FAQs

FEATURED QUESTION

Since the benefit of bivalirudin with percutaneous coronary intervention (PCI) is to decrease bleeding complications, does it make sense to use heparin with transradial PCI, given the cost savings? It seems unlikely that bivalirudin would be of benefit given the extremely low rate of access problems with the radial artery.

It's important to realize that there are several sites of bleeding in patients undergoing PCI and especially in patients with acute coronary syndromes (ACS). Access site bleeding accounts for the majority of bleeding in patients undergoing PCI, but the next most common site is gastrointestinal (GI) bleeding. GI bleeding is highly correlated wicth mortality and is not impacted by access site choice. In order to achieve "zero bleeding risk," it's best to combine an access site strategy (radial) with a pharmacological strategy (bivalirudin).

Access
Adjunctive Pharmacology
Cinical Considerations
Closure
Complications
Discharge
Navigation
Right Heart Catheterization
Set-Up
Grafts and Other Procedures
Miscellaneous

ACCESS

I routinely administer 4-5,000 U heparin into the radial sheath immediately after getting access. In one of Dr. Rao's videos, it is recommended to delay this until aortic root access is obtained in case of radial loops, etc. How early after sheath placement would radial occlusion occur? And so, does it matter if heparin is administered immediately after sheath placement vs. waiting until the root is reached, or even waiting until the coronaries are imaged?

The only reason we wait until the wire is into the ascending aorta is the possibility of femoral bailout. Waiting allows us to avoid sticking the femoral artery immediately after administering 5000u of heparin. No one really knows the time course of radial artery occlusion and the occlusion process involves heparin, sheath size, and whether or not the post-procedure hemostasis is occlusive or not. It's also not clear when the heparin needs to be given. There is a small study where it was given just before sheath removal and the rates of radial occlusion were consistent with prior studies. I think the bottom line is that heparin should be given, with a dose of at least 5000u. Everything else is just personal style.

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I typically use right radial access even when patients have LIMA grafts, because I believe that my radiation exposure (as opposed to total fluoroscopy time) is increased by using left radial access and leaning across the patient (I am 5'7" tall). I only use the left side when I must, as I find standing on the patient’s left side with the monitor at his or her feet to be more awkward. What are your favorite catheters for left subclavian access via the right radial?

When accessing the left subclavian and LIMA from the right radial, I tend to start with an IMA catheter. I like to use a Glidewire (0.035 angled) in order to have somewhat more ease of engagement, support and tracking. Generally, this catheter works for me; however, if the takeoff of the LIMA is angled unfavorably, then switching to something else that will have a more favorable angle is reasonable. In my opinion, it's important to remember that excessive manipulation in the arch or in the subclavian can lead to untoward events, so maintaining a relatively low threshold to switch to the left radial or femoral approach is reasonable.

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What is the guiding catheter of choice for transradial interventions for each of the coronary arteries?

For the left coronary artery, I use the EBU 3.5. Recently I have been using the EZ Radial Left by Medtronic. This comes in short, regular, and long tip versions. The regular is the standard size. If the root is large, then I will use a long tip. At times, I have found that the JL3.5 will work well for the left system.

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With the Allen's test, we have found upon occasion that while compressing the radial artery, the ulnar wave dampened and remained so. In such a case, is it reasonable to use the ulnar artery for access?

Ulnar access is less well-described than radial access. It does appear feasible, but the same principles apply. You want to make sure that there is collateral flow to the hand. Therefore, if the radial artery is not palpable, but the ulnar is, then do a reverse Allen's test (compress the radial and ulnar, then release the radial, make sure that there is a pulse ox waveform) before accessing the ulnar.

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How do you choose the veins in the right forearm for right heart cath? Is above or below elbow more appropriate, and should it always be medial? Where do you find 5 Fr Swan-Ganz catheters?

Any forearm vein will work. Medial is better so that you avoid the "T" junction at the point where the axillary and subclavian veins join together, but navigating this junction is quite easy. We prefer the antecubital vein because it is easy to access.

We use 5 French Swan-Ganz catheters made by Arrow International.

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Is there a contraindication to venous use (IVs, blood draws) on the affected arm after uncomplicated radial access?

One can immediately use the arm that the radial artery was accessed with no restriction for insertion of intravenous access, phlebotomy, or even repeat arterial access.

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Can you still access the radial artery if the waveform is Barbeau grade 4, but pulse ox is greater than 90%?

I guess you can, but the question is, should you? That's a bit more complicated. While there are no data to support the fact that a 'normal' (i.e., negative) Allen's test or Barbeau test is associated with lower rates of symptomatic radial artery occlusion, we generally have avoided accessing a radial with a grade 4 Barbeau test for medicolegal reasons. The oxygen saturation is irrelevant, because you are really interested in the waveform, which indicates arterial flow.

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Traditionally we have always been taught to keep the needle bevel upward when accessing an artery, the idea being that you get the full flush back once the whole tip of the needle is inside the vessel. The radial being a smaller vessel, do you see any advantage in accessing the artery with the bevel downward? My feeling is that once part of the bevel is inside the lumen, if you pass the wire, the wire itself may guide itself in the lumen (pushing from outside inward as opposed to pushing sort of into the vessel wall). This is just a thought. Any comment?

Interesting question. I don't see any reason to expect that facing the bevel downwards would provide any advantage. It is still a retrograde stick, so to facilitate arterial flow into the needle, the bevel should face upward. Wiring may be more difficult with the bevel facing down, as it may be directed antegrade toward the hand, rather than retrograde toward the elbow.

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I am new to the transradial approach. I have inconsistent results with getting access with the jelco (through and through) approach and more consistent results with the micropuncture anterior stick approach. I have been told that the Jelco through and through approach is a more durable technique and once learned, will allow you to access even the smallest radial artery. Is this true in your experience, or can I just stick with and fully master the micropuncture anterior approach?<

I find the counter puncture method faster, more successful and easier to learn. Having said that, if you already feel more comfortable with anterior wall puncture technique using a needle instead of angiocath, I would not recommend switching to angiocath and counter puncture technique. Just continue to polish the technique that works for you. The basic endpoint is fast access (so you can do STEMI, etc.) and least failed attempts at obtaining access.

I have found that the posterior wall puncture allows you more of a margin for error and therefore, you will know you are in the lumen. The anterior puncture on small arteries will often lead to the needle coming out of the artery.

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Please discuss radial access setup through the left radial.

Our institution uses the left radial artery frequently. We access the artery by standing on the left side of the patient with the arm extended. Once the sheath is in, we bring the arm parallel to the body and raised up on pillows. We then move to the patient's right side and do the procedure by reaching across the body. In non-emergent cases, where groin access for a support device is unlikely, we add additional operator radiation protection by draping a lead shield across the patient's groin so the operator's hands are protected. We avoid the practice of draping the patient's hand across their chest, as this makes it difficult for patients to keep the arm still. Of course, in obese patients, reaching across the body can be problematic, so we tend to use the left arm on smaller patients, particularly small, elderly patients, as the data suggest these are the patients with the highest failure rates from the right side.

