Background: Femoral access has traditionally been the preferred route for coronary angiography. However, the transradial approach has gained increasing acceptance due to its association with fewer vascular complications, improved patient comfort, and earlier mobilization. Despite these advantages, concerns remain regarding a longer learning curve, increased fluoroscopy time, and higher contrast volume usage.
Aim: To evaluate fluoroscopy time as a surrogate marker of radiation exposure during diagnostic coronary angiography, assess contrast volume usage, and compare findings with previously published studies.
Methodology: This retrospective observational study included patients who underwent diagnostic coronary angiography between January 2, 2021, and May 29, 2024. Data were collected such as demographics, vascular access site, fluoroscopy time, and contrast volume. Descriptive statistical analysis was performed.
Results: A total of 6,672 patients were included (77.3% male), with an age range of 45–70 years. The radial approach was used in 97.7% of cases. The mean fluoroscopy time was 2.25 ± 2.03 minutes, and the mean contrast volume was 54.23 ± 17.5 mL. Vascular complications were rare and limited to minor local hematomas.
Conclusion: The transradial approach is a safe and effective technique with low complication rates. Fluoroscopy time and contrast usage were within acceptable ranges, indicating no excess radiation or contrast burden.

Coronary angiography, Fluoroscopy time, Radiation exposure, Femoral approach, Radial.

Coronary artery disease (CAD) remains a leading cause of morbidity and mortality worldwide, accounting for a substantial proportion of cardiovascular deaths, particularly in low- and middle-income countries.[1,2] In developing countries such as Yemen, the burden of CAD is increasing due to epidemiological transition and limited preventive strategies.[2] Diagnostic coronary angiography continues to represent the gold standard for the assessment of coronary anatomy and plays a central role in guiding revascularization strategies.[3,4]

The femoral artery has traditionally been the favored access site for coronary interventions mainly due to its large diameter but has bleeding as the most feared complication.[5] Over the past two decades, the transradial approach has emerged as a safer alternative, offering significant reductions in bleeding complications, earlier ambulation, and improved patient comfort.[6-8] Large randomized trials such as radial vs. femoral access for coronary intervention (RIVAL) and minimizing adverse hemorrhagic events by transradial access site and systemic implementation of angiox (MATRIX) have demonstrated improved clinical outcomes with radial access, particularly in acute coronary syndrome (ACS) patients.[9,10] Despite these advantages, concerns remain regarding longer procedural time, increased fluoroscopy exposure, and the operator learning curve associated with the transradial approach.[11,12] Therefore, evaluating the safety and feasibility of radial access in different clinical settings, including resource-limited environments such as Yemen, is of significant clinical importance.

Aim of study: Our aim of this study is to study and compare the radiation exposure by taking fluoroscopy time (FT) as a surrogate of radiation exposure to the operator and patients with a radial approach and amount of contrast used in patients undergoing diagnostic catheterization and compare the results with other studies done in other centers in different countries.

This retrospective observational study was conducted at Nabdh Al-Hayat Cardiac Centre, Mukalla, Hadramout Governorate, Yemen, between January 2021 and May 2024. A total of 6,672 consecutive patients undergoing diagnostic coronary angiography were included. Patients who underwent percutaneous coronary intervention (PCI), had a prior history of coronary artery bypass graft surgery (CABG), or required procedures involving right heart catheterization were excluded from the study. In addition, pediatric patients and interventional procedures were excluded.

Data collection: The study protocol was reviewed and approved by the Institutional Ethics Committee of Nabdh Al Hayat Cardiac Centre, Mukalla, Yemen. Written informed consent was obtained from all patients prior to undergoing the procedure. A structured questionnaire was used to collect demographic and clinical data. Patient confidentiality was maintained, and the study was conducted in accordance with the principles of the Declaration of Helsinki. All procedures were performed in a high-volume cardiac catheterization laboratory by experienced interventional cardiologists. Standard catheterization techniques were followed, and radial access was the default vascular approach whenever feasible.

