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BackTable / VI / Topic / Procedure
Radial Access
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BackTable is a knowledge resource for physicians by physicians. Get practical advice on Radial Access and how to build your practice by listening to the BackTable VI Podcast, reading exclusing BackTable Articles, and following the work of our Contributors.
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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 mm 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
Radial Access Podcasts
Listen to leading physicians discuss radial access on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.
Episode #428
In this episode of the BackTable Podcast, host Dr. Michael Barraza interviews guest Dr. Marcelo Guimaraes about the advantages and implementation of radial access in interventional radiology. Dr. Guimaraes is a vascular and interventional radiologist from the Medical University of South Carolina (MUSC).
Episode #395
In this episode of the BackTable Podcast, host Dr. Aaron Fritts and Dr. Sameh Sayfo discuss radial to peripheral interventions, also known as R2P. Dr. Sayfo is an interventional cardiologist and the program director of the endovascular fellowship at Baylor Heart Hospital in Plano, Texas.
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
Radial Access Articles
Read our exclusive BackTable VI Articles for quick insights on radial access, provided by physicians for physicians.
Transradial access (TRA) has been shown to improve discharge and recovery times when compared to transfemoral access, though complications may arise. TRA expert Dr. Aaron Fischman discusses complications related to radial access as well as ways to circumvent these problems in episode 30 of the BackTable podcast.
As TRA has become a regular practice for IRs, equipment and devices have become increasingly versatile to encompass a wide variety of IR procedures. Radial access expert Dr. Aaron Fischman discusses his prefered TRA equipment including catheters, sheaths, and closure devices, that increase his success when using TRA.
For many interventional oncologists, the decision to go femoral or radial is often a matter of prior experience and comfort with the technique. In our recent podcast, Dr. Jason Iannuccilli, Dr. Chris Beck, and Dr. Michael Barraza provide rationale on their preferred access method in oncologic embolization procedures, covering the pros and cons of both approaches, and the distinct advantages that radial access may provide. We’ve provided the highlight reel and some insightful quotes from our IR
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
Radial Access Demos
Watch video walkthroughs of radial access on the BackTable VI expanded content network.
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/shows/vi
[6] BackTable, LLC (Producer). (2018, June 27). Ep 30 – Transradial Access: Basic to Advanced [Audio podcast]. Retrieved from https://www.backtable.com/shows/vi
Disclaimer: The Materials available on https://www.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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
Minimizing Complications During Radial Access Procedures
Radial Closure Devices
Choosing the Right Equipment for Radial Access Success
Contributors
Dr. Aaron Fischman
Dr. Jason Iannuccilli
Dr. Sameh Sayfo
Dr. Rami Tadros