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ADJUNCTIVE PHARMACOLOGY

Does spasm occur mostly in the radial artery or can it be anywhere? Does using a 5 French sheath significantly reduce spasm? (Is upsizing to a 6 French sheath problematic due to spasm?) Is there an advantage to using 5 French catheters with respect to spasm for diagnostic studies?

Spasm, of course, can occur anywhere, but it is most noticeable in the radial artery because of its relatively small caliber, which affects the ability to manipulate the catheter. In a randomized study, only hydrophilic coating appeared to influence spasm (Rathore S, et al, J Am Coll Cardiol Interv 2009), but smaller catheters do appear to be associated with less spasm. The general principle is that the less contact the equipment has with the arterial wall, the less spasm you get..

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What is the best treatment for spasm upon sheath removal? We are new to radials and the lab we observed said they started with 50-100 mcgs of nitro IA (intra-arterial) through the sheath. If that was not successful, they recommended nitro paste on the forearm and/or warm compresses on the forearm. Do you have any recommendations?

We usually just administer 200 mcg of nitroglycerin through the sheath prior to removal. We also use hydrophilic sheaths that are associated with less spasm and less patient discomfort (see Rathore S et al.) J Am Coll Cardiol Intv 2010; 3: 475-483, doi:10.1016/j.jcin.2010.03.009). If there is resistance to removing the sheath, then 3-5 mg verapamil can be administered as well. Remember to mix it well with blood to minimize the burning.

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When giving verapamil for arterial spasm, how long does it last? At what point during a lengthy procedure should you redose? Should you give the same dose or reduce the second dose?

IV verapamil lasts several hours. We only redose if there is evidence of spasm during the case. If we redose, we use the same 3 mg dosage.

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Does anyone use enoxaparin instead of heparin for their cases? I have been and I cannot decide for diagnostic cases if I should use 0.3 mg/kg or 0.5 mg/kg, and whether to give it through the sheath or through an IV.

I have not heard of anyone using enoxaparin for diagnostic cases, although there is a nice paper from the SYNERGY trial on the use of enoxaparin for transradial PCI in patients with NSTEMI. In addition, the recent ATOLL trial examined the use of 0.5 mg/kg IV enoxaparin in patients undergoing primary PCI for STEMI. This demonstrated that not only was it feasible, but it actually obviated the bleeding reduction effect of IV enoxaparin. If you were to use it for diagnostic purposes, I would think that the higher dose - 0.5 mg/kg - would be safer, because it has more anti-IIa effect and would prevent catheter thrombus compared with the lower dose.

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If a patient's PT-INR is "therapeutic": between 2 and 3 for a-fib, or between 2.5 and 3.5 for mechanical valves, should the coumadin be held until PT-INR is below 2, or can the coronary angio be done safely? In such a case, should no heparin be given? Is there any cut-off number above which radial access should be avoided?

Multiple studies suggest that interruption of oral anti-coagulation is not necessary for transradial procedures. Therefore, it is reasonable to keep patients in the therapeutic range for their condition, particularly if the indication for anti-coagulation is strong. Unfortunately, there is no clear data on how to dose heparin in this situation, so most physicians use a lighter dose of heparin - say 2 - 3,000 of UFH, to compliment the coumadin.

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For patients on coumadin, is there any particular cut-off number for the PT-INR that precludes radial access?

There is data that supports the safety of transradial access for patients on oral anticoagulation. It has, therefore, become reasonable for interventionalists to continue warfarin — particularly in patients with high-risk thrombotic conditions — throughout the catheterization. Our laboratory has no "cut-off" for the INR for a transradial procedure, but we try to keep patients in their usual therapeutic range. Obviously, the physician should weigh the risks and benefits of continued warfarin in all aspects of the case, but there is data to support continued oral anticoagulation with the radial approach, and physicians are becoming more comfortable with it..

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We have begun doing transradial cases at Bryn Mawr Hospital with Dr. Antonis Pratsos and Dr. Sean Janzer. Currently, we are using nitro and cardene for antispasmotics. I read that many physicians use nitro and ditilizem. What doses are recommended for these two drugs?

In our lab, it is our typical practice to utilize 200mcg of nitroglycerin and 5mg of diltiazem intra-arterially once the sheath is in place.

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For prevention or treatment of radial spasm, which is the best drug combination to be used?

There are several "cocktails" that operators give to prevent or treat arterial spasm. These include nitroglycerin, verapamil, diltiazem, nicardipine, papaverine, among others. Some of these agents can cause patient discomfort when administered arterially. Our preferred agent is nitroglycerin because it is readily available and does not cause any burning when given through the sheath. There have been some small randomized studies comparing agents and they all appear to be similar in terms of preventing spasm. I recommend watching many of the procedural videos on the Transradial University site as they provide insight into what agents are preferred by some of the high-volume radial operators.

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CLINICAL CONSIDERATIONS

Could bivalirudin be used in the radial cocktail in lieu of heparin? I realize that cost would be an issue, but if the case is a planned intervention and bivalirudin is the anticoagulant of choice for PCI, would it make sense to use one anticoagulant for the entire case? If so, any recommendations on dosing?

Regarding the use of bivalirudin, there is a randomized trial published in 2010 (Plante S et al, Catheterization and Cardiovascular Interventions 2010) that compared bivalirudin and heparin for use with transradial procedures. For patients who underwent diagnostic angio only, they gave unfractionated heparin (UFH) just before sheath removal. For patients who went on to PCI, they gave no UFH, but used bivalirudin per the labeled dose before proceeding with PCI. There was no difference in the rate of radial artery occlusion at 4-8 weeks between the groups.

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What catheter/vendor do you use for lower extremity angiography via the radial artery? I don't currently stock anything long enough to reach the iliac bifurcation.

There are a few catheters that I stock in my lab specifically for this purpose. First of all, when trying to get to the legs from the arm, using the left radial approach will often save 10-15 cm as compared to the right radial approach. If you are worried that the catheter won’t reach, then start with the left radial approach.

Most commonly I use a 4 or 5 Fr (125 cm) multipurpose diagnostic catheter (Cordis Corporation). Unless the patient is over 5’10”, I am able to get into the common or external iliac from the right radial approach (further if I use the left radial approach). I can do power injections from that location and can visualize to the feet. The other catheter that I have used on taller patients or when I need to get further down the leg is the CXI catheter family (Cook Medical). They come in 2.6/4 Fr, 90/135/150 cm lengths, and angled/straight tip. I have done both hand injection and low-pressure, power injection with these catheters. With the 150 cm length, one should be able to reach well into most patients’ legs. From a cost perspective, I usually start with the MP and if I need more length or cannot see to the leg, will go to a 4 Fr (150 cm) angled-tip CXI.

