1. 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

2. 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

3. 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

4. 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

5. 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

6. 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!

7. 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

8. 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

9. Radial set-up

10. Radial set-up

11. Radial access

12. Salvaging arterial access
Tincture of time – wait for the pulse to return
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

13. 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

14. 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

15. a c b d
Slide courtesy of Mauricio Cohen MD

16. 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!

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

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

19. 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’