FAQ

This page includes a library of frequently asked questions by the clinical community. The provided answers were provided by a selection of key opinion leaders and members of the industry. Please note that the views and opinions expressed on this page do not necessarily reflect the official policy or position of Terumo Interventional Systems.

Access

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.



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 of facing the bevel downwards when accessing the radial artery?

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.



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.



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.



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.


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.


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). Is this a valid concern?

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.



I routinely administer 4-5,000 units of heparin into the radial sheath immediately after getting access. I recently viewed a video which recommended to delay this until aortic root access is obtained in case of radial loops, etc. How early after sheath placeme

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 5,000 units 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 5,000 units. Everything else is just personal style.



In regards to cutting down on radiation exposure, at what point do you start using fluoroscopy to guide your wire tip? Right after initial puncture, or only after the sheath is in? Is there any information on incidence/risk of vascular complications in the rad

One should not be using fluoroscopy to place the sheath. It is not necessary unless there is resistance to advancing the wire. Similarly, a meticulous operator can feel when there is resistance to advancing the 0.035" J-wire, and thus fluoro is not necessary when advancing the guide wire up the arm, unless resistance is felt. The only exception is when using a hydrophilic wire. Fluoroscopy should always be used when advancing a hydrophilic wire, but a hydrophilic wire is almost never necessary. Almost all brachial or subclavian tortuosity can be navigated with a Wholey wire or 0.014" standard angioplasty wire. There are no published data on whether limiting the use of fluoroscopy is associated with an increase in vascular complications. It is highly unlikely, given how rare vascular complications are with the radial approach.



How do you feel about the catheterization of the radial artery in the field of anatomical "snuff box"?

I have never seen a case done from the anatomical snuff box and I don't see a reason why it wouldn't work. The radial artery is quite small in that location, however, so the risk of radial artery occlusion, I would guess, is high. Moreover, it is difficult to get hemostasis at that location and one would have to use manual pressure, I would think.


How do you feel about the catheterization of the radial artery in the field of anatomical "snuff box"?

I have never seen a case done from the anatomical snuff box and I don't see a reason why it wouldn't work. The radial artery is quite small in that location, however, so the risk of radial artery occlusion, I would guess, is high. Moreover, it is difficult to get hemostasis at that location and one would have to use manual pressure, I would think.


What are your thoughts regarding repeat radial access within days of the initial study?

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


Adjunctive Pharmacology

How soon can anticoagulation with unfractionated heparin per acute coronary syndromes protocol be safely started for an ST-elevation myocardial infarction (STEMI) patient with respect to TR Band removal? Usually we wait 2-4 hours post transradial cath to relieve the TR Band, but in a STEMI situation, it seems like a long time without anticoagulation.

Starting heparin post successful primary percutaneous coronary intervention is not common practice unless the patient has an Impella or intra-aortic balloon pump, or you have other reasons to start anticoagulation. Heparin can start 1 hour post removal of the TR Band; however, anticoagulation does not need to be interrupted to remove the TR Band. If the patient is on active anticoagulation, I will leave the TR Band inflated with patent hemostasis for 2 hours, then I start removing the TR Band by deflating 2 mL every 15 minutes.


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. 



We have begun doing transradial cases at our facility. Currently, we are using nitro and cardene for antispasmotics. I read that many physicians use nitro and ditilizem. What doses are recommended?

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.



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.


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.



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.



In many studies and research, I have seen the heparin doses given during a transradial procedure are around 70u/kg or up to 5000u/kg. What is the recommendation for heparin use in diagnostic and interventional procedures? Does this amount decrease for interventional procedures?

Yes, the dosage you described is acceptable for diagnostic cases, even those that go on to intervention. At our facility, interventional cases then switch over and receive bivalarudin.



What is your comfort level with using a glycoprotein (GP) IIb/IIIa inhibitor in a patient with a ST-elevation myocardial infarction (STEMI), along with ASA and bivalrudin, if the patient is on coumadin with an INR of 2.1, in the radial approach?