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I work in a diagnostic cardiac cath lab where we send patients to a nearby facility if they need interventions. We have recently started a radial program. Any advice about transporting patients with radial sheaths in place?

Provide and maintain a pressurized flush with heparinized saline and cover with sterile dressing. It is always a good idea to change out the sheath prior to beginning the new procedure.

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What are the different techniques for reduction of a knot or looping of the angiographic catheter during coronary angiography?

Well, prevention is key, so if the catheter tip isn't moving when you are torquing, then you need to fluoro the course of the catheter and make sure that it isn't knotted. Other ways to prevent this include using the 0.035" wire to straighten any tortuosity in the catheter and torque it with the wire in (make sure it's not poking out the end). If it does get knotted, then you can try and put the 0.035 through it, but if it isn't going through, then you can push the entire catheter down into the descending aorta, then pull it back to "hook" it in the left subclavian and then gently torque counter clockwise to unravel it. If the knot/loop is in the middle of the catheter, you can also try to pull it back into the arm, inflate a pediatric BP cuff where the distal end of the catheter is (this will stabilize one end), then torque to unravel it.

But...don't get into this situation.

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We have been overall fairly happy with the TR Band (Terumo), but in the constant effort to reduce costs and possibly eliminate radial occlusion, we are looking at the QuickClot system (Z-Medica Corporation). Does anyone have experience with it?

I have never used QuickClot. With any thrombus-promoting device, you really have to pay attention to prevention of radial artery occlusion. The TR Band seems to do a great job for us.

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What is your technique for doing right heart catheterizations from the arm (simultaneous with left heart catheterizations from the radial approach)?

There are resources on this website that will take you through the process of doing right heart caths from the arm. Basically, you need to place an IV in a forearm vein, insert the wire from the radial access kit through the IV, remove the IV and place the 5F hydrophilic sheath into the vein. The vein may collapse distal to the sheath and the sheath may not aspirate, but as long as the patient doesn't complain of pain, the sheath is in the vein. You can then use a 5F balloon-tip right heart catheter to do the case.

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How would you treat a radial artery pseudoaneurysm following a transradial percutaneous coronary intervention (PCI)? I have put a compressive bandage on the patient for 48 hrs and asked her to come back in 2 days time.

Small radial artery pseudoaneurysms can be compressed by the TR Band (Terumo) for a few hours (3-6 hrs) and re-evaluated. Large pseudoaneurysms, if symptomatic, should be surgically corrected. If not, just watch them with restrictions on high-impact activity. I have had 2 large pseudoaneurysms that took months to lose flow and both are doing well without surgery.

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Is there any reason to avoid the right radial in patients shorter than 5'4"? I have heard there may be issues related to reaching the right coronary artery (RCA).

The issue isn't one of "reach." There are now 2 studies, one from Italy and one from the Lahey Clinic that suggest an association between height and right subclavian tortuosity. Both studies indicate that the left radial approach is associated with shorter procedure times and less tortuosity.

At times, with short patients, it is a little more difficult to engage left system, but it is not a problem for the RCA.

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Are there any contraindications for intravenous sticks post transradial? We are trying to establish a policy with our laboratory regarding lab draws post procedure.

No – there are no restrictions and there is no reason to expect that there would be.

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How soon can you do blood pressure measurements on the arm post radial cath?

There are no restrictions; you can do BP immediately.

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I have a patient with bilateral radical mastectomies (left 2008 and right 1995). She has never had lymphedema. She did have lymph node dissections bilaterally. I have been doing transradial caths for approx 14 months and have performed approx 450 cases. Can I safely cath this lady from the right radial approac?

I would say yes. The major problem is with indwelling intravenous lines and the fear of cellulitis.

In theory, it should not matter unless axillary node dissection was performed. Often patients are very reluctant to have anything done including blood pressure from the arm, and unless it is a last option, I would not push the patient to perform the procedure from the affected side.

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I have heard from other cardiologists that use of the radial approach in younger women should be avoided because of a higher incidence of spasm. Are there data on this?

Several data sets support the clinical impression that spasm is more common in younger women. A very recent single-center registry examining the clinical predictors was published by Chinese investigators (Jia et al, Chinese Med Journ 2010, 123 (7) 843 - 47). The mean age of spasm patients was nearly 10 years younger than "non-spasm" patients. Analysis revealed that female sex, small radial artery, diabetes, and failed first puncture all increased the risk of symptomatic radial artery spasm. I think that experienced operators do not avoid these cases, but go into them knowing that techniques to decrease spasm should be high on their radar. These include good sedation, vasodilators, small sheath and catheters, and limited catheter use and exchanges. With these techniques, procedural failure from spasm can be limited greatly, although of course never completely eliminated.

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How should the XB or EBU catheter be manipulated to engage the left coronary artery safely? I have seen a few cases of dissection with this guide.

Enter the left coronary cusp over a 0.035" wire and face the tip down. Gently clock and counterclock the catheter to raise the tip gently into the left main. This works most of the time. From the right radial, undersize by 0.5.

Luckily I have never dissected a coronary thus far.

I first start by bringing the guide to the valve and then remove the guide wire, clockwise rotation of the catheter and advancing the catheter.

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Do female patients have a greater tendency to angio spasm than male patients, independent of vessel diameter?

Anecdotally, there does appear to be more spasm among female patients. However, this can be overcome by judicious use of sedation and spasmolytics.

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Is there any contraindication to transradial approach on the same side as a mastectomy, and if so, why?

There is no clear contraindication to accessing the artery on the same side as a mastectomy. Arterial puncture and the compression of the distal forearm should not impact lymphedema. That being said, most patients are very nervous about any procedures in the arm on the side of the mastectomy, as they have been told multiple times to avoid any instrumentation. Rather than risk worrying the patient, we generally use the opposite arm, even though we think the same side would be safe.

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Can we use an epsilateral radial approach in subclavian artery occlusion?

Accessing an occluded subclavian from the ipsilateral radial artery is certainly acceptable if you are attempting to intervene on the affected vessel; however, it would be ill-advised to attempt accessing the coronaries or any other procedure, as access to the aorta is compromised.

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For elderly patients (over the age of 70 years), do you advise the routine use of a left radial approach to avoid the tortuosity of subclavian-innominate artery?

Tortuosity is a common challenge when using the radial approach. At the recent American College of Cardiology Scientific Session, there was an abstract that examined the issue of left versus right radial artery as the initial approach. In this single-center study, they found that for patients over the age of 70 years and for patients who are shorter than 65 inches (165 cm), the left radial approach resulted in shorter procedure times. This suggests that for shorter, older patients, the left radial artery may be a better initial approach.

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When doing a right heart through the arm, I think most people are doing it via the brachial vein. What size of balloon wedge are they using, 5F or 6F?

