Updated: Mar 11, 2019
Trans-radial access can provide distinct advantages over a femoral approach in oncologic embolization cases, but many interventional radiologists still find the ergonomics of radial access to be awkward and even uncomfortable. To help bridge the gap, Dr. Jason Iannuccilli talks through his cath lab layout, how he positions his patient’s arm, and the tricks he uses to be successful with radial access.
The BackTable Brief
There are a variety of techniques that are used to achieve radial access: the patient’s arm may be folded in parallel to the patient’s body, extended to be perpendicular, or extended above the head depending on the procedure being performed and the preference of the operator.
Working at the radial access site can be made easier with a table and layout that complements the workspace around the patient’s arm.
Some interventional radiologists work in cath labs with fixed monitors, causing discomfort when working from the radial access site. The flexible positioning of a slave monitor can provide a more comfortable configuration than fixed monitors.
Learn more about the unique advantages of radial access in our previous article.
Disclaimer: The opinions expressed by the participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Positioning Your Patient’s Arm For Radial Access
So my question, whenever you guys were switching over, making the jump or slowly easing over to radial access … how do you have the room set up where the monitors are and the patient's arm is?
So the answer to that question depends on whether or not we want the capability of performing a 3D sort of XperCT during the case. We initially always start off with the right arm down by the patient's side, the left arm that we access off a little less than 90 degrees. We found that when patients are extended to 90 degrees it's a little more uncomfortable for them so it's probably something like 70 degrees. The arm is fixed to the arm board, more or less the sort of metatarsophalangeal junction of the hand is sort of wrapped and secured down to the board. And then the wrist itself is prepped and exposed. We will actually lay a table out along the length of that arm board so that we have at least a little bit of a support structure for our flush lines and everything that needs to be essentially level and not tugging once that sheath access is in place within the radial artery….
If we're doing 3D reformats or we're doing an XperCT we will actually, with the catheter in place, move the patient's arm. We'll move it up, believe it or not, we'll take the arm and we will extend it up so that the arms are sort of like as if you were putting your hands behind your head, they're sort of held in an angle. And we found that the catheter, it doesn't move all that much. We have to keep an eye on it while we're adjusting and we do it delicately, but by doing that we're able to get the II to actually do the correct spin either in propeller format or in a roll format to get the 3D information we need.
But there are various methods that are used out there in practice. I mean some people are using radial arm boards that go alongside the patient the entire time. So they'll access the radial artery and then they'll fold the arm in and keep it in parallel to the body and either reach over the body so they're working from the patient's right side or they'll stand on the ipsilateral side and work from there.
Positioning Your Equipment To Work From Your Radial Access Point
What we found is that table height is a consideration. We've sort of prepped our side table that's adjacent to the hand so that we take one of those kind of blue guide wire bowls, flip it over and put it underneath the sterile drape to create a little bit of a pedestal so everything is more or less flush and level. And then there is another table that we put at 90 degrees to that first table just slightly down toward the patient's feet. So it sort of forms like a little alcove that we stand in: we've got the patient to the left, another table to the right, and immediately in front of us we have the outstretched arm with the access.
Working With Your Monitors During Radial Access
...So whenever we do radial access we do have the arm out, like you said maybe not at 90 degrees, that's a bit of a stretch for the patient, but then my situation is always what to do with my monitors. For whatever reason, it may be other rooms are different around the country, [our monitor setup is] very much geared towards the monitors [having] to be on the other side of the patient that you're working on. If I have the arm abducted to get the monitors in front of me...I still have to turn my head over my left shoulder to see the monitors. Is that what you're also doing, Jason? Or are you working off of a slave monitor?
...So one of our rooms has that identical setup that you're saying where we kind of have to pull the monitor up as close to the patient's head as we can but it's still off to the left. So as you're working you can position your body so that you're working on the patient's wrist but you're more or less directing your body at a mid point between the monitor and the wrist so you're not craning your neck as much during the procedure. It's a little bit of a pain and to be honest with you, it's not as nice as our other room where we have a slave monitor. The slave monitor is nice because you can just wheel it over and put it right in front of you where you're working and you're standing on the other side of the wrist and just looking straight at the monitor.
So two different ways we do it. I prefer the slave but I've learned to cope with doing it the other way. I don't have any neck problems yet.
 A Technical Guide Describing the Use of Transradial Access Technique for Endovascular Interventions: https://www.techvir.com/article/S1089-2516(15)00022-0/fulltext
 Transradial Versus Transfemoral Arterial Access in Liver Cancer Embolization: Randomized Trial to Assess Patient Satisfaction: https://www.jvir.org/article/S1051-0443(17)30828-X/fulltext
Dr. Jason Iannuccilli is a practicing interventional radiologist with Rhode Island Medical Imaging.
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Dr. Michael Barraza is a practicing interventional radiologist with Radiology Alliance in Nashville.
Cite this podcast:
BackTable, LLC (Producer). (2018, April 4). Ep 26 – Radial vs. Femoral Access in IO Procedures [Audio podcast]. Retrieved from https://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 podcast referenced in this article was sponsored by Surefire Medical.