Statistical analysis: Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 13.0. Descriptive statistics were used to summarize the data. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages.

Procedural technique: All patients underwent standard preparation prior to coronary angiography, including clinical evaluation and assessment of vascular access suitability. Radial artery access was obtained using the modified Seldinger technique under local anesthesia. A 5F or 6F sheath was introduced, followed by administration of intra-arterial vasodilators and anticoagulation to prevent radial artery spasm and thrombosis. Diagnostic coronary angiography was performed using standard Judkins catheters. Image acquisition was conducted in multiple projections to adequately visualize coronary anatomy. Hemostasis following radial access was achieved using a compression device, while femoral access hemostasis was achieved by manual compression.

Outcome measures: The primary outcome of the study was fluoroscopy time, used as a surrogate marker of radiation exposure. Secondary outcomes included contrast volume used and the incidence of vascular complications.

Definitions:

• Fluoroscopy time was defined as the total duration of X-ray exposure during the procedure. Contrast volume was defined as the total amount of contrast media administered.
• Vascular complications included hematoma, pseudoaneurysm, arteriovenous fistula, or bleeding requiring intervention.

Retrospectively collected catheterization laboratory data of consecutive patient (n = 6671) who underwent a diagnostic coronary angiography at Nabdh Al hayat cardiac center, Mukalla, Hadramout Gov., Yemen, over a 41-month period (between January 2021 and May 2024) were reviewed for this analysis. The radial approach was used in 6523 cases (97.7%), the femoral approach in 147 cases (2.2%), and the brachial approach in two cases; all cases were done successfully.

Among the enrolled patients, 5157 (77.3%) were male and 1515 (22.7%) were female, with an age range of 45–70 years. For radial access procedures, fluoroscopy time ranged from 0.06 to 2.6 minutes, with a mean of 2.25 ± 2.03 minutes. Contrast volume ranged from 9 mL to 300 mL, with a mean of 54.23 ± 17.5 mL. Vascular complications were rare, with only five cases of minor local hematoma and no major complications observed (Table 1).

Further subgroup analysis demonstrated that procedures performed via the femoral approach were associated with longer fluoroscopy times and higher contrast usage compared to the radial approach. The mean fluoroscopy time for femoral access was 6.0 ± 6.12 minutes, significantly higher than that observed in radial procedures. Similarly, contrast volume was higher in femoral access cases, with a mean of 96 ± 6.39 mL, compared to 54.23 ± 17.46 mL in radial cases. The brachial approach, although rarely used, showed the highest fluoroscopy time and contrast volume, reflecting its limited use and potential technical challenges.

No statistically significant differences in procedural success rates were observed between access sites, as all procedures were successfully completed. These findings highlight the efficiency of the radial approach in reducing procedural time and contrast exposure in routine diagnostic coronary angiography.

Table 1: Results of the study

The radial approach for coronary angiography is increasingly used due to its association with a lower rate of access-site complications, improved patient comfort, and earlier mobilization compared with the femoral approach.[13-15] However, concerns have been raised regarding longer procedural duration and potentially increased radiation exposure to operators when the radial approach is used.[16-18] This study, representing one of the largest series from Yemen, demonstrated a mean fluoroscopy time of 2.25 minutes, which is lower than most previously reported studies. Earlier studies have reported fluoroscopy times ranging from approximately 3 to 6 minutes, with some reports showing even longer durations depending on operator experience and procedural complexity.

Similarly, the mean contrast volume in this study (54 mL) was at the lower end of values reported in the literature, which typically range between 50 and 100 mL. This suggests that with adequate experience, the radial approach does not necessitate increased contrast usage. The very low rate of vascular complications observed in this study further supports the safety advantage of the radial approach. These findings align with previous international studies that demonstrated reduced complication rates with radial access compared to femoral access.