This question raises several issues. The first is: How “anticoagulated” can a patient be when considering the radial approach? Although there is really no “correct” answer, it is my feeling that a careful diagnostic catheterization procedure can be safely performed on a fully anticoagulated patient (including a patient with a therapeutic INR on warfarin). The radial access site can be handled in the usual fashion, but may require a longer period of compression to avoid local complications. The radial approach significantly minimizes the potential for major access site complications. Most minor issues, such as bleeding, hematoma or the rare occurrence of pseudoaneurysm, can be addressed with compression. If, however, one is considering elective ad hoc PCI in a therapeutically anticoagulated patient, consideration should be given to holding oral anticoagulation in advance of the procedure to decrease any potential risk of non access site bleeding with the addition of IV anti-thrombin or IV anti-platelet therapy. In a STEMI patient with a therapeutic INR on oral (likely dual) anti-platelet therapy, one would need to weigh any perceived benefit of using the combination of GP IIb/IIIa receptor inhibitor and a direct thrombin inhibitor against the risk of non access site bleeding with this combination. Although there is no real choice in the setting of a STEMI regarding a patient with a therapeutic INR, careful consideration should be given to the choice of anticoagulant used (I would favor bivalirudin), and very careful consideration given prior to the decision to combine a GP IIb/IIIa receptor inhibitor and bivalirudin in this setting.



We usually give 5000IU of heparin after access is achieved. If we switch to a PCI and do not necessarily want to give bivalirudin, do we then give the remainder of the weight-adjusted heparin dose?


Administering the remainder of the weight-adjusted dose is completely reasonable. As an alternative, there is little downside to checking an activated clotting time (ACT) during the diagnostic catheterization and simply supplementing unfractionated heparin (UFH) as necessary. Either way, adding additional UFH once deciding to pursue intervention is appropriate.



Since intra arterial verapamil is painful for patients, can intra arterial diltiazem be used instead? Is this also painful? What dose should be used to prevent spasm of the radial artery?

Certainly IV diltiazem can be used, but I have no experience with it. The dose of verapamil that we use is very low (3 mg) compared with that used for treatment of hypertension, tachycardia, etc., so I would guess that a similar low dose of diltiazem would be needed. I have also heard of nicardipine being used.



Do you have experience using nicardipine for radial artery catheterization and could you provide literature supporting its use?


We haven't used nitroglycerin in years for blood pressure reasons. Verapamil is great. We like nicardipine, and our entire lab uses it. It is more expensive, but when mixed, you basically have a bucket of it on the table, and you can use as much as you want without affecting blood pressure.



Clinical Considerations

What is the technique for selective coronary catheterization access to the radial through an arteriovenous fistula hemodialysis?

You should never use the AV fistula or even the radial artery in patients who are expected to need the forearm vessel for a hemodialysis fistula, because closure of the radial artery will deprive the patient of potential lifesaving dialysis access.


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


Journal of Interventional Cardiology; 19:258-263 (2006)
- Catheterization and Cardiovascular Interventions; 73:44-47 (2009).




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.



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.



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.


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.



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.


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.



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.



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.



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. 



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.


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.



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


There are no restrictions; you can do blood pressure measurements immediately.



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.



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. 



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. 



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. 



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.



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.



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. 



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.



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

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.



Are there any contraindications to the radial approach in patients who are on Coumadin and have therapeutic INR? What anticoagulation/antiplatelet regime you are using if PCI is required in the above patient?


Great question! The beauty of the radial approach is that it can be used in patients with therapeutic INR values without having to discontinue warfarin. No one really knows the “right” anticoagulation regimen for these patients, but many operators use 1/2 dose heparin during diagnostic cath (35 u/kg up to a max of 2500 u) and bivalirudin for PCI. The anti-platelet regimen does not differ from other radial or femoral cases.