Generally, we begin by having the nurse start an IV in the anticubital area with a 20-gauge Angiocath and place a heparin lock on it. Once on the table, we prep and drape the area, and then place our 5 Fr radial introducer wire thru the Angiocath, followed by the introducer. The whole trick to this procedure is connecting the 5 Fr balloon catheter to a pressure flush once you are in the introducer. The pressure flush will expand the vein in front of the catheter. DO NOT inflate the balloon until you have advanced the catheter to the subclavian vein. The catheter should move through the arm without resistance, and then once in the subclavian, inflate the balloon. If the nurse started the IV in the lateral vein in the anticubital area, the balloon catheter has to make a turn from the cephalic vein into the subclavian vein. Deep breaths from the patient will often make this turn less acute and if this does not work, we will use an .014" coronary wire to guide the catheter.

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Any problems for radial access in those patients that have undergone an ipsilateral mastectomy?

I would avoid that upper extremity if the patient has lymphedema or has had axillary node removal. If an isolated breast operation, we would access the ipsilateral radial.

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Is a radial artery that has been used during heart catheterization unable to be used as a graft during future coronary surgery? What is known about this subject?

In a paper our group published, we found post-procedural evidence of increased inflammatory cells and vascular damage in the radial artery used to gain access for the catheterization procedure. At the time of surgery, the contralateral or ipsilateral radial artery was harvested for bypass use. At that time, a tissue specimen was provided for histological examination whereupon it was noted there was visual evidence of vascular disease. This may be why the radial artery is not such a great conduit for bypass graft. If the radial artery is expected to be used for bypass, then the contralateral radial artery should be utilized for catheterization.

After transradial catheterization, the radial artery develops minor structural changes throughout its course. If the radial artery used for cath is the only available conduit, there would be no choice. If there are other choices of conduits, the instrumented radial artery should not be used. In general, radial artery has a much higher plaque burden compared to other bypass conduits and therefore makes a poor choice for bypass conduit.

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When is it appropriate to perform catheterization though the ulnar artery in place of the radial artery?

Cardiac catheterization via ulnar access is uncommonly performed in our lab however this approach may be considered if the following 2 criteria are fulfilled: patent dual arterial supply to the hand and anatomic difficulties that render radial access difficult. The typical scenario in which this may occur is the patient who has a normal plethysmography-based Allen test and then is found at the time of attempted radial access to have radial disease/anomalies by angiography. When there is difficulty advancing the guidewire through the 20g Angiocath (prior to sheath insertion), I will typically advance the Angiocath into the radial artery and perform a radioulnar angiogram to evaluate the caliber, course and flow in both radial and ulnar vessels. If the ulnar artery appears more favorable and the radial artery has not been traumatized, ulnar access may be considered.

There really is no literature to guide us on this issue. It is a generally accepted rule of thumb, as well as the practice at our institution, that if the radial is likely to be used soon to create a dialysis fistula, then it is prudent to avoid it unless no other options exist. This is, of course, to avoid the potential for traumatic radial injury to jeopardize the fistula. Use of the radial for an A-V fistula more than 6 months from radial catheterization should not be a problem assuming non-invasive studies reveal no evidence of persistent radial artery occlusion.

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Can the performance of heart catheterization though the radial artery in a patient suffering of chronical renal failure to compromise the possibility of performance of hemodyalisis in the future?

Based on the prospectively collected registry data at our institution, post-procedural radial artery occlusion at 6-24 hours is <1%. It should be noted that we routinely use an anticoagulant/spasmolytic cocktail in all patients, immediately following sheath insertion and this may impact patency rates (vs. selective use). In other published literature, the rate of spontaneous radial recanalization has been estimated at 50-70%. In discussions with our vascular surgery colleagues, it seems unlikely that radial access would compromise dialysis access in the future.

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During the last time we began to perform Primary PCI for STEMI using a single catheter: Ikari guiding catheter 3.5 or 4 for the diagnosis and therapeutic catheterization looking for prevention of spasm, reduction of reperfusion times or manipulation. Is there experience with this strategy and which is your opinion?

Many operators do prefer using a universal catheter because it minimizes catheter exchanges and may reduce spasm. Anecdotally, this is true once you get proficient with a universal catheter. Early on in the learning process, there is often more spasm because of the repeated manipulation. Once this is overcome, however, the procedure times reduce, which has a secondary benefit of reducing radiation exposure to the patient and operator. For STEMI patients, a universal guiding catheter makes a lot of sense. One can shoot the non-infarct artery first and then begin the intervention without having to change out the catheter.

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What are the dosing parameters for Papaverine to prevent radial spasms? I have a doctor who wants to coat the sheath prior to access.

I have personally never used Papaverine. It is not stocked in our hospitals. There are no benefits over traditional spasmolytic meds that we use.

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Are there any articles or studies regarding using the radial approach with patients who have elevated INR level of 6.6-3.0?

The following two sources were cited by John T. Coppola, MD, FACC regarding INR:
- Journal of Interventional Cardiology; 19:258-263 (2006)
- Catheterization and Cardiovascular Interventions; 73:44-47 (2009).

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CLOSURE

What is the protocol for a patient with bivalirudin infusing post PCI? We are currently leaving the TR Band on until 2 hours after bivalirudin infusion is complete, then deflate 3 mL every 15 minutes. We would like to know what's being done elsewhere.

We have generally not been delaying air removal, but we often find that it does take longer to deflate completely, because of bleeding. It is entirely reasonable to wait until the bivalirudin infusion is discontinued, but there are no data.

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What is the preferred radial band for post cath site management?

The short answer is "whatever works for you." There aren't many head-to-head comparisons of the different options that are commercially available. We've tested many in our practice and at least in our hands, the TR Band appears to be the easiest to use. Our protocols are built around the use of the TR Band and our recovery area nurses also appear to like its ease of use. However, as I mentioned, there aren't many head-to-head comparisons.

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What is your average recovery time for a diagnostic patient before you feel comfortable to discharge them?

For diagnostic cases, we start releasing air in the TR Band 30 min after the sheath comes out and remove 3 cc of air every 15 min until empty. Since most patients end up with 8-10 cc of air, this process takes approximately an hour or so. Then we usually watch the patient's access site for another 1-2 hours. Total recovery time of 2.5-3.5 hours from time of sheath removal before they are discharged home.

For our femoral cases, the sheath is removed when the ACT is < 180 seconds, which, for diagnostics, is right away, since we don't give heparin (or use low-dose heparin) for diagnostic cases. Then pressure is held for 15-20 min. The patient has to lie still for 2 hours (for a 6F sheath) or 90 min (for a 5F sheath), and then the patient is monitored for 2-4 hours to ensure that they can walk around without any complications. Total time from sheath removal is around 4.5-6.5 hours.

Both of these sets of recovery times are longer than for other labs, but we are fairly conservative when it comes to recovering patients, because readmissions count against us in the VA system.

