We recently experienced increased problems with spasm in our cath lab for no apparent reason. No change in sheaths, antispasm medications, etc. Occurred whether we used 4F, 5F or 6F sheaths. What happened?

The .035" wire packaged with our angiography set up was changed from a Teflon coated wire to a non-coated wire, perhaps to save money. This uncoated wire appears to have been a coarser stimulant when in the radial/brachial artery causing spasm from its mechanical irritation of the vessel wall. Once this change was identified, we replaced these wires with the previously used coated wires and the mysterious out break of spasm disappeared.

One more thing to consider when spasm is a problem.

Radial artery loops are a prominent challenge in the transradial approach, especially for beginners. These loops increase with an aging population.

If you use the venous puncture technique and your 0.23" wire cannot be moved forward, stop and bring your venous canula into the radial artery in full size.

Inject contrast mixed with nitro (1:1). If you detect a loop, bring in a coronary extra support wire, not a floppy wire. In the majority of cases, the problem will be solved. If it is not, stop and try the other side (left radial). The venous canula is much smaller in size than a sheath and will make compression simple and radial damage unlikely.

When you succeed, retrieve the venous canula and insert your sheath over the extra support wire. This is the main advantage of an extra support wire contrary to a floppy wire, and is the advantage of venous puncture over bare needle puncture.

With the extra support wire on board, you can move forward a JR up to 6F into the aortic root.

Carotid stenting is performed transradially through a 6F shuttle sheath or Rabie catheter. The problem that must be surmounted is positioning the sheath in the common carotid across the acute angles that must be traversed from the arm approach. This is accomplished using a variation of the femoral technique of initially placing a diagnostic catheter into the external carotid artery. An exchange-length guide wire is then anchored in the external, and the diagnostic catheter is replaced with the shuttle sheath, which is positioned beneath the carotid bifurcation.

Bilateral carotid angiography is performed from the right radial artery with a 5F Simmons 1 diagnostic catheter. From the left radial, either a Simmons 1 or Tig (Terumo) catheter is used. After selection of the target carotid with the S1 catheter, a 0.14 inch extra support coronary guide wire or .025 inch angled glide wire is passed through the S1 catheter into the external carotid artery. A relatively soft guide wire is required to traverse the acute bend at the origin of the common carotid artery without dislodging the catheter, and we have had the most consistent success with a coronary guide wire. After advancing the diagnostic catheter into the external carotid, a stiff supportive wire is required to exchange for the shuttle sheath. From the right radial, a 260 cm .035 inch standard J guide wire provides adequate support for this exchange without creating excessive tension in the system. A .035” Amplatz Super stiff guide wire (Boston) or Supracore (Abbott) is used from left radial access. “Telescoping” a 5F right Judkins diagnostic catheter inside the shuttle sheath may be helpful in delivering the sheath to the common carotid. Carotid stenting is performed through the shuttle sheath using standard technique.

A major problem for the arm approach is inferior support for the shuttle sheath at the origin of the common carotid. Usually, the right subclavian artery or the first segment of the right common carotid artery has a transverse segment that provides a platform for the shuttle sheath. Similarly, there is usually sufficient support in cases involving a bovine left carotid artery, which is easily selected from the right arm with an Amplatz R2 catheter. In contrast, there is usually no inferior support for a shuttle sheath in cases involving the left common artery, and prolapse of the shuttle sheath into the ascending aorta may occur. Thus, transradial stenting of nonbovine left carotids is more difficult and procedural success rates are substantially lower.

All currently available carotid stents can be delivered through a 6F shuttle sheath, and selected carotid Wallstents can be delivered though 5F sheaths. However, caution must be observed during delivery since air can be introduced into the system creating the risk of air embolization. Using the “roadmap” fluoroscopy mode to position stents, as opposed to repeated contrast injections, will minimize this risk. Transradial experience is mandatory before undertaking these cases, and it is advisable to perform a few cases of carotid angiography alone before embarking on transradial stenting.

References

1. Castriota F, Cremonesi A. Manetti R, Lamarra M. Noera G. Carotid stenting using radial artery access. J Endovasc Surg 1999; 6 : 385-386.
   