Can you advise on strategy to cannulate coronary arteries via right radial access in short stature patients with regards to catheter selection and other helpful tips?


Although I have not found it necessary to make significant accommodations for patient height with regard to diagnostic catheter selection, short-statured patients often demonstrate shorter aortic roots, requiring downsizing of standard catheters or use of radial-specific catheters (Jacky, Tiger). This issue may become important when performing an intervention which requires both ease of vessel access and adequate backup.

For left coronary cannulation, I prefer the radial-specific Ikari Left guide catheter, which can be used in most settings and provides straightforward access and excellent backup in both smaller and larger aortic roots. This catheter can be advanced into the left coronary cusp over a wire and using the cusp, directed upward (Amplatz technique). The catheter can then be advanced with slight counter-clockwise torque into the left main coronary and gently lifted (pulled back) in order to securely engage the vessel. Although the Ikari Right catheter provides excellent backup, most of the “usual” catheter shapes can be used to provide easy access and adequate backup for right coronary artery interventions.

There is an association between short stature and right subclavian artery tortuosity. If this is a concern early in your transradial experience, you can consider using the left radial artery for access. However, as there is no way to accurately predict unfavorable subclavian anatomy and subclavian tortuosity is common in elderly patients, it is worthwhile developing skill in addressing this issue.



What is your standard treatment for symptomatic occlusion of the radial artery for someone returning 5 days post-cath, tenderness in forearm, and no ischemic changes?


Excellent question. In the absence of symptoms of ischemia or signs of ischemia, this would be consistent with inflammatory changes in the artery. I would treat with local hot or cold compresses. If need be, a short course of NSAIDS or a steroid may be given. Forearm exercises, including opening and closing the fist, are highly recommended to avoid subsequent chronic pain. The occlusion does not need to be treated.



How should one do rotablation through an aberrant right radial artery (arterio lusorio)?


Ateria lusoria is a rare occurrence in clinical practice. However, once your guiding catheter is engaged into the coronary ostia, the subsequent coronary intervention (including rotational atherectomy) is often straightforward. The engagement process is described well in Patel's Atlas (2nd edition, pgs 70-79) and I would refer the reader to that text. As for guide selection, extra back up guiding catheters, Judkins left, and Amplatz left have all been successfully used. A note of caution: this anatomic variant will require a lot more time/effort, catheter exchanges and wire manipulation. Converting to a left radial approach may facilitate the process greatly.



How frequently is the reverse Allen’s test done in the Post Op care area after a transradial cath? Is it done with each set of vitals and site assessment? For example: Q15MIN X 4, Q30MIN X 4 Q1HR X 2 and PRN....?


During the hemostasis process, we leave a disposable pulse oximeter on the index finger until the TR Band is weaned off completely. When the patient enters the holding room, we confirm that we have radial artery patency with the TR Band in place by occluding the ulnar artery with manual pressure; we then check for a waveform on the monitor. This is essentially the reverse Allen test (or the Barbeau test).

This process is repeated q30min until we begin weaning the TR Band. For diagnostic procedures, we begin to wean the band off after 30 minutes of pressure. For PCI, we begin weaning after 2 hours.

We also check radial artery patency with the reverse Allen test prior to discharge.



What is the range of INR in which we are allowed to do radial catheterization?


We routinely do radial cases in patients with INR values 2.5-3.5. Above that, one has to wonder why it is so high, regardless of your access approach. So we usually avoid doing the case at all if the INR is > 3.5, primarily to investigate why it is so high.



Closure

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.



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.



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.



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.



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.



If we perform a transradial heart cath on a patient with an elevated INR, how do you usually care for the arm afterward with the TR Band? Is it ok to leave it on for an extended period of time?


Sure. The management for us is no different than if the patient had a normal INR. The TR Band usually stays on a bit longer, but since the patient is anticoagulated, it's not an issue. There are very few studies on radial patency rates in this population.



