Radial Access 101 with Dr. Aaron Fischman

[Chris Beck]
… I'll tell you that in my practice I'm three years out, and when I first joined my group, there were some more senior IR guys in the group, who I'm their junior by like 10 years. First getting into the practice, being a junior guy, I don't know … I felt like the spotlight was on me to conform to their practice rather than go and turn everything upside down because I was definitely doing some things already very different from my partners. I shied away from radial access at first, but now I'm kind of starting to revisit it.

Getting your take on it and maybe some of the roadblocks and tips and tricks to troubleshoot those roadblocks would be helpful. I think like just for those who are either not as familiar with radial access, we'll just start with some of the basics, radial access 101. I guess it always starts with the patient evaluation. Will you take us through what that looks like?

[Aaron Fischman]
Yeah, absolutely. Before we go into that, I'll just say that you're absolutely right. It's very difficult, I think, when you're doing a newer type of procedure. I'll just give you an example, prostate embolization. If you're starting that practice, and then you're adding in something else new like radial access on top of that, it can be very challenging. One of the reasons that we were successful in adopting the transradial approach, as I mentioned before, is that we were already doing quite a bit of chemoembolization and that was the procedure that we chose to start with. We had such wealth of experience with that procedure from a femoral approach that it was the right procedure to try that on.

I always tell people that if you're doing a lot of something like interventional oncology, chemoembolization or Y90, or even fibroid embolization where you have a pretty busy practice, those are probably the procedures to start with.

[Chris Beck]
Yeah, maybe not. Maybe not off with your first prostate artery embolization?

[Aaron Fischman]
Yeah. Look, I obviously use radial access for that as well. Again, if you're not familiar with the radial approach, it may not be the best thing to start both at the same time. That being said, it really has a lot of advantages for that procedure in particular. Again, it's a complicated procedure in and of itself. To add something that you're not familiar with on top of that can be very challenging. I would caution people that are just starting out to start with things that they're very familiar with.

[Chris Beck]
Let me ask you this and you kind of touched on it. As far as ultrasounding both the ulnar artery and radial artery, are you looking for a size in general? I've heard some people in talks, and I don't do this routinely, but do you go all the way up the forearm checking for any radial loops? I'm assuming you're doing this on the table or maybe in clinic. Do you check for any loops up to the elbow?

[Aaron Fischman]
Well, we do a Barbeau exam, and I look at the pulses, and I check that in clinic when I see patients. Typically if I have my pulse oximeter in clinic with me I’ll document that in the medical record. If I’m in the room, my fellow or myself will check it again just to document it. And, yeah, we'll ultrasound as far up as we think we need to go. But to be honest, the incidence of radial loops is so low that I wouldn't say that’s something that comes up as much as people talk about. It's really important to understand the circulation and the Barbeau exam, but the radial loop is pretty rare.

You may know that somebody has a radial loop from a previous procedure, and if that's the case, you may not want to access the radial artery if you know that. However, there are a lot of techniques to do radial loop cannulation and access, but you just need to be aware that if there are other options, you may not consider that your first choice.

[Chris Beck]
Maybe just anecdotally, but as far as Barbeau type D or radial loops go, we talk about them all the time. These are really the exception, right?

[Aaron Fischman]
Most people say Barbeau D is around 1%. Radial loop is probably less than that in my experience. If you look at some of the literature, people talk about 1% for that as well, or 1-2%, but you just don't see it that much. Maybe you have a small loop, but you may not have a full loop. But a real radial loop is challenging, but 50%, 60%, 70% of the time you can get through it.