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Challenges of Radial Access: Anatomy, Tools and Successful TechniquesJordan Safirstein MD FACC FSCAIDirector, Transradial InterventionMorristown Medical Center
Still Small
Patient SelectionCases 1-50 (Rookie):Young, large malesNormal renal functionDx onlyCases 51-100 (Getting Comfortable)Short, thin womenMorbidly obese ptsNo grafts>100 Cases (Wiley veteran)CABG ptsSevere PADSTEMIs
Learning CurveAs operator TRI volume incraeses:Higher risk patients are chosen for TRILess bail outDec flouro time & contrast volLearning curve appears to be approx 30-50 cases. Ball et al. Circulation: Cardiovascular Interventions. 2011; 4: 336-341 Hess et al. Circ Cardiovasc Interv. 2015;8:e002745,
Ball et al. Circulation: Cardiovascular Interventions. 2011; 4: 336-341 4
Predicting FailureAge > 75Operator inexperience (lessened by more cases)FemaleShort staturePrior CABGLe at al. The American Journal of Cardiology Volume 116, Issue 3, 1 August 2015, Pages 379383Hu et al. Int J Clin Exp Med. 2015; 8(7): 1177011776.
Multivariable predictors of TRA crossover; n= 1600; NYU Le et al. Binita Shah and CoppolaLe et al. The American Journal of Cardiology Volume 116, Issue 3, 1 August 2015, Pages 379383Hu et al. Int J Clin Exp Med. 2015; 8(7): 1177011776. Dehghani, Payam et al. J Am Coll Cardiol Intv. 2009;2(11):1057-1064
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Anatomical Advantage
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Radial Versus Femoral
NerveArteryVeinRadial
Ulnar
Superficial Palmar Arch
In the upper third of its course it lies between the Brachioradialis and the Pronator teres; in the lower two-thirds, between the tendons of the Brachioradialis and Flexor carpi radialis.
Getting Your Lab EquippedSome key essential pieces of equipment that save time, patience and make the radial experience more pleasurable
Puncture Site and Position of Wrist
Slight Wrist extensionPulse Ox to assess for ischemia
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20 G Teflon coatedMore freedom of angleLess access timeFewer attemptsNO DIFFERENCE in vascular complications
Rigid needleShallow angle critical (coaxiality)Counter Puncture TechniqueAnterior Puncture TechniqueKotowycz et al. Circulation: Cardiovascular Interventions. 2012; 5: 127-133
Radial Access Technique Evaluation (RATE) TrialCounterpuncture vs. Anterior Approach- Randomized trial; n = 400Shorter access timeFewer attemptsHigher success rate of 1st pass attemptsNO Difference in hematoma or RAOCatheter Cardiovasc Interv. 2012 Aug 1;80(2):288-91. Epub 2012 Mar 14.
Radial artery access technique evaluation trial: randomized comparison of Seldinger versus modified Seldinger technique for arterial access for transradial catheterization.Catheter Cardiovasc Interv. 2012 Aug 1;80(2):288-91. Epub 2012 Mar 14.11
RATE (Radial Artery Access Technique Evaluation) Trial**** P < 0.01Pancholy S et al., CCI
Ultrasound?RAUST Trial - multicenter randomized controlled trial; 698 pts undergoing TR cathRandomized to palpation v US-guidanceEndpts:# of attempts1st-pass successTime to access
JACC Cardiovasc Interv. 2015 Jan 8. pii: S1936-8798(14)01649-5
JACC Cardiovasc Interv. 2015 Jan 8. pii: S1936-8798(14)01649-5. doi: 10.1016/j.jcin.2014.05.036. [Epub ahead of print]Real-Time Ultrasound Guidance Facilitates Transradial Access: The Radial Artery Access With Ultrasound Trial (RAUST).
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US-guidanceFewer attemptsDecreased time to accessMore success with first pass attemptsNo sig diff in clinical events/outcomes (spasm, bleeding or patient pain)
CocktailsVasodilator Prevent spasmNitrates (100 mcg NTG) Immed onset of effect, short-livedCCBs (2.5 mg verapamil, nicardipene)Sustained effect, slower onset, cause burningAnticoagulants prevent RAO50 U/kg (or 5000 U)Can be given IA or IV (no diff in RAO)[Even if INR therapeutic, heparin required]
Radial artery cocktailIntravenous or intra-arterial heparin have similar efficacy in preventing RAOPancholy S. Am J Cardiol. 2009 Oct 15;104(8):1083-5
Radial artery cocktailNitroglycerin 200 mcg + CCB IAHeparin 50 U/Kg or 5000U IV or IA.
Know Your ChallengesSpasmMinimize exchanges5 Fr diagnosticsSEDATE WELL!Challenging anatomyTerumo GlideWireTake picturesAccess/sheath insertionDont force wireRe-stick proximallyDehghani et al. J Am Coll Cardiol Intv 2009;2:105764
Dehghani et al. J Am Coll Cardiol Intv 2009;2:105764
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Ignorance is Not BlissBe able to recognize and manage complications PerforationsDissectionsAccess site hematomasInfectionPseudoaneurysmHave a plan for navigating tough anatomy, spasm, and rare complications that could arise
One Size Does NotThere WILL be small variation between operatorsHave the basics available and all will run smoothHave protocols for RHC, left radial approach, CABG pts and STEMIsUtilize industry support for in-services (Terumo, Merit, Medtronic, etc)
Normal Radial Anatomy
Patel's Atlas of Transradial Intervention: The Basic. Seascript Company (January 1, 2007)
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Modified Allens Test
Patel's Atlas of Transradial Intervention: The Basic. Seascript Company (January 1, 2007)
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Modified Allens Test
Patel's Atlas of Transradial Intervention: The Basic. Seascript Company (January 1, 2007)
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Radial Puncture
Patel's Atlas of Transradial Intervention: The Basic. Seascript Company (January 1, 2007)
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Radial Puncture
True Seldinger Technique
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Radial Puncture
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Radial Puncture
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Thank You