Is there a protocol that you know of relating to when to pull radial sheaths post-intervention? Do you use the typical activated clotting time (ACT) below 150?


The radial sheath can (and should) be pulled immediately after the case, regardless of the ACT or INR, with a TR Band (Terumo) placed appropriately (non-occlusive hemostasis). There are protocols available for hemostasis, and it is important to have these in place before starting a radial program. In addition, it is encouraged that the physicians and staff attend a radial course to learn about hemostasis and post-procedure protocols before starting radial cases.



After catheterizing the left internal mammary artery (LIMA) in post CABG patients and doing angiography, which of the following is your routine:


1. To prevent LIMA dissection, first passing a 0.035" wire into the LIMA, then pulling back the catheter and extracting it.

2. First pull back the catheter out of the LIMA ostium and then pass a 0.035"wire into the subclavian artery and then extract it.

My practice with LIMA engagement, regardless of access site (radial or femoral), is to advance an 0.035” wire (usually J-tipped) beyond the ostium of the LIMA. Specifically, if coming from the left radial, I will advance the wire past the LIMA into the aorta. If coming from the right radial or femoral, I will advance the wire to the shoulder (at least 5-10 cm beyond the suspected origin of the LIMA). Once the wire is in place, I advance an IMA catheter over the 0.035” wire until the tip of the catheter is 2-3 cm beyond the origin of the ostium. I will remove the wire, check that there is a reasonable pressure wave, and then aspirate/flush the catheter.

Under pressure and fluoroscopic guidance, I will withdraw the IMA catheter until it drops into the LIMA. I use puffs of contrast to better visualize where the catheter is with relation to the LIMA.

Once angiography is completed, I will gently rotate the catheter until it is no longer engaged and then slowly retract it into the aorta (for transfemoral access) or into the more distal subclavian (left radial artery access). Once safely out of the IMA, you can use an 0.035” wire to remove the catheter.

TIP: The left anterior oblique (LAO) projection is useful for entering the subclavian and the right anterior oblique (RAO) projection is useful for visualizing the LIMA origin.



Complications

Can you tell us the incidence of forearm hematoma in the transradial interventions?

Radial artery perforation is a rare complication, but can lead to severe forearm hematoma if not managed promptly. In their analysis, Calvino-Santos et al reported the incidence to be approximately 1%, and found it greatest among older and shorter women with tortuous arteries.

However, the incidence is likely lower than 1%. Although perforation can necessitate conversion to transfemoral access, several case series have demonstrated the safety of continuing the procedure either with the use of a long sheath, guiding catheter, or peripheral balloon to seal the perforation. Furthermore, none of these patients experienced long-term vascular complications.


I have done a literature review in attempting to find best practice for the "post" complaints related to the position/limitation of the arm/shoulder during the procedures. Following the procedure, one of our greatest complaints is shoulder pain that seems to be related to the position during the procedure. We provide as much support as viable on our cath table, utilize pain relief, warmth to the shoulder, and gentle massage. Other suggestions of how to better alleviate or even lessen this challenge for the radial approach? Thanks.

I do not limit the arm by securing it or by restraining it during radial cath, so that the patient can have the best anatomical positioning of the arm. I also many times need to move the arm for angiography of the radial/brachial vessels in case of radial loop.

There were some difficulties we encountered early on in our radial program when we were using J wires up the radial artery. The J would come out straight and then as the vessel became larger or then the wire encountered a side branch, it would go into the side branch to go into the J conformation, but would perforate the side branch as the wire was advanced. We found this out by watching the wire advance on fluoro.
The small perforations would manifest as arm pain, especially right at the elbow, and hematoma. This has been completely alleviated by use of a floppy tip straight wire (Tiger or Wholey).