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What is the protocol post procedure for radial cases, i.e., decompression of the TR Band, removal, and time to discharge? What about arm boards and activity instructions?

We apply the TR Band for 2 hours after sheath pull, regardless of sheath size or adjuvant anticoagulant use. After 2 hours, it is gradually deflated over 15 minutes and if no bleeding is seen, a band-aid is applied and the patient is discharged. We do not use arm boards or other immobolizers.

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When we have a hematoma post-femoral artery catheterization, manual pressure is applied. Should manual pressure also be applied to a hematoma post radial approach? The video of hematoma management only shows placing a second TR Band over the hematoma.

Hematomas after transradial cath or PCI are rare, but can occur. There is a grading system for severity. For most hematomas, the key is to wrap the forearm in an Ace bandage to compress it and make sure to check circulation to the hand (cap refill). Early recognition is extremely important to avoid progression of the hematoma to the point where arterial flow is compromised and compartment syndrome occurs.

Hematomas at the arterial entry site can be controlled by manual pressure by hand or by applying the TR Band at the site; it would be ideal if the pressure is non-occlusive.

Forearm hematomas are best controlled, in my experience, by manual compression. I would compress the most prominent point, "flatten" them out and use all eight fingers to control the surrounding radial artery along its course. After the prominence has been flattened and you do not see growth upon release, an Ace wrap with elevation works well. There has been description of leeches being applied, etc., but I would hope one would not let it get that that far! The recovery room staff needs to be trained to keep a very high index of suspicion and early intervention.

One may apply a second TR Band proximal to the first one if it is a flat hematoma at the proximal edge of the first band. We monitor plethysmographic signal and local sensory function very closely to act promptly on a compartment syndrome. Fortunately, large hematomas are rare.

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Is there a well-defined protocol for TR-band removal after a transradial catheterization? I searched for this online, but found many different protocols.

While there is no defined protocol to guide you on radial compression management, there are important ideas you need to keep in mind when constructing your own lab's post management strategy. The post cath radial compression must balance the needs of immediate hemostasis with the risk of long-term radial artery injury and occlusion. Heavy and protracted pressure will achieve excellent hemostasis, but will clearly increase the risk of long-term radial artery damage, which could eliminate its availability for future procedures.

Most operators try to achieve active hemostasis; that is, place enough pressure on the artery to stop any bleeding, but still allow some flow in the artery. The goal after this is achieved is to keep the compression device on for as short a period as possible. From a practical standpoint, we place the band on full strength, and then remove some air until we see pulsatile flow through the compression bladder, and then add back 1 or 2 cc of air until we are sure hemostasis is achieved. If the patient is at low risk for bleeding, we will keep that pressure for 90 minutes and then slowly withdraw air over an hour before completely removing the band. We then observe the site for an hour. If patients are at high risk for bleeding, then we will keep the band on for 2 - 3 hours.

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Is the recommendation/universal practice/evidence/research supportive of all radial sheaths being removed in the cath lab, especially if patients are returning to in-patient floors and not an observation area post cardiac catheterization? Is there a recommended ACT level required before the sheath can be removed?

I would say yes – it is clinical practice to remove all sheaths in the cath lab regardless of ACT or INR. The longer the sheath stays in, the higher the chance of radial artery occlusion.

Yes, the more rapid removal of the sheath will hopefully lead to less radial artery damage. We remove the sheath on the table and use a Terumo wrist band for hemostasis, but other devices, or 4x4 and tape can be used. We have done this for patients on IIb/IIIa agents and heparin, on bivalirudin (Angiomax, The Medicines Company), and on patients with acute myocardial infarctions who were transferred after failing lytics. We do not measure ACT before pulling.

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COMPLICATIONS

I've been performing transradial angiography/PCI/STEMI for almost 12 months now. I recently had a gentleman develop an ipsilateral DVT s/p LEFT radial artery access. Anyone else with this unexpected complication? Could he have developed the clot for a reason unrelated to the radial access? I'm pretty certain that I did not inadvertently stick the vein during attempts at access.

In the absence of concomitant venous access, it's difficult to imagine how radial arterial access would have been related to that.

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For TRI, which wires can we use inside a diagnostic or guiding catheter to overcome the difficulty in torque transmission due to subclavian tortiousity? How would we inject contrast with the presence of the wire inside the catheter?

To overcome subclavian problems, I will often leave an Amplatz stiff wire in the catheter. I will pull the wire back to before the primary bend. The added stiffness of the wire allows the catheter to be torqued. Once I engage the coronary I remove the wire and aspirate, then hook up for my injections. I don't, as a practice, inject with the wire in place. I suppose, if you want, you can place a Y connector that you would use for a PTCA and inject. This would even work with a diagnostic catheter, but I would make sure that I vigorously aspirate and back bleed so as not to introduce air into the system. Again, I generally use the wire to help transmit torque and once in or close to the ostia, I remove the wire before injection.

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Why is the radial artery sometimes occluded after the procedure and how it could be saved?

I believe the greatest reason for occlusion is the compression of the radial artery at the end of the case. If a tape pressure dressing or band is applied too tightly during the hemostasis process, no flow will occur, thus leading to thrombosis. Generally, we use a TR Band and inflate to 18cc, then slowly let out 1cc of air at a time until a radial pulse distal to the insertion site is felt, or if we see a drop of blood from the access site, we stop deflation. Heparin is important and operators use a low of 2500 units to 50 units/kg as high dose. The size of sheath compared to radial artery is also a factor. I try to do diagnostic work with 5 Fr catheters. I hope this helps.

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I wanted to ask a question on behalf of physicians who recently began performing transradial access a few months ago. Is there any correlation between navigating a "recurrent" radial and spasm? In a recent radial case, it was noted that the patient had a right radial loop. Rather than negotiating the loop, the .035 J-Wire easily navigated the "recurrent" radial that was noted under angiography. The wire and diagnostic catheter easily entered the ascending aorta without incident. However, prior to exchange, it was noted that the patient went into severe spasm that lasted over 30 minutes. After more sedation and a nitro drip, the wire, catheter and sheath were removed, and the procedure was finished via the right femoral artery. A very similar type of transradial procedure was noted with a "recurrent" radial with another physician within the same facility. The "recurrent" radial was very large and could have been easily navigated with the J-Wire. However, due to concern of severe spasm due to the anatomy, the operator decided the convert to the femoral approach. If you could please share your thoughts regarding the incidence of spasm and the recurrent radial, it would be greatly appreciated.

The recurrent radial is very much prone to spasm, more so than a normal anatomy radial artery, mostly because of its smaller caliber. High origin (supracubital) radials behave similarly. I have performed coronary angiograms with a one- pass universal catheter with no difficulty in the majority of cases, but the second catheter usually does not track. I have done PCI through large-caliber, high origin radials with 5 French guides.