   
2. Bendok BR, Przybylo JH, Parkinson R, et al. Neuroendovascular interventions for intracranial posterior circulation disease via the transradial approach: Technical case report. Neurosurgery 2005; 56: 626.
   
   
3. Folmar J, Sachar R, Mann T. Transradial approach for carotid artery stenting: A feasibility study. Catheter Cardiovasc Interv 2007 ; 69 : 355-361.
   
   
4. Pinter L, Cagiannos C, Ruzsa Z, Bakoyiannis C, Kolvenbach R. Report on initial experience with transradial access for carotid artery stenting. J Vasc Surg 2007; 45: 1136-1141.
   
   
5. Patel T, Shah S, Ranian A, et al. Contralateral transradial approach for carotid artery stenting: A feasibility study. Catheter Cardiovas Interv. Early View (in press).
   
   
6. Trani C, Burzotta F, and Coroleu F. Transradial carotid artery stenting with proximal embolic protection. Catheter Cardiovascular Interv. Early View (in press).

Primary Percutaneous Intervention (PPCI) with stent implantation is the preferred modality to treat ST-segment elevation myocardial infarction (STEMI).  However, high success rates are often counterbalanced by severe bleeding at the femoral puncture site.

During the last decade, many investigators have compared TRA (transradial approach) vs. TFA (transfemoral approach) in STEMI in randomized- and non-randomized studies.

Louvard, et al. (2002) demonstrated in a large cohort of patients (n = 1,224; 185 TRA) in a prospective dual centre registry the benefit of TRA over TFA.  Success rates were similar in both cohorts (> 95% for both) and procedural time did not differ.  But severe access-site related bleeding was solely observed in TFA groups, despite using a femoral closure device in the majority of TFA patients (0% vs. 2% for closure device and 0% vs. 7% for manual compression).

Of interest, the TRA patients more often received 2B3A inhibitors; also, they had been given more antecedent thrombolysis.  These results have meanwhile been confirmed by many others worldwide.

Just to mention some of the trials: Saito, et al. (2003, Japan; n = 213; 77 TRA), Valsecchi, et al. (2003, Italy; n = 726; 163 TRA), Philippe, et al. (2004, France; n = 119; 64 TRA), Diaz de la Liera (2004, Spain; n = 162; 103 TRA), Ranjan, et al. (2005, India; n = 103), and Brasselet C, et al. (2007, France).

Recently, Ziakas, et al. (2007, Canada; >60-yrs; n = 155; 87 TRA), Yan, et al. (2008, China; >70-yrs; n = 103; 57 TRA), and Zimmermann, et al. (2009, Germany; >75-yrs; n = 115; 55 TRA) also converted the access-site benefit to elderly patients presenting with STEMI.

The decision was to perform angiography via the radial approach. We gave 5000 units of heparin intravenously because we were told from ICPS in France (Dr. Louvard; Dr. Lefevre) that 5000 units would reduce postprocedural radial artery closure.

Since heparin is an acid, we give it intravenously. I have recommended for two years not to administer heparin before the guide wire is in the aortic arch in case one must cross over to the femoral; or in case one perforates the radial or brachial artery, even if the latter is very rare.

Today this unlikely event happened and, because there was no heparin on board, the patient did well without any forearm problems. Thus, it is strongly suggested, especially for beginners, not to administer heparin before reaching the aortic arch.

Alternatively, heparin can also be administered via a catheter into the aorta, if you do not want to give it intravenously.

Transradial procedures do not need to be limited to the arterial system. The forearm, as shown in Figure 1, has a rich supply of veins that can be used as conduits to the heart for pulmonary artery catheterization (1-4), temporary pacemaker placement, myocardial biopsy (5), and other transvenous procedures. The technique is analogous to, but usually easier than, arterial access.

For efficiency in the laboratory, intravenous (IV) access is obtained in the pre-procedural area by the staff and capped to allow later needle puncture in the cath lab. While the antecubital veins may be most available, more distal veins can also be used. Using ultrasound, one can even identify deep veins that can be used if superficial veins are not present.

