This document summarizes a study examining the use of transradial access (TRA) for non-coronary interventions in patients with severe hepatic dysfunction (MELD score ≥ 20). The study found TRA to be feasible in this high-risk population with a 100% technical success rate and very low rates of bleeding (0%) and access site (1 minor hematoma) complications. TRA in patients with liver dysfunction was shown to be safe and effective for renal/visceral interventions like embolization and stenting as well as radioembolization procedures, with few coagulation blood products required.

1. TRANSRADIAL ACCESS FOR NON-CORONARY
INTERVENTIONS IN PATIENTS WITH MARKED
HEPATIC DYSFUNCTION
Icahn School of Medicine at Mount Sinai
Division of Interventional Radiology
New York, NY
D . M . B I E D E R M A N , R P O S H A M , V. B I S H AY, R
J . J T I TA N O , R . S . PAT E L , E . K I M , G .
S I VA N A N T H A N , F. S . N O W A K O W S K I , N . E .
TA B O R I , R . A . L O O K S T E I N & A . M . F I S C H M A N

2. DISCLOSURES
 DM Biederman: Nothing to disclose
 R Posham: Nothing to disclose
 V Bishay: Nothing to disclose
 JJ Titano: Nothing to disclose
 RS Patel: Consultant, Sirtex Medical Ltd Research; Consultant, Arstasis, Inc
 E Kim: Consultant, Koninklijke Philips Electronics NV; Advisory Board, Onyx
Pharmaceuticals; Speaker’s Bureau, BTG International Inc
 FS Nowakowski: Nothing to disclose
 NE Tabori: Nothing to disclose
 RA Lookstein: Consultant, Bayer AG; Consultant, Johnson & Johnson; Consultant,
Boston Scientific Corporation
 AM Fischman: Consultant, Surefire Medical, Inc; Consultant, Terumo Corporation

3. MELD SCORE
Malinchoc, M., Kamath, P. S., Gordon, F. D., Peine, C. J., Rank, J., &
ter Borg, P. C. (2000). A model to predict poor survival in patients
undergoing transjugular intrahepatic portosystemic shunts. Hepatology,
31(4), 864-871. doi:10.1053/he.2000.5852
9.57 × ln 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 + 3.78 × ln 𝑏𝑖𝑙𝑖𝑟𝑢𝑏𝑖𝑛 + 1.12 × ln 𝐼𝑁𝑅 + 6.43
 UNOS – Liver Transplant Allocation
 TIPS
 Organ allocation
 MELD score in IR
 Oncology interventions
 Bridging to liver transplant
 Renal failure
 Active hemorrhage

4. INTERVENTIONAL ONCOLOGY

5. INTERVENTIONAL ONCOLOGY

6. INTERVENTIONAL ONCOLOGY

7. INTERVENTIONAL ONCOLOGY

8. INTERVENTIONAL ONCOLOGY
Y90 bead

9. PURPOSE
 Review our experience performing non-coronary
interventions using TRA in patients marked hepatic
dysfunction (MELD score ≥ 20).
Technical outcomes
Safety

10. STUDY DESIGN
 Outcomes
 Technical Success
 Major and Minor Bleeding Complications
 Major and Minor Access Site Complications
 Neurological Complications
All TRA cases 1/12 to 8/15
(n = 1,512)
MELD < 20 (n = 1,474) MELD ≥ 20 (n = 38)
Renal/Visceral (n = 16)
Chemoembolization (n = 10)
Radioembolization (n = 7)
Other (n = 5)
1. Sacks, D., et al., Society of Interventional Radiology Clinical Practice Guidelines.
Journal of Vascular and Interventional Radiology, 2003. 14(9): p. S199-S202.
2. Health, U.D.o. and H. Services, Common terminology criteria for adverse events
(CTCAE) version 4.0. National Institutes of Health, National Cancer Institute, 2009.
 Single Center Retrospective
Review
 Inclusion: MELD ≥ 20
 Exclusion: None

11. PATIENT DEMOGRAPHICS
Characteristic Value
Age (years) 57.7 ± 16.3
Sex
Male 25 (73.5)
Female 9 (26.5)
Kilograms 75.2 ± 18.7
Meters (m) 1.68 ± 0.11
BMI (kg/m2) 42.7 (41.4 – 44.9)

12. TRA PROCEDURE: BARBEAU TEST
No damping of pulse tracing immediately
after radial artery compression – 15%
Damping of pulse tracing – 75%
Loss of pulse tracing followed by recovery
of pulse tracing within 2 minutes – 5%
Loss of pulse tracing without
recovery within 2 minutes - 5%

13. TRA PROCEDURE: VESSEL ACCESS
 Hydrophilic sheath
 IA cocktail:
 3000 U Heparin
 2.5 mg Verapamil
 200 mcg Nitroglycerin

14. RESULTS Characteristic Value
Laboratory Values
Creatinine (mg/dL) 3.5 (1.5-5.2)
Bilirubin (mg/dL) 1.4 (0.4-4.7)
INR 1.5 (1.1-2.1)
MELD 22.5 (20 – 24)
Platelets ( x 109 /L) 95 (65 – 173)
Hemoglobin (g/dL) 10.1 ± 2.1
Hematocrit (%) 29.6 ± 7.7
Sheath Size
4-Fr 2 (5.3)
5-Fr 26 (68.4)
6-Fr 10 (26.3)
 Renal/Visceral (n =16)
 Renal embolization (n = 4)
 Renal stent (n = 2)
 Embolizations of the celiac, SMA,
GDA, inferior epigastric and
splenic arteries (n = 8)
 SMA stent (n = 1)
 GI bleed (n = 1)
 Radioembolization (n = 7)
 Mapping (n = 4)
 Treatment (n =3)
 Chemoembolization (n = 10)
Values represented as mean ± standard deviation and
median (interquartile range) as appropriate

15. RESULTS
 Technical Success
 100%
 Bleeding Complications
 None
 Access Site Complications
 1 (Grade 1 Hematoma)
 Neurological complications
 None

16. BLOOD PRODUCT TRANSFUSIONS
Blood Product Pre (1-10) days Day (0) Post (1-10 days)
RBC 12 (31.6) 7 (18.4) 7 (1.8)
Platelets 3 (7.9) 4 (10.2) 1 (2.6)
FFP/cryo 7 (18.4) 8 (21.1) 1 (2.6)
Numbers represent procedures for which blood products were
used. Percentages calculated with respect to total number of
procedures (n = 38)

17. CONCLUSIONS
 TRA in Patients with marked hepatic dysfunction
 Feasible with high technical success
 Safe
 Very low incidence of bleeding and access site complications
 Low number of coagulation blood products utilized to achieve results
(especially considering the study population)
 Limitations
 Retrospective
 Single center
 Small sample size