In general, a recurrent radial will let you go through once, and usually goes into spasm after the first pass. Use glide-coated catheters, when available, to avoid entrapment. The spasm in the recurrent radial is also difficult to break and more diffuse compared to forearm radial spasm. Hope this helps.

Completely agree. The recurrent radial is not only prone to spasm, but there are case reports of avulsion with resultant forearm hematomas. I would avoid these. If the loop can't be negotiated, I would go to the other arm rather than the femoral.

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If you can't complete the procedure from the radial after the sheath is in, should you remove the sheath and apply the TR Band before completing the procedure from the groin or other radial, or just leave the radial sheath in and remove it at the end of the case? I assume the longer the sheath stays in, the more likely you are to have radial artery occlusion down the line.

We remove it at the end of the case. It stays in longer that way, but it's minutes, not hours.

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How do you prevent occlusion of the radial artery? Is the time of radial artery compression after PCI related to the frequency of radial artery occlusion? How long should the radial artery be compressed after PCI?

Radial artery occlusion (RAO) can be prevented by heparin use with all radial procedures and maintaining radial artery patency during hemostasis.

Duration of compression probably has an impact, although if patency is maintained, the effect of duration is neutralized.

If using a TR Band, a 2-hour band application for PCI is effective in achieving hemostasis.

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At what point do you decide to switch to femoral from radial?

You should persist on the radial path until it increases the risk of complications. The point when you switch will be pushed further out as you gain more experience. If possible, in your initial experience, keep a low threshold to switch from radial to femoral.

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DISCHARGE

What is the standard of care regarding discharge time for patients undergoing diagnostic radial procedures utilizing the TR Band?

We keep TR Band on for 2 hours. This also fulfills conscious sedation requirements of monitoring. They go home after 2 hours.

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What specific restrictions are given to patients post procedure about lifting, return to work/etc? And would you avoid using a transradial approach in someone who works with their hands (such as a masseuse)?

Here is what we tell patients: No lifting over 5 lbs for 24 hours, no driving for 24 hours.

We would not be worried about doing radial on someone who uses their hands (unless they themselves refused), because we always check Allen's tests and don't do radial on anyone who has an abnormal test, and we always use patent hemostasis.

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What are your discharge instructions for diagnostic and interventional catheterization with the radial approach?

Our instructions to the patient are related to the radial arteriotomy. Specifically, we tell patients not to drive or lift anything over 5 lbs with the affected hand for 24 hours. This is not based on any data or evidence, but just an overall gestalt of what the risks may be.

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Please see the following D/C instructions. Does your group have any guidelines for activity restrictions?

• Protect your wrist from bending for 48 hours. Deep bending of your wrist could cause bleeding.
• Do not lift, push or pull anything over 5 pounds for 48 hours.
• Do not use hand/arm to support weight when rising from a chair or bed for 48 hours.
• Do not drive a car for 48 hours unless instructed by your doctor. Someone else should drive you home.
• Do not operate a lawnmower, motorcycle, chainsaw, or all-terrain vehicle for 48 hours.

Your list addresses the restrictions quite well. We also encourage no lifting greater than 10 lbs. for 1 week and no soaking the arm or swimming for 1 week.

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We are putting discharge instructions together for our radial artery access patients. We are looking for evidence-based guidelines for activity restrictions, i.e. driving restrictions, lifting restrictions, and bending. Do you have any specific home wound care guidelines?

Our discharge instructions include:
• No driving for 24 hours (conscious sedation related)
• No underwater submersion of instrumented arm for 3-4 days. Showering is okay.
• No heavy impact activity/ lifting >30 lbs (no data) for 1 week (based on anecdotal reports of hematomas caused by these, no other data).
• Bending the wrist allowable at discharge for activities such as writing, eating, typing, etc.
• All patients are advised to use generic caution.
• All activities are permitted after a week if no problems occur.

We tell patients to avoid lifting anything over 5 lbs for 24 hours and avoid driving for 24 hours. This is based on some trial and error, and so far, it seems to be working well.

Our facility is probably over-conservative and therefore, we tell the patient no lifting greater than 10 lbs for 1 week; no driving or writing/typing for 1-2 days and no dishwashing (to keep site dry) for 1 week (patients like this part!).

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I enjoy using the radial artery for cath and PCI. I have always kept patients overnight after undergoing PCI from femoral access, and most of my PCIs are performed ad hoc without prior thienopyridine administration. What portion of your radial access PCI patients are discharged on the same day, and what criteria have you established to determine which go and which stay?

We have implemented a protocol for same-day discharge that is consistent with the Society of Cardiovascular Angiography & Interventions (SCAI) guidelines – a successful radial procedure without post-PCI bleeding or complications, no glycoprotein IIb/IIIa inhibitors, live within 60 miles, and have someone to go home to. We've only had 3 patients discharged the same day, with the major reason being that they live 60 miles away.

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NAVIGATION

In our institution, we use standard JL and JR catheters for diagnostic transradial angiography. Are there any specific maneuvers for coronary artery cannulation with these catheters?

For the right, I generally find that the JR4 works best. I will bring the catheter to the valve and as I put clockwise torque on catheter, I slowly pull back. The trick is not to over torque the catheter. If the JR4 is not working, the next catheter I try is an ARmod 1. This works very well for high anterior take-offs.

For the left system, the workhorse is the JL3.5 catheter. With the .035 wire in the catheter, I advance down into the sinus towards the valve and then, while pulling back on the .035 wire, I clock and lift the JL3.5. If the arch is elongated, as in elderly, hypertensive patients, you may need to use a JL4. At times, having the patient take in a breath will lift the catheter and help canulation of the coronary.

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What is the most sensitive way to detect radial/brachial artery spasm during a case? Is it pain, resistance to catheter movement, etc.? If it occurs during a case, what is the sequence of treatment? Is it NTG through the catheter, IV NTG, spasmolytic cocktail through the sheath? What is the role of extra sedation and how long does it take to work?

I believe a vast amount of the time spasm is related to pain; at times the tortuous subclavian system can make it difficult to move the catheter. If there is difficulty advancing the catheter and the patient has no pain, I quickly look to the subclavian and may place a .035 wire back into the catheter to help with engagement. If the patient is having pain, I would start by giving nitroglycerin thru the catheter or even SL nitro will work, but the most effective method is sedation and pain control, so I give additional versed and fentanyl.

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I would like to know if anyone has used hydrophilic catheters in patients with ulnar loops and/or tortuous subclavian arteries. I know there was an article in one of the interventional journals several years ago, but I can not find any information regarding this topic. It would seem to be advantageous in cases of brachial artery spasm as well.

Glide-coated catheters clearly have better ability to navigate difficult anatomy, either structural, i.e., loops, tortuosity, etc., or functional, i.e., spasm. We have been successful with 5F glide-coated catheters like the Tiger (Terumo Medical Corp., Somerset, NJ) when 4F non-coated catheters have failed. I have never used them in ulnar loops, but certainly have used them in radial loops.