In the catheterization laboratory a small amount of local anesthesia is applied to the entry site to prevent pain and the cap on the intravenous catheter is punctured with the access needle. The wire for the introducer sheath is passed up the vein, the IV catheter is removed, and a vascular sheat is inserted. The wire and dilator are then removed from the sheath and it is flushed with saline. There is usually no need for antispasmodic medication, although NTG would be the agent of choice.

When passing a catheter up from the forearm, there are two primary courses the venous system may take. Veins on the medial (ulnar) side tend to coalesce into the basilic vein that continues as the axillary and subclavian. This is a very straight course that can be traversed usually without fluoroscopy.

Access from the radial side and some medial veins will pass laterally along the upper arm forming the cephalic vein that will then enter the axillary vein to form the subclavian vein. This cephalic/axillary junction may form a 90-degree "T" junction and raise some challenge to catheter passage. Do not push here against resistance. Watch under fluoroscopy or take a brief venogram to define the anatomy. A deep breath may alter the anatomic shape and allow passage. If these simple measures do not work, placing a hydrophilic wire through the catheter typically allows passage up the axillary vein and into the subclavian.

Once the catheter has reached the subclavian, it can be manipulated into the central venous position or passed through the right heart out into the pulmonary artery similarly to that done with central venous catheters placed via the usual routes. One must remember to deflate flow-directing balloons before pulling back into the smaller caliper veins, but otherwise no special precautions are necessary. At the conclusion of the procedure, the vascular sheath is removed and a pressure dressing is applied. Haemostatic devices used on the radial artery are not needed in the case of the low-pressure venous system. Overall, this is a very simple procedure that can significantly broaden one’s potential radial skills.

References

1. Gilchrist IC, Moyer CD, Gascho JA. Trans-radial right and left heart catheterization: a comparison to traditional femoral approach. Cathet Cardiovasc Interv 2006;67:585-8.
   
   
2. Cheng NJ, Ho WC, Ko YH, et al. Percutaneous cardiac catheterization combining direct venipuncture of superficial forearm veins and transradial arterial approach - A Feasible Approach. Acta Cardiol Sin 2003;19:159-64.
   
   
3. Yang C-H, Guo B-F, Yip H-K, et al. Bilateral cardiac catheterization: The safety and feasibility of a superficial forearm venous and transradial arterial approach. International Heart Journal 2006;47:21-27.
   
   
4. Lo TSN, Buch AN, Hall IR, Hildick-Smith DJ, Nolan J. Percutaneous left and right heart catheterization in fully anticoagulated patients utilizing the radial artery and forearm vein: A two-center experience. Journal of Interventional Cardiology 2006;19:258-263.
   
   
5. Moyer CD, Gilchrist IC. Transradial bilateral-cardiac catheterization with endomyocardial biopsy: a feasibility study. Cathet Cardiovasc Interv 2005;64:134-137.

Coronary bifurcation lesions occur in approximately 15% of all interventional cases. One-stent technique with provisional side-branch stenting is the preferred strategy for daily practice. However, in selected patients, especially in a large side branch, jeopardizing a large amount of myocardium may require a double-stent strategy. 

From transradial approach to bifurcation lesions, we routinely use a 6F sheath and a 6F large-lumen guiding catheter, e.g. Launcher, Metronic. For provisional stenting, we insert guidewires in both the main vessel and the side branch. The main vessel is stented with jailing the side branch guidewire. The radio-opaque marker of the jailed guidewire should be away from the stent to avoid the breakage of the guidewire. If there is a suboptimal result of the side-branch, then kissing balloon inflations of the main vessel and side branch can be performed by using two high-pressure monorail balloons, e.g. Quantum Maverick, Boston Scientific. If there is dissection or a suboptimal result of the side branch after kissing balloon inflations, perform a T-stent or TAP (T and Protusion) strategy.