I have a patient who developed severe forearm muscle pain after transradial catheterization. He presented to my clinic 5 days post procedure. The local exam showed a grade one hematoma with faint radial pulse. I gave him NSAIDs p.o. and local, but he returned to me complaining of the same pain, now also radiating to his arm and shoulder. What further investigation and management should occur?

Although uncommon, we have seen some patients return with inflammation-related pain in the arm of the radial access site. It sounds as though the patient has a palpable pulse. We also document a plethysmographic-directed Allen’s test (SPO2 sensor placed on the index or middle finger of the hand while performing Allen’s test maneuver). Trusting that the patient does not have compartment syndrome with compromised circulation, treatment is largely “tincture of time.” We would use NSAIDs, ice, and elevation to treat the discomfort. Generally, the pain should subside after a couple of weeks, but in speaking with my providers, they have seen occasional instances where the discomfort may persist up to a month. I understand there is a rare association of Complex Regional Pain Syndrome after radial catheterization that would benefit from physical and occupational therapy.


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.



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.



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.



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.



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 rea

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



I recently changed primary hospitals and went from primarily Cordis to Medtronic catheters. For the first time, I'm encountering spasm in the axillary fossa area and this has happened 6 times in the last 6 months. I've never had spasm before in this area;

Although I use primarily Terumo diagnostic catheters, I cannot say that I have noticed more vasospasm when using other curves (all Medtronic in our lab). The same applies to my experience with guides (Terumo and Medtronic only). I use primarily short sheaths. I still tend to think that vasospasm is more often patient-related (small women, smokers, etc), and dose anti-spasm drugs and sedation accordingly. Also, you may wish to use a Glidewire instead of a standard 0.035 wire for catheter insertion in these patients. Hope this is somewhat helpful.



What is the best approach to the management of a forearm hematoma post diagnostic transradial angioplasty?


This is a big question. Prevention is the first step. The next is awareness and rapid diagnosis. If the sheath is still in place, cross the perforation site with a wire, then a catheter, to provide internal tamponade. This is the best described treatment strategy. If the sheath is out, the options become much less clear cut. Applying pressure over the region of the suspected perforation site is helpful either with manual pressure, a blood pressure cuff or an elastic bandage wrap. Close attention must be paid so that the signs and symptoms of a compartment syndrome do not develop. Also, that perfusion to the hand is present. Have a low threshold to contact a vascular surgeon. Please refer to a great reference from Tizón-Marcos H, Barbeau GR. Incidence of compartment syndrome of the arm in a large series of transradial approach for coronary procedures. J Interv Cardiol. 2008 Oct;21(5):380-384. doi: 10.1111/j.1540-8183.2008.00361.x.


The keys are prevention, early recognition, and external compression.


Discharge

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

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.



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.



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.



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.



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.



For same-day discharge after radial PCI, how long do you keep the patients prior to discharge?


Generally most same-day discharge programs observe patients for 6 hours post PCI.



Grafts and Other Procedures

I would like to confirm that there are no restrictions regarding the use of a tourniquet, non-invasive blood pressure measurements, phlebotomy, or IV insertion in the arm used for radial artery catheterization within the first 24hours after the procedure is performed.
Thank you.

We recommend that you try to use the opposite arm for blood pressure, since it occludes flow to the area, especially if the patient is moving around and the blood pressure cuff has to keep trying to pump up and down, and can take a prolonged time period. We commonly insert the IV in the same arm, just not around where the hemostasis band would have to be placed. I don’t think there are any contra-indications to this, but we try to maintain flow to the radial artery for 24 hours. There are no studies to support this (or not support this) that I am aware of. I will ask at the International Radial Conference in September, in England.


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.



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.



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.



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.



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.



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 mor

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.



Miscellaneous

I am interested in exploring the reasons for the slow adoption of transradial PCI in the United States. I do appreciate that there is a steep learning curve to proficiency. If you could estimate or quantify gaining proficiency in terms of time and/or cost, I would be most appreciative. Thank you.