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What diagnostic and guiding catheters can be used for transradial saphenous vein graft procedures?

I do my bypass cases from the left radial, since it makes it easier to cannulate the left internal mammary artery (LIMA) or, if needed, to do an intervention via the LIMA. For the vein grafts, I have found that the Jacky radial catheter works well. I will at times use a JR 4 for the right or MP if the Jacky is not working. Another option is the AL as a guide. I have also used a SVB catheter from the left wrist.

For left radial access procedures, we use the same choices as we would from femoral access.

For right radial access procedures, for the left circumflex (LCX) and left anterior descending artery (LAD) SVG, we use an AL catheter, size dependent on the width of the aorta. For a right coronary artery (RCA) graft, the AL may work, although for a normal-caliber ascending aorta, MP works best.

For LIMA, we go left radial and use a LIMA shape or JR. If we have to go right radial and try to get LIMA, we use a multi-step approach, using JL/TIG/VTK to enter the left subclavian and then exchange out for JR/LIMA to engage the LIMA.

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When exchanging catheters over a wire, is it better to use an exchange length wire versus a standard wire even if there was no difficulty in placing the wire into the ascending aorta? Is it better to use a < 0.035" guidewire?

We routinely use an exchange length wire because our principle is "never pay for the same real estate twice"; however, other centers have experience using regular length exchanges. You should try both and see which one you feel more confident with.

We use 0.035" guidewires. The only reason we use smaller wires would be if we experience tortuosity. We then use 0.014" wires.

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RIGHT HEART CATHETERIZATION

The Langston Pig Tail (Dual Lumen) only comes as small as 6 French (Fr). For patients on the smaller side, have you ever used a 5 Fr alternative to the Langston?.

Thank you for this interesting question. In our lab, we have been doing most of our valve cases using an upper extremity approach, including right heart catheterization from the antecubital vein. We use a similar dual lumen catheter in our lab. I am not aware of a similar system in 5 Fr currently available on the market.

There are several potential options:

1. Go ahead and use the 6 Fr system through a 6 Fr access sheath
2. Consider a sheathless approach with either the 6 Fr or 7 Fr Langston catheter system:
   
   1. Get access with a standard radial access kit, temporarily place a 4 Fr sheath (OD 1.96 mm).
   2. Cross the aortic valve in your standard manner using a 4 Fr catheter.
   3. Exchange the catheter for a 0.035", 300 cm wire.
   4. Remove the catheter and sheath.
   5. Over this long wire, advance the 6 Fr dual-lumen catheter (OD < 2.2mm) into the left ventricle.

   Given the relatively similar sizes of the catheters, there should be relatively minimal bleeding.

3. You can use a 5 Fr sheath with a 4 Fr pigtail. Just make sure that there is no pressure gradient between the ascending aorta and the distal end of the sheath.
4. Long, 5 Fr hydrophilic-coated sheaths are available for many peripheral applications. Using an 0.035" wire, it is possible to advance such a catheter into the upper arm where spasm is less likely. The pressure at this site and the ascending aorta are likely to be similar.
5. In a less cost-effective manner, I have seen an 0.014" wire with a built-in pressure transducer (used in commercially available systems for fractional flow reserve measurement) advanced into the left ventricle while using the diagnostic catheter as the proximal measurement. It may be difficult to incorporate these measurements into the automated hemodynamic software package found in most cath labs.

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SET-UP

Is there an extension made for radiology tables other than slider boards on which to put the patient's arm? We need an area strong enough to support rotoblator equipment.

Although there is no ideal after-market product from radiology equipment providers, the best solution in our experience thus far seems to be the customized solution. Your biomedical department should be able to help you with customized measurements and preparation of a plexiglass surface that will provide exactly the amount of surface area for your physician and equipment. This solution offers several advantages. The material can be cut and customized to exactly what will suit your operators (i.e. length, width, curves, etc.) and it can be modified or cut out to accommodate table or C-arm controls. We recommend having corners and edges rounded, and in some hospitals, the surface area has been heated and rolled up on the outer edge, providing a lip in order to prevent equipment from falling off. As other solutions become available, we will attempt to make the viewers of our website aware.

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How do you set up the table for left radial catheterization? It always seems awkward every time we do it from the left arm. Do you flip-flop and switch sides for everything (monitor, IV/contrast pole, transducer set, etc.)?

After placing the introducer in the left wrist, we move the left arm in towards the table and then have one of our techs place folded towels (pillows) under the left arm board to elevate the arm and allow the arm to rest towards the center line of the body; this allows us to work from the right side and access the left wrist much in the same position as if accessing the left groin. Therefore, utilizing this method does not require adjustment of any of our monitors, transducers or IV poles.

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GRAFTS AND OTHER PROCEDURES

As we do more graft cases from the left radial approach, we are noticing that the usual backward angle of the LIMA relative to the subclavian from the radial approach often makes selective cannulation difficult, which may result in suboptimal angiograms. Is there an alternative catheter to try? Any tips or tricks?

Catheters to try include the Tiger (Terumo), LIMA, VB1 (Cordis), or the Mann IMA catheter (Boston Scientific).

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For grafts, we have found that the IMT is very useful when coming from the left radial; however, we are still in the learning curve when it comes to grafts. One physician is incredibly competent with a 5F Expo AL1 (Boston Scientific), but others are still experiencing some difficulties in finding grafts and keeping the fluoro time to a minimum. Can you recommend any others? Since we have done few radials with grafts thus far, what has worked well from the radial approach in your experience?

When cannulating vein grafts from a left radial artery approach, I tend to stick with the same catheter selection as in standard diagnostics and then adjust based on what I see. I usually start with a dedicated radial catheter (usually a Jacky [Terumo]), as the Jacky behaves somewhat more like an AL1. It gives a little more versatility reaching over to the left coronary grafts. If this doesn't work, then I tend to reach for an LCB (Merit Medical), then AL1. We've had almost universal success in this manner. With regard to posterior descending coronary artery (PDA) grafts, I have almost always had success with the MPA catheter (Cook Medical) if the Jacky doesn't work. On one or two occasions, I've needed an AR1 in order to get good contrast opacification.

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Is switching from a 5F to 6F sheath problematic in the radial artery (from spasm, etc.)? We often use 5F diagnostic catheters through 6F sheaths, but I notice, especially in women, removing the 6F sheath is uncomfortable for some patients and requires more force than I like. I assume a 5F sheath would reduce those problems, but I wonder about upsizing the sheath if we want to use 6F guides for interventions.