Beside T-stent or TAP, other double-stenting techniques using a 6F large-lumen guide are Cullote or modified Crush technique. For Cullote technique, insert a stent in the side-branch first. Then perform balloon inflation through the main vessel strut, followed by main vessel stenting and final kissing balloon inflations. For a modified crush-stenting technique, predilate the side-branch lesion first. Then stent the side branch with a high-pressure balloon in the main vessel. After removing the balloon and guidewire from the side branch, crush the side-branch stent with the main vessel balloon. Then stent the main vessel, followed by final kissing balloon inflation. Many operators, including myself, do a double- kissing inflation before placing the main vessel stent.

The radial artery has a mean diameter close to 2.9 mm (in France) which allows the use of 6F guiding catheters in the majority of cases (87% of cases), frequently 7F (76%), or even 8F. 

Nevertheless, 13% of vessels are too small for a 6F guiding (frequently in small women). In this case, it is still possible to use 5F guiding catheters; unfortunately, not compatible with a safe treatment of a bifurcation lesion. Sheathless catheters give a lumen of a 6F catheter with the external diameter close to 5F sheath; hydrophilic-guiding catheter allows slight oversizing of the catheter.

To perform safely a bifurcation stenting, a 6F lumen is big enough even for distal left main. Provisional side-branch (SB) stenting strategy is recognized today as the gold standard for treatment of bifurcation lesions after 6 randomized studies recently meta-analysed (Pan, Colombo, Nordic I and II, Bad Krozingen, Cactus, BBC One). This strategy consists in all types of bifurcation lesions (excepted Medina 0,0,1, the SB isolated ostial lesion) to insert 2 wires in the 2 branches, beginning with the most difficult branch in order to minimize the risk of twisting. The second step is normally a predilatation of the main branch, if necessary. We normally avoid predilating the SB. Then the main branch is stented across the SB with an adequate stent (maximal expansion and cell surface adapted to the treated vessel). A DES clearly reduces the risk of re-intervention. After stenting of the main vessel, the next steps are provisional: either the side branch is very small, patent, without pain and EKG change and the procedure is finished, or the SB is important and/or damaged and the two wires have to be exchanged to perform a kissing-balloon inflation. This kissing is performed with short balloons adapted to distal vessels in order to improve the results without stent distortion and also to give the proximal segment its own normal diameter. After kissing-balloon inflation when the result is poor in the SB (but take care angio and FFR are not giving the same results!)(BK. Koo study), a second stent can be deployed in the SB as a T stenting, Culotte, Internal Crush or TAP (T and Protrusion), followed by a new mandatory kissing-balloon inflation. This strategy is fully compatible with 6F transradial approach, even with 4 + 3.5 mm kissing balloon with some specific balloons (for example, Maverick). Recently it became possible to perform KB with non-compliant balloons through 6F (Hiryu balloons from Terumo). 

Some operators argue that in very complex lesions (those with a very long SB lesion) it is still necessary to perform complex techniques beginning with SB. Using the most recent comparison of techniques (randomised or not), we can say that the best are Culotte (beginning with MB or SB, better that Crush in Nordic II), double-kissing crush technique (or Sleeve, from Chen study), Minicrush (mini DK crush, from Galassi studies). 

Culotte technique and Crush technique have to be avoided when the angle between the two distal branches is widely opened. But don’t forget that the worst lesions can also be treated by elective T stenting technique beginning with the main branch. All these techniques can be performed through radial 6F approach! A classical Crush technique cannot!

In fact the only one technique which is not compatible with 6F, but can be performed with 7F (frequently possible transradially) is the SKS (simultaneous kissing stent, SK. Sharma). Nevertheless, this technique has not yet been randomly compared with other techniques in the same setting.

Why perform the transradial approach? Everyone knows! It is the preferred approach by patients (reduced bed rest, early ambulation, less vascular complications), by nurses (less patient care), by hospital directors, by insurance companies (outpatient coronary angiography and angioplasty are less expensive), and by doctors (fewer bleeding complications, fewer transfusions, and less mortality (MORTAL study).)

The concept of “Net Clinical Benefit” - efficacy minus safety - is now used widely in pharmaceutical trials.

