Transradial Primary Percutaneous Coronary Intervention Sasko Kedev, MD, PhD, FESC, FACC KEYWORDS  Transradial approach  ST segment elevation myocardial infarction  Acute coronary syndrome  Percutaneous coronary intervention  Transfemoral approach  Bleeding complications KEY POINTS  Bleeding complications remain an important cause of morbidity and mortality in patients with acute ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI).  Access-site bleeding is greatest among the STEMI population.  Transradial access PPCI is associated with significant reduction in bleeding and vascular complications and with lower mortality compared with the transfemoral approach (TFA).  Specific radial skills providing procedural times and success rates comparable with those of the TFA are strongly recommended before using this technique in the STEMI PPCI setting.  A stepwise approach to learning is proposed and high-risk STEMI percutaneous coronary intervention is recommended as the last step.  A team approach to patient management is crucial in the catheterization laboratory. Videos of right forearm angiogram demonstrating significant radial artery tortuosity and tortuosity negotiated with 0.014-inch guidewire accompany this article at http://www. interventional.theclinics.com/ INTRODUCTION Primary percutaneous coronary intervention (PPCI) improves clinical outcomes in patients with ST segment elevation myocardial infarction (STEMI) and in high-risk patients with non–ST segment elevation acute coronary syndrome (NSTEACS). 1,2 The transfemoral approach (TFA) is still the most widely used percutaneous access site in most cardiac catheterization laboratories worldwide. However, being a deep and terminal vessel the femoral artery may expose the patient to frequent bleeding and vascular complica- tions, 3,4 especially in the setting of STEMI, in which potent antithrombotic drugs are frequently used. 5,6 Since its initial description as a safe and feasible access route for cardiac catheteriza- tion, 7,8 transradial access (TRA) has increasingly been used for percutaneous coronary interven- tion (PCI). The main advantage compared with TFA is a reduced risk of access-site bleeding and major vascular complications, particularly in the presence of multiple and more powerful anti- platelet and antithrombotic agents. 9 This risk is mainly related to the more favorable anatomy of the radial artery, which runs superficially, sepa- rated from major neurovascular structures, thus allowing shorter times to hemostasis and ambula- tion compared with TFA. 10 Disclosure: The author has nothing to disclose. Medical Faculty, University Clinic of Cardiology, University of St. Cyril & Methodius, Vodnjanska 17, Skopje 1000, Macedonia E-mail address: skedev@gmail.com Intervent Cardiol Clin 4 (2015) 167–177 http://dx.doi.org/10.1016/j.iccl.2014.12.003 2211-7458/15/$ – see front matter ª 2015 Elsevier Inc. All rights reserved.