Although you will likely see less vasospasm using a 5F sheath and catheters in patients at risk for vasospasm (women, smokers, etc.), a 6F sheath can certainly be used without sacrificing patient comfort with adequate pre-treatment for vasospasm. If vasospasm is noted on sheath/catheter removal, more aggressive anti-spasm therapy (higher does of intra-arterial nitrates and calcium blockers) should be utilized in addition to sedation. Do not underestimate the importance of sedation when dealing with vasospasm post procedure. The catheter and sheath can usually be withdrawn uneventfully with this approach and a little patience.

In my practice, I commonly use a 5F sheath for diagnostic cath and upsize to 6F for PCI. In acute MI patients or those with a high likelihood of requiring PCI, I perform the diagnostic cath through a 6F sheath. Another option for patients with significant vasospasm requiring PCI is the use of 5F guiding catheters through a 5F sheath. Complex lesion morphology and guide catheter selection may limit this approach.

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What about patients with prior CABG?

Using the left radial artery is relatively easy, but does require specific patient set up so that the left wrist is at, or above, the left groin. It is advisable to start with non-CABG patients first.

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Can I use a rotablator or do bifurcation lesions through the radial approach?

Yes - rotablator burrs up to 1.5 mm will fit through a 6F guide catheter. Similarly, two rapid exchange balloons will fit through a 6F guide to kiss balloons after bifurcation stenting. One cannot do kissing stent or crush techniques through a 6F guide however, and there is limited experience with 7F or larger guides through the radial artery.

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Should I do attempt CABG cases early in my experience?

You can, but it is better not to do it in the steep part of the learning curve. Suggest using the left radial for easy engagement of the LIMA.

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Can a STEMI patient be managed via the radial in a timely manner?

The simple answer to this question is yes. Multiple groups have looked at their STEMI procedural times comparing the radial and femoral approach and the times are nearly equivalent. It is our feeling that the radial approach adds about 4 minutes to the lesion crossing time which is not likely to be clinically significant in most patients. Failed access and "crossover" to the femoral approach will occur more frequently than with the femoral approach, but with experience it should be less than 5% of cases. It is important to understand that most STEMI data is collected by experienced operators who know all the "tips and tricks." Therefore, although clearly an emerging and important tool for STEMI management, TRI should not be the default approach until the physician is well along the learning curve.

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MISCELLANEOUS

Have there been any studies done comparing femoral access with radial access in terms of patient satisfaction?

This is one of the largest and most frequently cited:

Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. Am Heart J 1999;138:430–436.

It showed a marked effect of radial over femoral approach for most quality of life (QOL) measures. The limitation of the study is that none of the QOL instruments used were specifically designed to compare radial and femoral.

The other piece of evidence is the RIVAL trial of radial vs. femoral where patients were asked if they would prefer the same access site for a subsequent cath/PCI. Ninety percent (90%) of patients preferred the radial approach again, while only 55% preferred the femoral approach again.

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A lab wants to begin doing transradial caths. Should there be a semi-formal credentialing process? Assuming the cath lab insists on some minimal credentialing process, what type of prior cath experience minimum volume (grandfathering those with prior experience) should be acceptable?

Certification is not currently offered for many interventional procedures, but probably should be for specific complex procedures. There is no current certification process for the radial approach offered by any professional society. The profession as a whole needs to decide on this issue and also decide which procedures require "certification." While it is likely that the minimum number of radial cases required for proficiency will vary by operator, it is clear that greater experience is associated with greater procedural success rates and lower procedure times, access site crossover, and radiation exposure. Anecdotally, most operators report feeling more comfortable with the radial approach after 50 to 100 transradial PCI cases.

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Some patients complain of forearm discomfort after the case. How do you handle that call from the nurse?

Assuming you have a low index of suspicion for a complication, we treat this conservatively with acetaminophen. Some of our nurses will apply a warm compres to the forearm. In our experience, it resolves in 60-90 minutes.

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Can you re-access the radial artery?

We have re-accessed the radial artery later the same day. I would go more proximal on the arm for the radial stick.

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What is the association of sterile granulomas with radial access?

This phenomenon has only been reported with a single brand of gel-coated sheath. The granuloma typically appears as a non-fluctuant erythematous nodule, 2-4 weeks after the initial index procedure. Biopsy of the site reveals a culture negative, amorphous blue-gray substance, suspected to be the hydrophilic gel, surrounded by chronic inflammation with a prominent giant-cell reaction. Incision and drainage of the wound appears to accelerate the healing process, perhaps through extrusion of the foreign substance. Those treated conservatively, without punch biopsy or surgical incision can have a protracted course, taking as long as several months to heal. Empiric antibiotic therapy is of no benefit. The published incidence of this complication is between 1-2%, although the true incidence is likely higher as many cases can go unreported. Its occurrence may be accentuated by the additional use of powdered latex gloves.

After my own personal experience with this situation, I switched to the Glidesheath (Terumo, Japan) and have not had a single recurrence.

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How many cases do I need to become proficient?

Of course, there is no exact answer. It is very operator and training dependent. With the benefit of some "tips and tricks" offerred by seasoned operators and courses, the learning curve should be less steep. Clearly, one needs to be proficient at diagnostic procedures prior to embarking on interventions. Nonetheless, the usual quoted number is around 100-150.

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What about radiation exposure?

Always try and position the arm parallel, and not perpendicular, to the body. This location brings the wrist to below the level of the groin, further from image intensifier.

Consider adding extension tubing between the manifold and catheter; This further distances the operator from radiation source (at the level of patient's foot). Place a three-way stopcock between extension tubing and catheter so the catheter can torque freely via the swivel.

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Has your radiation exposure increased via the radial? Why or why not?

The radiation exposure and fluoro time was definitely higher in the first few months, while I was learning how to do radial procedures. Over time, the radiation exposure and fluoro time diminished, and is now comparable to the femoral approach.

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Is there greater radiation exposure associated with radial access?

Due to the learning curve associated with transradial catheterization, the inexperienced operator can expect higher radiation exposure as catheter manipulation and coronary cannulation via the wrist is mastered. Once this initial hurdle is overcome, radiation exposure from the radial approach is no different than that received from the traditional femoral approach.

To minimize radiation exposure, the arm should be positioned parallel to the table (by the patient's side). In this way, the radial access site sits below the groin, distancing the operator from the x-ray tube. Second, the use of dedicated radial catheters allow for left and right coronary cannulation, as well as left ventriculograms. By avoiding catheter exchange, procedure and fluoroscopy time is reduced.

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Should radial access be introduced into fellowship training and if so and what point?

This obviously depends on the volume and expertise of the mentoring physicians in the training program. Our fellows are introduced to radial and femoral access early in their training and learn both approaches simultaneously. Assuming the program has attending expertise and adequate volume in TRA, then there really is no reason not to expose the fellows to the technique as soon as they start their cath rotations. If training volume is limited, then the experience should be concentrated on the interventional fellows. Considering the increase interest in the procedure, it really makes sense for every interventional fellow to have at least moderate exposure to the technique in training.

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