Radiation exposure remains a critical concern in interventional cardiology. Although fluoroscopy time is not a direct measure of radiation dose, it correlates reasonably well with radiation exposure in routine practice. The relatively short FT observed in this study suggests that the radial approach, when performed by experienced operators, does not necessarily result in increased radiation exposure. Several studies have reported increased radiation exposure with radial access, particularly during the early learning phase. However, with increasing operator experience and technological advancements, this difference appears to diminish over time.

The success of the radial approach is highly dependent on operator expertise. The shorter FT observed in this study likely reflects the high procedural volume and familiarity of operators with the radial technique at our center. Previous studies have demonstrated that after an initial learning curve, procedural efficiency improves significantly, resulting in reduced fluoroscopy time and contrast usage.

The findings of this study have important clinical implications, particularly in resource-limited settings. The ability to perform coronary angiography safely with low complication rates, minimal radiation exposure, and reduced contrast usage supports the adoption of the radial approach as the default strategy.

Compared to international studies, our results demonstrate favorable outcomes in terms of both FT and contrast volume. This indicates that high-quality cardiac care can be delivered effectively even in developing healthcare systems when appropriate expertise and infrastructure are available (Table 2).

Table 2: Studies of other centers used fluoroscopy time and amount of dye

Our results regarding fluoro time are 3.6±3.8 min, and the amount of dye used was 55 ml (mean); these results are within the international range as seen in the table above, and all these studies conclude that the radial approach is a safe alternative access for coronary angiography.

Limitations: This study has several limitations that should be acknowledged. First, retrospective observational design may introduce selection bias and limits the ability to establish causal relationships. Second, this was a single-center study, which may limit the generalizability of the findings to other institutions with different procedural volumes or operator experience. Third, radiation exposure was not directly measured using dose–area product (DAP) or air kerma, and instead, fluoroscopy time was used as a surrogate marker of radiation exposure. Although fluoroscopy time correlates with radiation dose, it does not fully reflect the total radiation exposure to patients and operators. Finally, procedural complexity and anatomical variations were not specifically analyzed in this study.

Future directions: Future research should focus on prospective multicenter studies incorporating direct radiation measurements such as dose–area product and air kerma. Additionally, studies evaluating patient outcomes, cost-effectiveness, and long-term complications would further strengthen the evidence supporting the radial approach.

In conclusion, the transradial approach for diagnostic coronary angiography in our center was associated with short FT, modest contrast volume, and a very low rate of vascular complications. These findings suggest that the radial approach can be performed safely and efficiently in experienced centers. Further prospective and multicenter studies including direct radiation dose measurements are warranted to better evaluate radiation exposure associated with the transradial approach.

We would like to express our sincere gratitude to all the patients who participated in this study. We also thank the staff of Nabdh Al-Hayat Cardiac Centre, Mukalla, for their valuable support and cooperation. Special appreciation is extended to our colleagues who contributed to data collection and technical assistance.

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Tayeb Ali Bafadhl
Department of Cardiology
Nabdh Al-Hayat Cardiac Center, Hadramout Government, Mukalla, Republic of Yemen
Email: [email protected]

The author contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles and involved in the writing – original draft preparation and writing – review & editing to refine the manuscript.

Ethical approval for this study was obtained from the Institutional Review Board of Nabdh Al-Hayat Cardiac Center, Mukalla, Yemen, with approval reference number: 2023 – 10. The study complied with the Declaration of Helsinki, and informed consent was obtained from all patients prior to inclusion.

The authors declare that there is no conflict of interest regarding the publication of this paper.

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https://doi.org/10.63096/medtigo3092322

Bafadhl TA. Safety of Radial Approach in Yemeni Patients, Local Experience of Nabdh Al-Hayat Cardiac Centre, Mukalla. medtigo J Emerg Med. 2026;3(2):e3092322. doi:10.63096/medtigo3092322 Crossref