Transradial Best Practices for Radial Access Mladen I. Vidovich, MD, FACC, FSCAI Associate Professor of Medicine, University of Illinois at Chicago Chief, Cardiology, Jesse Brown VA Medical Center Chicago, Illinois

Disclosure Statement of Financial Interest Within the past 12 months, I have had a financial interest/arrangement or affiliation with the organization(s) listed below. Grant Support/Research Contract: Sanofi Aventis VA Cooperative Study Consulting Fees/Honoraria/Speakers Bureau: Merit Medical St. Jude Medical Eli Lilly CSI Boston Scientific Equity Interests: None Royalty Income/Intellectual Property Rights: Merit Medical Salary/Salary Support/Employee: None

Need for Best Practices? With rapid growth in use of this technique, many practices have developed Many of these approaches are supported by high-quality evidence, some not so much Goal is to improve quality and outcomes by promoting those practices with solid base of evidence Identify area where more work is needed

Best Practices Consensus Statement-2014 FOCUS AREAS Prevention of radial artery occlusion Reduction of patient and operator radiation exposure Transitioning to transradial for primary PCI Catheterization and Cardiovascular Interventions 83:228–236 (2014)

Radial Artery Occlusion Radial artery patency assessed before discharge and at the first post-procedure visit Catheterization and Cardiovascular Interventions 83:228–236 (2014)

Radial Artery Occlusion Adequate anticoagulation UFH (at least 50 u/kg or 5,000 units iv/ia) Bivalirudin for heparin allergic Catheterization and Cardiovascular Interventions 83:228–236 (2014)

Radial Artery Occlusion Patent hemostasis Lowest profile equipment Catheterization and Cardiovascular Interventions 83:228–236 (2014)

Radiation Protection Follow routine ALARA practices Position arm next to torso Increase TR experience Use of extension tubing, additional draping Left radial approach when tortuous anatomy is a consideration (elderly, short stature) Minimize fluoroscopy for catheter exchanges Utilization of “low frame” rates or stored fluoroscopic images when feasible Catheterization and Cardiovascular Interventions 83:228–236 (2014)

Radial access for Primary PCI Demonstrate proficiency with TR-PCI 100 PCI with radial-first approach Low femoral cross-over rate (<4%) Consider L radial approach: LIMA Risk of tortuous anatomy: >75, <5’5’’ (165cm) Catheterization and Cardiovascular Interventions 83:228–236 (2014)

Systematic use of LRA in Primary PCI Lahey Clinic as a case study Slide courtesy of Chris Pyne MD Systematic use of LRA in Primary PCI Lahey Clinic as a case study Larsen P, et. al. CCI 2010

Radial access for Primary PCI Demonstrate proficiency with TR-PCI 100 PCI with radial-first approach Low femoral cross-over rate (<4%) Consider L radial approach: LIMA Risk of tortuous anatomy: >75, <5’5’’ (165cm) Establish time criteria to bailout to contralateral radial or femoral Catheterization and Cardiovascular Interventions 83:228–236 (2014)

Algorithm for transradial primary PCI Courtesy of SV Rao Patient presents with STEMI Administration of dual antiplatelet therapy Administration of parenteral anti-thrombin therapy Arrival to cath lab Radial access Consider Left Radial Approach if prior CABG, age ≥ 70 years, height ≤ 5’5” Diagnostic angiography of non-IRA Guiding catheter to IRA PCI of IRA > 3 min > 10 min > 20 min BAILOUT Rao SV, et. al. Transradial Best Practices. CCI 2014

Radial access for Primary PCI Demonstrate proficiency with TR-PCI 100 PCI with radial-first approach Low femoral cross-over rate (<4%) Consider L radial approach: LIMA Risk of tortuous anatomy: >75, <5’5’’ (165cm) Establish time criteria to bailout to contralateral radial or femoral Prep femoral access site in case HD support needed Catheterization and Cardiovascular Interventions 83:228–236 (2014)

Future Directions… New topics: Updates: Ultrasound Ulnar access Routine Allen’s testing Radiation protections strategies RAO prevention: Ulnar compression

Questions????? Thank you. arshroff@uic.edu 312-485-4511