<International Circulation>: Could you firstly outline the differences in efficacy and safety between transradial intervention and transfemoral intervention?

    Prof. Weisz: The main advantage of the transradial approach is the significantly greater safety. There are almost zero access site complications with respect to bleeding， and there is also the advantage of convenience for the patient as they are able to sit after the procedure and can be mobile on the same day as the intervention.

    <International Circulation>:So then what are the indications and contraindications for each of the procedures?

    Prof. Weisz: The transradial technique is applicable to almost any patient. Today， we can do most of the procedures with a 6 French guide which can go through almost any radial artery and as we have seen at this meeting in the live case sessions， very complex and diffuse disease procedures， complex CTO， left mains can be done with a 6 French guiding catheter with perfect and efficacious results. I would use the transfemoral approach in those cases that would need a 7 or 8 French guide， such as in the case of bifurcations and when you need extra support. Sometimes if there is an anomaly of the radial or brachial vessels it is difficult to approach through the radial artery， although it must be said， if you cannot go through the right radial， it does not mean you cannot go through the left radial. Additionally， the transradial approach may be a little more difficult with a short stature， elderly patient where the brachial artery might be very tortuous， the subclavian artery might be tortuous or there might be elongation and tortuosity of the aorta. In these situations though the experience of the operator comes into play and it is certainly possible to perform transradial procedures in the elderly， even octogenarians， with very good results.

<International Circulation>: What are the differences in antithrombotic therapies between transradial and transfemoral access intervention techniques?

Prof. Weisz: One big advantage， and certainly another major indication for the radial approach， is if the patient is on warfarin， you do not need to stop it and you can perform at least a diagnostic angiogram while the patient is using warfarin via the transradial approach very safely. This is not possible transfemorally. Giving anticoagulation during the procedure for PCI， you can use any anticoagulant agents as long as it is a combination of heparin and  IIb/IIIa inhibitors. There is a higher risk of bleeding using the transfemoral approach and no more risk of bleeding using the radial - the higher the risk for bleeding， the greater the advantage for the transradial approach.

<International Circulation>: With stent thrombosis in mind， how long should patients be maintained on dual platelet therapy post-procedure and what factors are determining the duration of that therapy?

Prof. Weisz: This is an excellent question with no good answer unfortunately. I hope we will have better evidence-based medicine in the next two or three years. Currently in the United States， we recommend dual antiplatelet therapy for just one year for the majority of the patients. This is an empirical decision – it is not that we know that one year is better than six months or that one year is as good as two years， because right now we just don’t know. There are a couple of exceptions. For patients with left main stenting， we usually recommend lifelong dual antiplatelet therapy. And secondly， those patients who are on warfarin and for whom the risk of bleeding is really increased on aspirin， Plavix and warfarin， if the intervention was not too complex， a simple stenting with no increased risk of stent thrombosis， then I would recommend using Plavix for six months to reduce the risk of bleeding from being on triple blood-thinning therapy. If you ask me if there is any difference between the stents regarding the need for dual antiplatelet therapy， from the data that we have right now， there is no evidence that one stent is safer long term than the others. Some stents claim to be safer and have less stent thrombosis， and some head-to-head comparisons show different results， so personally I am not convinced that one stent is better than the others in this respect.

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