We have determined that you must start out with trying ALL (appropriate) cases radial and the learning curve is about 50 cases. You should not cherry-pick your cases. Start out doing diagnostic and you can use the same catheters (left: JL 3.5 and right: JR4.0) of special catheters. Do not start doing STEMI cases of known PCI at first. Of course if the diagnostic turns into a PCI, we use XB 3.5, etc., guides. By 100 cases, you should be able to do the STEMI. Leave the LIMA cases alone from the right; not worth the work. Just go to the left radial.


We have seen an increase in red areas on the forearm post radial cath. They vary in sizes and are slightly raised. They are usually gone before discharge. Any ideas?

Are you using any cleaning products or tegaderm “sticky” around the area with the drape? It could be an allergic reaction to this. Also, they may be allergic to the type of hemostasis band. I have not seen this before in thousands of cases. It would be good to do a case discussion.


Any strategies to retrieve a deformed stent via transradial route when initially having a 6F long sheath?

I have removed the whole guide and wire with the stent that was deformed out the radial. Doing this, I have also lost a stent in the radial artery and had to snare it when it fell off the delivery device. It is important to always image as the deformed stent is removed. I am not a fan of long 6F sheaths, as I believe they limit distal flow and increase the incidence of radial closure.


Is there a recommended minimum wrist diameter for use of the Regular TR Band?

The regular TR Band – or the smallest available – is 24cm in length. There is no recommended minimum wrist size for the patient.


We have several interventional cardiologists interested in doing radial access cardiac caths. These physicians were doing radial access caths back in 2001, but have not done any since. I am curious if hospitals are requiring proof of training and competency before allowing physicians to use this approach? At our hospital, the physician must ask for privileges and meet the following credentialing requirement of attendance at a transradial approach training course and at least two cases must be performed under the supervision of a trained physician already approved for privileges; OR documentation of training in cardiac cath transradial approach from a program director of a cardiology fellowship program. Once above is met, then provisional privileges are granted. The applicant must then perform 10 cases in a 12-month period with no problems identified. At that time, full privileges will be granted.

What have you seen other hospitals require before a physician can do transradial access? Thank you in advance for your assistance.

Different hospitals and administrations have different rules. Often, criteria such as these are not data driven. It may be easier to just fulfill the requirements rather than change them.

I have not come across a standardized requirement. With that being said, I think it is reasonable to understand the basic concepts of radial catheterization and also some basic understanding of possible complications and management strategies...spasm, small perforation, ulnar circulation assessment and arch patency, etc.
Our institution recommends basic competency through fellowship or internal/external training of the basic concepts, but it is not mandatory.


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.



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.



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.



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.



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.



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.



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.



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.



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.



What is the protocol for removing the TR Band?


Although the protocol varies, typically accounts will leave the TR Band on for 1 hour post diagnostic and 2 hours post intervention. Following this time, 3ccs of air is removed every 15 minutes in an effort to achieve patent hemostasis. If bleeding occurs, then put 1cc-2ccs back into the band and wait another 15 minutes.


This falls under the more moderate approach for aggressive approach. The conservative protocol is 2 hour diagnostic and 4 hour interventional.

Daniel Martin
Terumo


Navigation

Sometimes transradial artery cardiac catheterization becomes challenging with the tortuous subclavian artery. Even the super stiff Amplatz 035-inch wire would not be able to straighten the tortuous artery. In these uncommon situations, there are case reports you are aware of? In my personal experience, using a hydrophilic 90cm 5F or 6F sheath to navigate the tortuosity helps. Do you mind sharing your experience? Thanks.

Tortuous subclavian anatomy is a great challenge to radialists. The goal is either to straighten or conform to the tortuosity. In over
4000 radial cases, I have never used long sheaths to deal with this, as I think it probably increases the incidence of radial artery closure, likely limiting distal perfusion during the case, although a long 5F guide is probably a good idea that I have just not tried.