This leads to a selection of treatments with the greatest clinical benefit for patients with coronary artery disease, whether we’re talking about stable angina, acute coronary syndrome, or acute myocardial infarction.

The same standard should be used throughout medicine, and specifically in the invasive approach to coronary artery disease, whether for diagnosis or treatment.

Focus on bleeding as a safety endpoint has been analyzed and shown to have a significant negative impact on patient outcomes, including an associated mortality that may greatly offset the initial proposed benefit.

The GRACE registry of coronary events, conducted between April 1999 and September 2002 in 94 hospitals, looked at 24,045 patients and found that the bleeding rate in patients treated invasively was 3.9%. (1) In an analysis of the OASIS Registry, OASIS-2, and CURE (N=34,146), John Eikelboom showed a strong mortality risk associated with bleeding; 2.5% without bleeding and a 5-times risk, or 12.5%, mortality with bleeding. (2)

In the ACUITY Trial, the mortality of those with a major bleed, rose from 1.2% to 7.3%. (3)  Recently, there has been much discussion about the Net Clinical Benefit of Prasugrel used in acute coronary syndrome as studied in the TRITON-TIMI 38 Trial, where the clinical benefit in the reduction of MACE and death and late stent thrombosis was offset by increased bleeding in certain populations. (4)

Radial access was first published by Dr. Campeau in 1989 in a study of the feasibility of this route to gain access to the coronaries for angiography. (5) Drs. Kiemeneij and Laarman followed in 1992 with the first reports of percutaneous intervention via the radial route. (6)

Since that time, there have been numerous reports documenting equivalence of outcome of the primary intervention, while at the same time having greater safety, mainly in the form of fewer access site complications. (7,8,9) This has led to discussion of patient preference, earlier ambulation, and lower cost. (10) These papers alone have not been enough to encourage much of the world to switch from the routine femoral approach to the radial approach, as there is a well- recognized learning curve, and it has not generally been perceived that the benefits were enough to have operators switch from femoral to radial.

Last year we published the British Columbia experience (11), involving over five years and 39,000 patients, of the difference that post- angioplasty transfusion had on mortality. The one-year mortality for those transfused was roughly 10 times that of the non-transfused. Mortality in transfused patients was 24% and the non-transfused mortality ranged between 2.5-3.5% (radial versus femoral). Importantly, however, access-site complications accounted for half of the total bleeds that needed to be transfused. 7,900 patients had a radial approach with a transfusion rate of 1.4 % versus 2.8%. This reduction of the need for transfusion by 50% therefore leads to a lower mortality on its own.

The concept of Net Clinical Benefit should apply to invasive procedures as well as medical studies. The efficacy of angioplasty is equivalent independent of access site, but the safety, when measured for mortality, is significantly greater using the radial approach.

The dictum “Physician Do No Harm,” from the Hippocratic Corpus thousands of years ago, is no less true today. There is now evidence of harm from the femoral approach that can be overcome simply by changing access site, and all physicians should endeavour to use this route whenever possible.

References

1. Moscucci M, Fox KA, Cannon CP, Klein W, López-Sendón J, Montalescot G, White K, Goldberg RJ. Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (Grace), Eur Heart J. 2003 Oct;24(20):1815-23.
   
   
2. Eikelboom JW, Mehta SR, Anand SS, Xie C, Fox KA, Yusuf S. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006 Aug 22;114(8):774-82.
   
   
3. Manoukian SV, Feit F, Mehran R, Voeltz MD, Ebrahimi R, Hamon M, Dangas GD, Lincoff AM, White HD, Moses JW, King SB 3rd, Ohman EM, Stone GW. Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes: an analysis from the ACUITY Trial. J Am Coll Cardiol. 2007 Mar 27;49(12):1362-8.
   
   
4. Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, Neumann FJ, Ardissino D, De Servi S, Murphy SA, Riesmeyer J, Weerakkody G, Gibson CM, Antman EM; TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007 Nov 15;357(20):2001-15.
   
