This document provides guidance on starting a successful transradial cardiac catheterization program. It discusses how the author started their program during fellowship by attending courses and enrolling patients in clinical trials. It highlights advantages of transradial access such as reduced access complications, earlier ambulation, and improved patient comfort. The document also reviews data demonstrating reduced bleeding and improved outcomes with transradial compared to transfemoral access. Overall, it presents a case for transradial access and provides tips for establishing a successful transradial program.

1. How to Start a Successful
Transradial Program
Mauricio G. Cohen, MD, FACC
Associate Professor of Medicine
Director, Cardiac Cath Lab

2. How did I start?
Exposure during fellowship
Attended a course
Became a PI in a trial enrolling pts > 275 lbs.
KILO trial (Kinetics of Integrilin Limited by Obesity)
Very bad outcome with a VCD
Infected pseudoaneurysm in a diabetic despite
prophylactic antibiotics
I have not used a closure device in 7 years
Agostoni P et al. JACC 2004;;44:349-­56

3. How did I start?
Learning curve
Start with obese patients
Obese pts referred for cath are usually younger
Larger radial arteries
Less subclavian tortuosity
Teach the staff and highlight the advantages of TRI
No groins to hold. Less access-related complications
Better patient comfort No back pain, bedpans or urinals
They will become your biggest fans
Megamorbid obese, severe PAD (no femoral access), on oral
anticoagulation
Develop referrals and recognition from other angiographers
Become a better angiographer Understand the anatomy and
catheter manipulation

4. NCDR-­Cath PCI Registry
TRI Trends at a Single Center One Operator
11 10
15
25
47
57
53
0
20
40
60
Q
3
2006Q
4
2006Q
1
2007Q
2
2007Q
3
2007Q
4
2007Q
1
2008
Patients(n)
2.8 2.3
3.1
5.9
9.7
13.5
10.9
0
5
10
15
Q
3
2006Q
4
2006Q
1
2007Q
2
2007Q
3
2007Q
4
2007Q
1
2008
Patients(%)
Q2 2007 Q1 2008:
UNC: 10.9% (182 cases)
Like Hospitals: 1.9%
Nationwide: 1.3%

7. ACUITY Access
450 centers in 17 countries
0
10
20
30
40
50
60
70
80
90
100
N
orw
ay
France
Sw
eden
U
K
Finland
D
enm
ark
Italy
C
anada
Spain
N
Z
B
elgium
G
erm
any
U
SA
A
ustralia
% of Radial & Femoral access per country
Radial (798) Femoral (11,988)
Hamon M et al. EuroIntervention 2009;;5:115-­20

8. Rao, S. V. et al. J Am Coll Cardiol Intv 2008;1:379-386
CATH-PCI Registry: Trend in the Use of
radial PCI Over Time in Key Subgroups
n=593,094
Radial access: 1.32%

9. Rao, S. V. et al. J Am Coll Cardiol Intv 2008;1:379-386
CATH-PCI Registry: Proportion of PCI Cases
Performed Via the Radial Artery
UNC
BMC2: <1% use of TRA in Michigan

10. Transfemoral Advantages
Long history and technically easy to perform
Facilitates the use of larger catheters
Early sheath removal with using closure
devices
However, closure device complication rates are
not lower than manual compression in some
series
Add significant cost to cath lab budget

11. Transfemoral Disadvantages
Prolonged bedrest (usually about 4 hrs)
Associated with more back pain, urinary
retention, and neuropathy
Bleeding (including retroperitoneal
hemorrhage)
Increased incidence of other vascular
complications
Vascular closure devices allows earlier
ambulation but do not decrease vascular
complications

12. Bleeding and Outcomes: 4 RCTs
Rao SV, et al. Am J Cardiol 2005; 96:1200-6
Kaplan Meier Curves for 30-Day Death, Stratified by Bleed Severity
n = 26,452
log rank p-value for all four categories <0.0001
log-rank p-value for no bleeding vs. mild bleeding = 0.02
log-rank p-value for mild vs. moderate bleeding <0.0001
log-rank p-value for moderate vs. severe <0.001
0.7
0.75
0.8
0.85
0.9
0.95
1
0 5 10 15 20 25 30Days to Death
None
Mild (16.6%)
Moderate (9.8%)
Severe (1.2%)

13. Transfusion in ACS
30 Day Survival By Transfusion Group
0.9
0.92
0.94
0.96
0.98
1
0 5 10 15 20 25 30 35
Days
SurvivalRates
No Transfusion
Transfusion
Rao SV, et. al., JAMA 2004;;292:1555-­1562

14. Major Bleeding: Day 30
Days
CumulativeHazard
0.00.010.020.030.040.05
0 3 6 9 12 15 18 21 24 27 30
HR 0.63HR 0.62
95% CI 0.5595% CI 0.54--0.730.72
P<0.001
Enoxaparin
Fondaparinux
Oasis 5 Investigators, N Engl J Med 2006;;354:1464-­76

15. Mortality: Day 30
Days
CumulativeHazard
0.00.010.020.03
0 3 6 9 12 15 18 21 24 27 30
HR 0.83HR 0.83
95% CI 0.7195% CI 0.71 --0.970.97
P=0.02
Enoxaparin
Fondaparinux
Oasis 5 Investigators, N Engl J Med 2006;;354:1464-­76

16. The Longer the Sheath Stays In,
the Higher the Risk of Bleeding
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
0 4 8 12 16 20 24
Time to Sheath Removal (hours)
AdjustedProbabilityofTransfusion
p < 0.001
Cantor WJ, et al. Sinergy Trial Subanalysis. CCI 2007;; 69:73 83

