured compared to the proximal part of the artery.

Based on the above issues, it would make sense to avoid radial artery catheterization, especially in CKD patients.

With the advent of EndoAVF, RC AVFs may be successful as the proximal radial artery is used (when using the Ellipsys device). However, this isn't available everywhere.

In some centers, surgeons may preferentially place AVFs in the upper arm ( brachiocephalic or brachial basilic) than at the wrist since only 20-40% RC AVF will mature. At these centers, it may be fine to go ahead with RA-CA.

REFERENCE

Lim et al., PMID 24254539

A major reason for primary failure and inadequate maturation of forearm radio-cephalic arteriovenous fistulas is poor arterial blood flow. Transradial cardiac catheterization can lead to radial artery occlusion (1-12%) and non-occlusive radial artery stenosis in 31% of patients based on Doppler ultrasound evaluation. I would therefore not recommend the radial artery approach to cardiac catheterization in patients with advanced CKD. The femoral artery access to cardiac catheterization has been used for many years with a good track record. I would try to preserve arterial real estate for hemodialysis fistula construction as much as possible in patients with advanced CKD.

Alkagiet et al., PMID 32814536

Generally speaking at our center, we continue to use the radial artery access as a default for Cardiac procedures.

We don’t think that these interventions affect the future creation of AV access. Further, most of these patients end up having upper arm fistulas or forearm AV grafts in general practice.

In fact, radial access is becoming the default access for cardiac procedures due to the short time of controlling bleeding after procedures.

I think it is a good idea. I am not aware of the advantages of radial artery access versus femoral artery access but for years only femoral artery access was performed for cardiac caths. Thus, I believe femoral artery access even though may be less ideal but still very safe and there is tons of experience with it. Having a good fistula is so important in dialysis patients as such anything that would increase the success rate is definitely worthwhile. 

Most of our CKD patients don't get Cimino fistulas because of vascular disease and the majority have upper arm AVFs. Therefore, we don't usually interfere with cardiologists' choices regarding arterial access for angiograms.

I utilize distal (snuffbox) radial access for these patients. This approach theoretically leads to less proximal/forearm radial occlusion. This has been demonstrated in a number of studies. Radial artery access is safer and should not be avoided due to the concern related to future dialysis access. When I have to utilize the forearm radial artery, I am meticulous about "patent" hemostasis technique. This is a nice review of radial artery access in patients with CKD.

The data published (Latif et al., PMID 34389155) shows an important advantage to radial access in this subset of patients with reduced mortality and bleeding compared to femoral approaches. Emotional responses based on theoretical concerns is not supported in real-world practice. Renal patients often are hypertensive with calcified femoral arteries that further enhance the risk of femoral puncture.