Minimizing Complications During Radial Access Procedures

[Chris Beck]
... Thinking about other things that can be a little, maybe daunting, about radial access is, we hear a lot about vasospasm. Miraculously, we're probably 30 minutes in and we haven't actually mentioned the radial cocktail obligatory. You want to talk about that a little bit here?

[Aaron Fischman]
Sure. The cocktail is something where everybody has a different one. People always ask about the cocktail we use. We talk about this when we do courses. It's pretty simple. We use heparin, nitroglycerin and verapamil. The doses are randomly picked, really, because when we first started doing this, I went on a website called Transradial University and I just looked at different cocktails that cardiologists were using at the time, and I really just picked something that I thought was easy for our nurses to draw up, and I knew that our verapamil came in 5 milligram vials. I said, "Why don't we just use half of that?” And then we use a little bit of nitro, around 200 nitro, then I use 3000 of heparin. You can use whatever you want to be honest.

I think using heparin is pretty important, and nitro I think is really important too. With verapamil, I know a lot of operators don't use a calcium channel blocker. There are cardiologists that instead of verapamil will use nicardipine. Definitely cost differences there. You have to look and see what's easier for you. You definitely need to use something. It's not like the femoral where you just put the catheter in. You really need to use something that vasodilates and tries to reduce vasospasm, because this vessel is not a big vessel. Even somebody who has a three millimeter radial, which for the radial is a big vessel, putting in a sheath is going to create a lot of vasospasm.

[Chris Beck]
Okay. Good tips. One of the things that also gets discussed by people who are not comfortable with radial access is a stroke. It's reported in the cardiology literature. Maybe talking about the literature a little bit, then also anecdotally, how you feel about that? Do you counsel your patients regarding it?

[Aaron Fischman]
Yeah. This is something that comes up almost every time you have a discussion about radial access in a meeting. It's not something to take lightly. There have been reports of stroke in the literature, and there are even reports that I've heard about outside of the literature that have not been reported, but people talk about it. Really what it comes down to is, yeah, we could look at the cardiology literature and compare right radial versus left radial, and femoral versus radial, but really doesn't apply to us because we're not really accessing the ascending aorta. We're accessing the descending aorta. The data from cardiology is not super relevant for us. The only vessel that we're crossing, really, from the radial approach is left vertebral.

If you remember that paper from Miami that looked at an 89-year-old gentleman who had a Y90 from the radial approach and had multiple catheter exchanges and developed the posterior fossa stroke. You have to wonder whether that was a good patient for radial access. The question is, "Well, should you screen people for a disease in their arch?" I don't do that typically, but I use common sense. If I know somebody who's elderly, and I know that they have a lot of atherosclerotic disease. Again, a lot of the patients that we're doing do not have that, right? Chemoembolization patients, fibroid patients … they're not always those with severe atherosclerotic disease. You have to think about that.

If you encounter somebody who you think might be in that category, you have to really think about whether radial access is the right way to go. Do I counsel patients? Absolutely. A great example would be a prostate embolization case. These are older men, right? They come in and they say, “Well, can you really reach from the wrist?" I said, "You can absolutely reach." And they said, "Well, why would anybody want to do it from the groin?" Then we have that discussion.

I tell them stroke is something that can happen regardless of the approach, but it could potentially be higher from the radial approach because we're crossing that one vessel. There are people who form femoral catheters in the arch. I would argue that if you're one of those types of operators that does that, you're probably creating more trauma to the arch than if you were doing a radial cannulation.

You have to think about your practice and what you do, but you always have to be vigilant when you remove the catheter. I always remove the catheter over a wire. I don't pull the catheter on a wire because I think that can also create trauma to the vertebral if you're not careful.