How to Convert Your Access to the Radial Approach Sunil V. Rao MD The Duke Clinical Research Institute The Durham VA Medical Center Duke University Medical Center

Disclosures Consultant, Honoraria Sanofi-Aventis, BMS, Astra Zeneca, The Medicines Company, Daiichi Sankyo Lilly, Terumo Medical Research funding Cordis Corporation, Novartis, Ikaria Off-label uses of drugs/devices will be discussed Fondaparinux in STEMI; Bivalirudin in STEMI

What’s wrong with business as usual? “Great invention and I’d love to invest, but I can’t spend time to learn how to use it and I never have trouble getting places when I have to anyway. I’ll just stick with what I’m doing…” It’s not about YOU; It’s about the patient and better outcomes! Slide courtesy of Ian Gilchrist MD

Radial access Why do it? If you are going to do it, how do you do it? Patient evaluation and set-up Arterial access technique Venous access technique Bailing out when access fails

Why do it? Radial approach is associated with a 70% reduction in periprocedural bleeding risk Radial approach can accomplish complex PCI Patients prefer the radial approach over the femoral approach Radial approach is associated with reduced healthcare resource utilization Jolly SS, et. al. AHJ 2008 Rao SV, et. al. JACC 2010 Cooper CJ, et. al. AHJ 1999 Mann TJ, et. al. CCI 2000

Elements of a successful transradial program Adapting the three domains of Quality + 1 Structure – Arms board, access kits, exchange length guidewires, catheters and guides, hemostasis devices Process – Training of physicians and nursing staff, order sets (pre-procedure, procedural, post-procedure), patient education Outcomes –Procedure times, Radiation exposure, Contrast load, Bleeding complications, Patient satisfaction, Radial artery occlusion “Other” – A commitment to transradial by all stakeholders – don’t get frustrated!

Oxymetry + Plethysmography The clamp sensor is applied to the thumb No damping of pulse tracing immediately after radial artery compression Damping of pulse tracing Loss of pulse tracing followed by recovery of pulse tracing within 2 minutes Loss of pulse tracing without recovery within 2 minutes. 15% 75% 5% Although the ulnar artery is often dominant in the hand circulation,[22, 26 and 32] the thenar eminence and the thumb are predominantly dependent on the radial artery, especially when the palmar arches are incomplete, so the sensor clamp is preferably applied to the thumb. [3, 14, 19, 33, 35 and 36] The presence of a pulse tracing during radial artery compression, as in types A and B, represents uninterrupted pulsatile arterial blood filling. Because the radial artery pulse could be present with a patent palmar arch in several cases of radial artery occlusion, differentiation between types A and B serves to unmask the occlusion of the radial artery that is occasionally seen in the type A pattern; in such a case, radial artery compression does not reduce pulsatile blood flow to the thumb. Radial artery occlusion can then be suspected when ulnar artery compression produces a type D reading, enabling pre- and post-procedural evaluation of radial artery patency. In type C, pulsatile blood flow, and pulse oximetry, is abolished temporarily by radial artery compression, but it reappears within a pre-specified amount of time, arbitrarily chosen to be 2 minutes. When radial artery compression is repeated within approximately 1 minute, a type C pattern is often changed into a type B pattern, suggesting collaterals recruitment induced by relative hand ischemia. The development of collaterals has been shown to occur in time with Doppler ultrasound scanning examination 1 year after the excision of the radial artery for bypass grafting.[37] This phenomenon cannot be easily evaluated with the MAT. In type D, pulsatile blood flow, and OX, is abolished by radial artery compression and does not reappear within 2 minutes. Because pulsatile blood flow has been correlated with wound healing and the absence of ischemic necrosis, the type D pattern was considered to be inadequate for the transradial approach. [38] Barbeau et al. Am Heart J 2004;147:489–93

Structure and process - Radial artery access General principles Pre-procedure Barbeau test on all patients scheduled for cath No need to hold warfarin (no heparin during diagnostic cases) Materials needed Micropuncture kit or angiocath Short hydrophilic sheath Spasmolytic cocktail (NTG,verapamil) IV UFH – give once catheters is in ascending aorta Exchange length (260 cm) 0.035” wire Hemostasis device

Radial set-up

Radial set-up

Radial access

Salvaging arterial access Tincture of time – wait for the pulse to return 100-400 mcg of SQ NTG over the artery1 Access slightly more proximal to original stick If the initial wire went subintimal, then use a bare needle and a springcoil tip wire – will find the true lumen more easily than a hydrophilic wire Sequence: RRA > LRA > RFA 1Pancholy S, et. al. CCI 2006

Left radial cases Prop up arm to be above left groin Access artery from left side, then have patient pronate arm and place it over the left leg Case is performed from the right side as usual Catheters JR4, JL3.5, MPA2 TIG 4.0 May need IMA for LIMA, AL1.0 for SVGs

Post-procedure process: Patent hemostasis Apply hemostasis device (TR-Band, RAD- STAT, etc.) Place pulse oximeter on ipsilateral index finger or thumb Tighten device and remove sheath Occlude ipsilateralulnar artery Loosen hemostasis device until plethysmographic signal returns or bleeding occurs Recovery area – air removal starts 30 min after sheath removal for diagnostic cases; 90 min for PCI 3 cc every 15 min until empty Replace air for bleeding and reset clock Pancholy S, et. al. CCI 2008

a c b d Slide courtesy of Mauricio Cohen MD

Right heart caths from the arm Place IV under sterile conditions in the antecubital or other medial vein Anesthetize around the IV and wire through it with the radial access wire (0.018” or smaller) Remove IV and insert hydrophilic sheath (5F preferred but can use 7F) The sheath may not aspirate, but is still in the vein! 5F balloon-tipped catheters are available Don’t inflate balloon until it enters the axillary vein Hemostasis is 2 min of manual pressure and a Band-Aid!

R + LHC from the arm – no IV access possible Place arterial sheath Inject contrast – wait 10-15 sec for levophase filling of venous system Access basilic or cephalic vein using bony landmarks and 19g angiocath

Pancholy SS, et. al. CCI (in press)

Converting to radial approach Develop a problem-solving attitude Procedure times will be longer in the beginning Commit to doing radials – intermittent use of radial approach leads to frustration and lack of proficiency Learn from your peers Femorals aren’t going away The philosophy should be ‘Radial first, femoral as bailout’