   
5. Campeau, L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn. 1989 Jan;16(1):3-7.
   
   
6. Kiemeneij F, Laarman GJ, de Melker E. Transradial artery coronary angioplasty. Am Heart J. 1995 Jan;129(1):1-7.
   
   
7. Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol. 1997 May;29(6):1269-75.
   
   
8. Cantor WJ, Mahaffey KW, Huang Z, Das P, Gulba DC, Glezer S, Gallo R, Ducas J, Cohen M, Antman EM, Langer A, Kleiman NS, White HD, Chisholm RJ, Harrington RA, Ferguson JJ, Califf RM, Goodman SG. Bleeding complications in patients with acute coronary syndrome undergoing early invasive management can be reduced with radical access, smaller sheath sizes, and timely sheath removal; Catheter Cardiovascular Interv. 2007 Jan;69(1):73-83.
   
   
9. Yatskar L, Selzer F, Feit F, Cohen HA, Jacobs AK, Williams DO, Slater J. Access site hematoma requiring blood transfusion predicts mortality in patients undergoing percutaneous coronary intervention: data from the National Heart, Lung, and Blood Institute Dynamic Registry. Catheter Cardiovasc Interv. 2007 June 1;69(7):961-6.
   
   
10. Ziakas A, Klinke P, Fretz E, Mildenberger R, Williams MB, Siega AD, Kinloch RD, Hilton JD. Same-day discharge is preferred by the majority of patients undergoing radial PCI. J Invasive Cardiol. 2004 Oct;16(10):562-5.
    
    
11. Chase AJ, Fretz EB, Warburton WP, Klinke WP, Carere RG, Pi D, Berry B, Hilton JD. Association of the arterial access site at angioplasty with transfusion and mortality: the M.O.R.T.A.L. study (Mortality benefit Of Reduced Transfusion after percutaneous coronary intervention via the Arm or Leg). Heart. 2008 Aug;94(8):1019-25.

Our approach to renal and iliac procedures is to use the left radial artery. 

In all but the tallest patients, this allows for selective conflation of the renal artery with a standard length coronary guiding catheter and the use of balloons and stents with a 135 cm shaft.

We use a standard 6F glide sheath for radial access and, using a .035 exchange length guide wire, enter the descending aorta. 

If difficulty is encountered entering the descending aorta, a LAO projection and a hydrophic-coated glide wire make the passage easier. 

Once at the level of L1, the guide wire is removed and the catheter is vigorously aspirated to prevent injection of atherosclerotic material into the renal artery.

The renal arteries tend to be oriented from the aorta in a direction that allows easy cannulation with a standard right Judkins guide or a multipurpose guide catheter.  The support from the upper extremity is very good and allows for easy passage of balloons and stents into the renal artery.

A non-hydrophic .014 guide wire is used.  Avoid hydrophic wires since they can lead to wire perforations. The lesion is often pre-dilated with an undersized balloon to avoid dissection and to allow for easier expansion of the stent.

The 6 mm balloon-expandable stents can pass without difficulty through a 6F guide; 7 mm or greater require a 7F guide catheter or a 6F guide sheath.

Multiple views are needed at times to ensure adequate coverage of the renal artery ostium.  If the patient complains of any back pain, stop and deflate the balloon.

A quick test shot is performed to rule out perforation or dissection.  At the completion of stenting, the guide catheter is removed over a .035 J tip wire to avoid trauma to the descending aorta or subclavian system.

The left-sided approach avoids the need to cross the aortic arch and saves 10-12 cm of catheter length, thus allowing the guide to reach the renal artery.

Iliac interventions are done in a similar fashion from the left radial artery. 

An introducer sheath is placed in the artery to allow for passage of a diagnostic catheter into the descending aorta.  This is then changed over a .035 exchange length wire for 90 cm hydrophilic coated sheaths (Terumo destination) or, in taller patients, a 110 cm Cook sheath. 

The lesion in the iliac artery is crossed with a wire, .014 or .035, and the iliac stenosis is pre-dilated with an undersized balloon. 

We prefer a balloon-expandable stent when working in the ostium of the iliac vessels, but use a self-expanding stent elsewhere. 

