Radial Access

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Pre-Procedure Prep

Pre-Procedural Evaluation

• Evaluate circulation of ulnopalmar arch with modified Allen or Barbeau test
• Type D is only contraindication for radial access (some institutions forgo Barbeau test because of ulnar-palmar collateralisation)
• Is patient on dialysis or nearing dialysis and may need radial artery for potential access
• US to evaluate the size of the radial artery - 2 cm is reasonable minimal diameter

Left vs right radial artery
Left:
• Catheter will only cross left vertebral artery
• Extra working length of catheter
• Less chance of radial loop or difficult anatomy
Right:
• Can position arm by side which closely approximates femoral set up
• Helpful for neurointerventional procedures involving carotids or intracranial vasculature

Procedure Steps

Day of Procedure

• 30 mg of topical nitroglycerin to left wrist
• EMLA cream (lidocaine 2.5% and prilocaine 2.5%) to left wrist
• Apply 30 minutes prior to procedure and cover with tegaderm

Position

• Wrist extended with palm facing up
• Arm abducted vs adducted - operator preference
Access:
• 2 cm proximal to the radial styloid
• Puncture angle of ~ 30-45°
• Recommend a radial access kit: many products available.
• US guidance with single wall puncture using 21g needle
Insert 0.018" guidewire
Visualize wire with any signs of resistance
Important to use hydrophilic sheath - make sure sheath is wet to activate coating

Tips

• Dermatotomy typically unnecessary
• Do not overuse lidocaine. Can spasm radial artery
• Keep patient calm and room warm

Radial Cocktail

• Some operators do not use
• Many combinations of drugs: 2.5 mg verapamil, 200 µg of nitroglycerin, 3000 units heparin
• Hemodilution - draw up the radial cocktail in a 20 or 30 ml syringe and dilute the cocktail with arterial blood from recently placed sheath. Administer slowly during diastole.
• Consider securing sheath to wrist - can cut "X" in tegaderm and place over sheath

Post-Procedure

Key Concept

• Patent hemostasis (non-occlusive) minimizes risk of radial artery occlusion

Sheath Removal

• Radial compression device following procedure: many products
• Tip: partially removing sheath 1-2 cm and place gauze proximal to access site: will allow room for compression band and wick away oozing during sheath removal/band placement
• Slowly inject air into band (usually ~15 ml) while removing sheath - confirm no oozing
• Remove 1 ml of air incrementally until oozing at access site occurs
• Inject 1-2 ml of air
• Confirm radial pulse is present following compression band placement - evaluate waveform

Deflation Protocol

• Depends on patient, procedure and sheath size
• For routine procedure without anticoagulation and 5 Fr access sheath a reasonable protocol is as follows: begin deflation 30-60 minutes after band placement, remove 3 cc of air Q5 minutes until sheath deflated. If bleeding occurs during deflation, reinflate band with air until hemostasis achieved and restart deflation protocol in 20 minutes.
• Observe patient for 30 minutes before discharge
• Check pulse and site before discharge

Discharge Instructions

• No lifting above 2 lbs x 24 hours
• No strenuous activity x 24 hours
• Keep bandage on for at least 24 hours.
• Ok to shower, but do not submerge access site for 48 hours

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Radial Access Podcasts

 

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Transradial Access Podcast with Dr. Aaron Fischman

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Radial Access Articles

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Radial Access Demos

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Radial Access Tools

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Radial Access Literature

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Join The Discussion

References

[1] Scalise RFM, Salito AM, Polimeni A, et al. Radial Artery Access for Percutaneous Cardiovascular Interventions: Contemporary Insights and Novel Approaches. J Clin Med. 2019;8(10):1727. Published 2019 Oct 18. doi:10.3390/jcm8101727
[2] Ferrante G, Rao SV, Jüni P, et al. Radial Versus Femoral Access for Coronary Interventions Across the Entire Spectrum of Patients With Coronary Artery Disease: A Meta-Analysis of Randomized Trials. JACC Cardiovasc Interv. 2016;9(14):1419‐1434. doi:10.1016/j.jcin.2016.04.014
[3] Bishay VL, Biederman DM, Ward TJ, et al. Transradial Approach for Hepatic Radioembolization: Initial Results and Technique. AJR Am J Roentgenol. 2016;207(5):1112‐1121. doi:10.2214/AJR.15.15615
[4] Fischman AM, Swinburne NC, Patel RS. A Technical Guide Describing the Use of Transradial Access Technique for Endovascular Interventions. Tech Vasc Interv Radiol. 2015;18(2):58‐65. doi:10.1053/j.tvir.2015.04.002
[5] BackTable, LLC (Producer). (2018, April 4). Ep 26 – Radial vs. Femoral Access in IO Procedures [Audio podcast]. Retrieved from https://www.backtable.com/podcasts
[6] BackTable, LLC (Producer). (2018, June 27). Ep 30 – Transradial Access: Basic to Advanced [Audio podcast]. Retrieved from https://www.backtable.com/podcasts

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.