Initial transradial access (TRA) techniques in interventional radiology were limited by medical device availability, as many devices were adopted from those used by interventional cardiologists. As TRA has become a regular practice for interventional radiologists, equipment and devices have become increasingly versatile to encompass a wide variety of IR procedures. Radial access expert Dr. Aaron Fischman discusses his preferred TRA equipment including catheters, sheaths, and closure devices, that increase his success when using TRA.
The BackTable Brief
Ultrasound for TRA can improve first attempt rates and may decrease chances of complications; ultrasound is an absolute must for Dr. Fischman when accessing the radial artery.
Closure bands, such as the TR Band, should be used to achieve patent hemostasis instead of manual compression.
Always use a hydrophilic sheath within the radial artery, as it may minimize occlusions rates and make for easier removal during severe radial artery vasospasm.
Using a 110 cm catheter for cases requiring celiac or SMA access may be preferable over the 100 cm length; Dr. Fischman estimates that up to 20% of patients may need a longer catheter if initial attempts are made with the 100 cm length catheter.
Dr. Fischman recommends having the 150 cm microcatheter option available in addition to the 130 cm length, as the extra distance may be needed for radial access cases.
Disclaimer: The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Starting and Ending Procedures Successfully
There are a few techniques that can be done at the beginning and end of TRA procedures to set them up for success. Using ultrasound for vascular access is an absolute must, says Dr. Fischman, as it may decrease complication and occlusion rates. Achieving hemostasis of the radial artery at the end of the procedure is also critical. Dr. Fischman opts for closure bands over manual compression to achieve patent hemostasis.
[Chris Beck] Having seen the radial access practice mature, what are some of the things that you guys do now that maybe you weren't doing at first? I'm thinking things that have set me up for success on the front end. I'll do the EMLA cream with the Nitropaste for patients in pre-op. That to me has been helpful. Things like that, that people may find helpful when you're just getting started that you may not necessarily think about.
[Aaron Fischman] Well, this is something that is pretty obvious for us, but ultrasound access is an absolute must. Cardiologists really weren't doing that at the time. When you look at papers that look at complication rates, occlusion rates, a lot of that has to do with, in my view, not using ultrasound. That's always been our experience. I wouldn't ever recommend anybody to do this without ultrasound.
… Then using the right closure bands. Using manual compression on the radial artery I think is probably not the way to go. I know some people have done that, but in general, it's really not necessary. We have such good closure devices now for the radial artery that leave nothing in the vessel and allow you to get hemostasis without occluding the vessel. There really is no reason to do that with manual compression. But these are things that maybe come as second nature to us, but there are people that take shortcuts and I've seen a lot of operators that have not followed some of those principles and get problems.
What type of sheath should I use for radial artery access interventions?
Using a hydrophilic sheath for transradial access is critical for minimizing adverse outcomes. Non-hydrophilic sheaths are associated with increased occlusion rates and may complicate cases of radial artery vasospasm. If severe radial artery vasospasm occurs, a hydrophilic sheath will be easier to remove compared to a non-hydrophilic sheath.
[Aaron Fischman] You would never want to put in a non-hydrophilic sheath into the radial artery. That would be an absolute no, no. I know people have done that in the past, and if you look at the literature regarding hydrophilic sheets, you could get occlusion rates up to 20%, 30% using non-hydrophilic sheaths. That's a simple thing because we have that equipment now.
… There are the very rare cases where you have severe vasospasm. Number one is making sure you're using the hydrophilic sheath. That will come out even with severe vasospasm. We're talking about the one of the thousand type cases where the catheter sheath is really stuck.
What are the best catheters to use for radial access interventions?
Certain procedures may require different length catheters and microcatheters; have the right equipment available to navigate any patient’s anatomy. For interventions requiring access of the celiac trunk and SMA, Dr. Fischman recommends using a Sarah, Jacky, or Ultimate 110 cm catheter (instead of 100 cm), as up to 20% of patients require catheter length beyond 100 cm. A 125 cm or longer catheter is recommended for pelvic access. As for microcatheters, Dr. Fischman uses the 130 cm length, but recommends having the 150 cm option available as well.
[Aaron Fischman] Having the right equipment and knowing the catheters that you need if you're doing liver work, and making sure that you have the right length catheter. The catheters that I like for liver are typically the Sarah/Jacky Catheter, or the Ultimate Catheter. Those are really the best catheters and they weren’t really designed for our procedures, but they work really well. When you're going down to the pelvis, making sure that you have a 125 or longer catheter is critical. Having longer microcatheters is also critical.
[Chris Beck] Just to clarify, as far as celiac or SMA, or any liver-directed therapy, the Sarah/Jacky Catheters are 110 or, or maybe 130?
[Aaron Fischman] Yeah. Those come in 100 and 110, but I always use the 110 just just because I think, when we first started doing this, we were using the 100 centimeter Cobras which was described in that paper from Japan, but about 20% of patients needed longer catheters. If you have a 110 catheter, you're going to be able to access the Celiac in almost everybody. On top of that, you can take that 110 catheter and you can advance it, a lot of times, into the proper hepatic artery with the 110 length, which is super helpful when you're doing some distal embolization. 110 is really critical.
[Chris Beck] And then the microcatheter is 150 cm?
[Aaron Fischman] Yeah, you can do some things with the 130s, but in reality, if you're doing a radial case, you really should have a 150 available. If you don't have it, any of the companies will be able to get you the catheters if you ask. Almost everything now is available in 150 in addition to 130. That wasn't the case six, seven years ago. It was harder to get the 150 catheter. Now you can just get whatever you want in the 150, but it really wasn't so easy to just just all of a sudden say, "Hey, I need a 150 microcatheter." Not everybody had them back then.
---------- Podcast Participants:
Dr. Aaron Fischman is a practicing interventional radiologist at Mount Sinai Hospital New York.
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite this podcast:
BackTable, LLC (Producer). (2018, June 27). Ep 30 – Transradial Access: Basic to Advanced [Audio podcast]. Retrieved from http://www.backtable.com/podcasts
The Materials available on the BackTable Blog 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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.