Since the size of the iliac vessels will quickly taper at times, the use of a self-expanding stent allows us to match the size of the stent to the vessel’s proximal large end without fear of dissection in the smaller segment, since the radial force exerted by these stents is low. 

After stent deployment, a balloon dilation is often performed to optimize the results.  The catheter is withdrawn over a .035 guide wire and local pressure is applied.

The radial approach allows for rapid ambulation and same day discharge, and avoids the use of a closure device in a diseased vessel or manual compression over a site just stented. 

With current self-expanding stents, stents with diameters of 14 mm can be placed via a 6F sheath.  Using balloon-expandable stents, maximal diameters of 8 mm are possible.

In very tall patients, a 125 cm diagnostic multipurpose catheter can be placed via the introducer sheath into each iliac artery and selective studies can be performed. 

Radial artery occlusion (RAO) after transradial access (TRA) is one of the very few complications of TRA1. It has deterred some transfemoral operators from accepting TRA as their preferred access route.

The incidence of RAO ranges from 2-11% in the published literature. It is a thrombotic process that in a subset of patients leads to fibrotic occlusion. Administration of heparin has been shown to significantly reduce the incidence of RAO2, making heparin an integral part of the “radial cocktail.”

RAO is usually clinically quiescent and does not lead to limb-threatening ischemia. Pre-procedural confirmation of patency of palmar arches eliminates the clinical sequela of RAO.

MYTH: It is frequently argued that RAO is a reason not to use the radial artery as an access site. The truth is, RAO is not a frequently occurring complication and, with the new understanding of pathophysiology, its incidence can be further lowered to make it truly rare.

SUBSETS AT RISK: Patients with small-caliber radial arteries are at higher risk for RAO. Women, especially those with diabetes mellitus, tend to have a higher incidence of RAO. Heparin administration eliminates the predictive value of these demographic and morphologic variables, corroborating the fact that these patients are probably at higher risk for acute thrombotic occlusion after radial artery instrumentation. Occlusive pressure at the time of hemostatis is the most potent predictor of risk for RAO.

PREVENTION: RAO can be prevented by the administration of anticoagulation (heparin), with evidence suggesting a marked decrease (71% to 4%) in the incidence of RAO after administering 5000 units of heparin at the time of the procedure2. We have recently shown the efficacy of a “patent” hemostatic technique to further lower the incidence of RAO. These interventions do not increase hemorrhagic complications3.

TREATMENT: As RAO is almost always clinically quiescent, no active treatment is needed. The rare symptoms are from local thrombus that probably cause an inflammatory milieu, although limb-threatening ischemia after TRA has not been reported. If one encounters severe and unequivocal evidence of distal ischemia, surgical intervention should be considered. We have described a technique to reaccess the occluded radial artery to perform coronary procedures and have found a much lower incidence of reocclusion after the second procedure4. The reaccess technique may be used for symptomatic RAO patients.

TIPS:

• Always use heparin during TRA if the patient does not have an unusual bleeding risk.
• Use the smallest possible profile access sheath to complete the procedure.
• Use universal patent hemostatic techniques. 

1. Stella PR, Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. Incidence and outcome of radial artery occlusion following transradial artery coronary angioplasty. Cathet Cardiovasc Diagn. 1997 Feb;40(2):156-8.
2. Lefevre T, Thebault B, Spaulding C, Funck F, Chaveau M, Guillard N, Chalet Y, Bellorini M, Guerin F: Radial artery patency after percutaneous left radial artery approach for coronary angiography. The role of heparin.  Eur Heart J 16:293, 1995.
3. Pancholy S, Coppola J, Patel T, Roke-Thomas M.
   Prevention of Radial Artery Occlusion—Patent Hemostasis Evaluation Trial (PROPHET Study): A Randomized Comparison of Traditional Versus Patency Documented Hemostasis After Transradial Catheterization. Catheterization and Cardiovascular Interventions 2008:72:335–340.
4. Pancholy SB. Transradial access in an occluded radial artery: New Technique. J Invasive Cardiol.  2007 Dec; 19(12):541-4.