arterial access of the upper limb for angiography

1. Dr. Ameel Toma
Cardiology department
23/11/19

2. Trans-radial approach:
Advantages:
 TRA is more easily compressible, minimizing
hematoma risk,
 Lower crossover rates to another access.
 Patients may ambulate immediately after procedure.
 Hospitalization can be shortened significantly

3. TRA has its own limitations:
 Small diameter, arterial spasm, tortuosity, anatomic
variation
 longer learning curve for junior operators.
 asymptomatic radial artery occlusion(4-10%).
 Access crossover rate(5-10%)
 Unsuitable additional 10 %
 In addition, an occluded radial artery restricts future
cardiac catheterization,bypass grafts, and dialysis
fistulae.

4. Trans-ulnar artery:
Q- Is ulnar artery larger diameter than radial artery?

6. Trans-ulnar artery access:
 Palm is secured in a supinated hyperextended position
similar to the TRA procedure.
 Cannulation failure results from an inability to palpate
or access the ulnar artery or difficulty in initially
advancing the wire, despite adequate blood flow.
 Hyperextension of the wrist is crucial for a successful
procedure because it stabilizes the wrist.

7. Complications:
The combined complication rate of TUA does not exceed
10%, and most complications are mild and similar to
those encountered with TRA.
-Ulnar artery occlusion(usually asymptomatic).
- Hematoma, bleeding
- arterial spasm
- ulnar nerve injury.

8. Ipsilateral radial and ulnar artery cannulation during the
same coronary
catheterization procedure

9. Axillary and Brachial access:
The indications for brachial and axillary access are quite
similar to those of the radial approach:
 occluded or severely diseased aortoiliac segment,
 Operator preference in visceral artery interventions
 when working with stent grafts requiring multiple
accesses or larger diameter sheath .
 infected/excoriated inguinal regions
 severely obese patients

10. Trans-brachial artery access:
 Many interventional cardiologists considered that TBA
is outdated and risky access.
 It has been demonstrated significantly higher rate of
vascular and neurological complications than other
access
 Adequate manual compression is difficult to perform
on limited underlying bone surface.

11. Procedure of Brachial Artery
Punctures:
 A 2% xylocaine solution is injected subdermally just
above the crease in the elbow region where the
brachial pulsation is best palpated
 Using the modified Seldinger technique or
 single puncture technique
 Catheters were used according to operator preference

12.  At the end of the procedure, the arterial sheath was
removed and direct digital pressure was applied to the
brachial artery for a minimum of 10 minutes in order
to achieve haemostasis
 further local compression was applied to the brachial
artery using an elastic bandage

13. Complication:
 5-10 %
 Thrombosis
 Median nerve injury

15. Axillary artery access:
 The axillary artery has emerged as a feasible and safe
alternative access for delivering large bore sheaths in
TAVR or MCS.
 Although smaller than the common femoral artery, the
axillary arteries demonstrated substantially lower rates
of stenosis and of calcification compared with the ilio-
femoral arteries.

18.  the axillary artery should be accessed between the
second and third portion at the lateral border of the
pectoralis minor muscle.
 This is clinically important because it is associated
with the lowest chance of causing brachial plexus
injury, does not invade the chest and thus reduces the
chance of a pneumothorax,
 is manually compressible for hemostatic purposes.

19. Additional assistance:
 Ultra-sound guidance
 Angiography from same ipsilateral radial
 Guide wire itroduced from femoral approach into
subclavian artery.

20. Points to consider:
 The less puncture attempts, the better.
 Lowest profile material and less manipulation.
 Motor and sensory symptoms in hand may be delayed,
even out to 15 days after the procedure.
 Surgical backup is usually necessary.

21. Interesting approach:
distal radial artery approach(DRA):
-- artery is superficial
-- lie on bone, more easy to control hemostasis
-- may preserve the radial pulse at the wrist,so low risk
of hand ischemia

22. Disadvantage:
it is smaller than RA
 May difficult to access
 More spasm high rate of occlusion

24.  Height >188 cm
 Routine use of 5 French (Fr) sheath and 5 Fr catheters

26. Arterial diameter