My approach to the tortuous subclavian is to first get into the ascending aorta with a wire, many times a soft tip, straight wire i.e., Tiger or Wholey with a Judkins right (JR) diagnostic. Sometimes more catheter support is needed, i.e., an Amplatz left (AL), to wire into the ascending aorta. If the catheter won't advance into the ascending aorta, I will change to a J wire and then to an Amplatz as you mentioned. Most times, the catheter itself will straighten out the subclavian sufficiently. Sometimes I will increase the diagnostic catheter size to 6F (I usually use 5F catheters). My catheter progression with tortuosity for the right is JR, 3DRC, MPA, AR. For the left: JL, AL.

For guides, I will usually use Ikari and if the tortuosity is from leftward exit of the brachiocephalic artery/unfolding of the aorta, then the guide size needs to be increased to conform to the aortic root, i.e., Ikari left (IL) 4.5 or I go to the AL guide. The Amplatz technique with the Ikari guide is also useful in the left cusp to get the catheter to the left main. Ultimately, I will bailout to the contralateral radial artery if the tortuosity is excessive.


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.


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 regardi

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.



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.



I used an Ikari right guide for a mid right coronary artery (RCA) lesion. Although my balloon catheters traveled without any problems, the stent would not pass the proximal curve in the RCA which was somewhat of a Shepherd's Crook. I used a GuideLiner cat

Although it appears that the Guideliner catheter served its intended purpose, there are other guide catheter options. It may have been worthwhile attempting to deeply intubate the Ikari Guide. This should be done very carefully to avoid dissection. Also, if guide support is problematic, an AL 0.75 or 1 can be used (again, carefully) and will give excellent support. Often, a JL (3.5 or 4), straightened with a 0.035 wire inside the catheter can be used to cannulate the RCA and will provide good back up when the wire is removed.



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
3. Given the relatively similar sizes of the catheters, there should be relatively minimal bleeding.
4. 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.
5. 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.
6. 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.


What’s the incidence of venous occlusion following a 5 French sheath for a right heart brachial cath?


Over the last 12 years, we have done on the order of 1,000 right hearts from the forearm (brachial region and below to the wrist). I know of one venous thrombosis from a catheter placed in a small vein about 6 inches below the elbow. We have an active surveillance post-discharge, as all patients are contacted after caths at our institution. We have seen a fair number of arteritis from thrombus in radial arteries and vein thrombosis from IVs used for fluids and meds over the years, but essentially no problems from veins used.
Looking at the history books, when brachial cut downs were used, the veins were rarely repaired and commonly tied off at the end of the procedures. This region has many collaterals and vein thrombosis is not an issue.



Set-Up

I'm studying the potential for a reduced radiation dose to the patient and operators with a brachial lead shield.
Have you used this kind of shield during radial artery catheterization?
If yes, can I have some information?

There are the Radishields (ITW Mazel), which are also on arm boards. You can also just throw a radiation shield across the pelvis and reduce exposure.

The following reference might be useful:
Musallam A, Volis I, Dadaev S, et al. A randomized study comparing the use of a pelvic lead shield during trans-radial interventions: Threefold decrease in radiation to the operator but double exposure to the patient. Catheter Cardiovasc Interv. 2015 Jun; 85(7): 1164-1170. doi: 10.1002/ccd.25777.


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.



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. 



Regarding the need to transport patients with radial sheaths to another hospital to receive needed PCI, I need to know two things:
 1. Is it safe to transport these patients with radial sheaths?
2. How long can a radial sheath remain in place without caus

It is safe to transfer a patient with a radial sheath in place as long as it is secured in place and hooked up to a pressure bag like an arterial line. The duration isn't as much of an issue, because the longer it stays in place, the more likely the patient is to recruit collateral circulation to the hand. The sheath should be replaced with a new sterile one before the next procedure takes place.