PowerPoint Presentation
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