17. Bleeding in PCI patients
TIMI Major 588 (5.4%)
Hemorrhagic strokes 15
Gastrointestinal 63
Retroperitoneal 30
Hematoma 370
TIMI minor 1394 (12.7%)
Gastrointestinal 88
Retroperitoneal 11
Hematoma 823
Transfusion (5.4%)
None 8992 (81.9%)
Kinnaird et al. Am J Cardiol 2003
68%
60%

18. Vascular Access

19. Vascular Complications
Gurm HS et al. Circulation 2009;;120:S423
n=132,687
2003-2008

20. Vascular Closure Devices
Not a Solution
Some of these complications are additive
to those seen with manual compression
Embolization
Infection
Vessel Obstruction
Direct Mechanical
Injection into vessel
Bleeding
Mechanical secondary
to device
Secondary to early
sheath pull

21. Vascular Closure Devices
Cleveland Clinic Experience
Variables Manual Angio-­Seal Perclose p
n=2,099 n=411 n=408
Hematoma > 5 cm 1.4% 1.5% 1.0% 0.8
A-­V fistula 0.7% 0% 0.2% 0.13
Pseudoaneurysm 0.9% 0.5% 0.7% 0.29
Retroperitoneal Bleed 0.1% 1.0% 0.8% 0.01
Transfusion 0.8% 1.2% 1.7% 0.16
Vasc Occlusion 0.3% 0.2% 0% 0.49
Site infection 0% 0% 0.5% 0.25
Vasc Surgery 0.4% 0.2% 1.0% 0.25
All 3.1% 2.9% 3.2% 0.96
Cura FA, et al. Am J Cardiol 2001;;87:504
January 1998 -­ April 1999

22. Sometimes Femoral Access may not be
Possible for Miscellaneous Reasons

25. Why Radial? Look at the Anatomy
Anatomic Features Clinical Consequences
Flat bony prominence of the radius Ease of compression
Collateralization of the radial artery Absence of Ischemia
Puncture not over joint Motion does not increase risk
No major adjacent nerve No neurologic sequellae

28. Why Radial? The Advantages
Decreased incidence of major access
complications
Decreased access-related bleeding
Immediate sheath removal
Superficial location and easy hemostasis
(ideal for obese patients)
Decreased time to ambulation
Decreased post-procedural cost
Improved patient mobility

29. NCDR Cath PCI Registry
95.5
0.2 0.8
94.7
0.7 1.8
0.0
25.0
50.0
75.0
100.0
Procedure
success
Vascular
Complication
Bleeding
Complication
Patients(%)
Rao SV et al. JACC Interventions 2008;;1:379-­386
Adj OR 1.02 (0.92 1.12) 0.42 (0.31 0.56)
n=593,094
Radial access: 7,804 (1.32%)

30. M.O.R.T.A.L. Study
British Columbia Registry
n=38,872 (radial 7,972;; femoral 30,900)
Adjusted OR 1-yr Mortality
Chase A. Heart 2008;94:1019 1025

31. Radial vs. Femoral Meta-Analysis
Access Failure
Jolly SS et al. Am Heart J 2009;;157:132-­40
23 Trials, n=7,020 1980 to 2008

32. Radial vs. Femoral Meta-Analysis
Major Bleeding
Jolly SS et al. Am Heart J 2009;;157:132-­40
23 Trials, n=7,020 1980 to 2008
transfusion, or requiring surgery

33. Radial vs. Femoral Meta-Analysis
Death, MI, or Stroke
Jolly SS et al. Am Heart J 2009;;157:132-­40
23 Trials, n=7,020 1980 to 2008

34. ACUITY: Radial Substudy
10.5%
8.1%
3.0%
4.8%
11.2%
7.5%
Net clinical
outcome
Ischemic
composite
Major bleeding
30dayevents(%)
Radial (n=798) Femoral (n=11,989)
Radial vs. Femoral
HR 0.97 [0.76-1.23]
p=0.78
HR 1.20 [0.92-1.58]
p=0.18
HR 0.61 [0.40-0.94]
p=0.03
Hamon et al. Eurointervention 2009;;5:115-­120

35. ACUITY: Radial Substudy
6.9%
2.2%
7.1%
5.8% 5.4%
3.0%
7.7%
8.6%
2.7%
4.2%
9.1%
7.7%
Ischemic
composite
Major bleeding Ischemic
composite
Major bleeding
30dayevents(%)
Heparin+GPI Bivalirudin + GPI Bivalirudin
Study Endpoints According to Access Site
p=0.35 p=0.19 p=0.29
Hamon et al. Eurointervention 2009;;5:115-­120
p<0.0001
Radial Access Femoral Access

36. Monitoring Anticoagulation in PCI:
Overview of 6 RCTs
Chew DP. Circulation 2001;103:961
10.1
11.1
8.6 8.9
6.6
7.5 7.7
9.8
16.9
12.4
8.6
9.9
12.4
13.7
12.4
16.3
N = 5216
ACT and Clinical Outcome among pts on UFH alone:
Best target 350-375 s?
n=5,216; 1992-1998

37. Should the ACT Target Change with TRA?
EASY Trial
0.1 1 10 100
BMI > 30
Unstable
angina
ACT > 330
sec
No angio
success
Compromised
sidebranch
TIMI < 3 post-
stent
P value
0.045
0.0021
0.024
0.019
<0.0001
0.048
33
2
30
1
22
0.7
0
10
20
30
40
TnT > 0.1
ng/ml
Bleeding
(Replace-2)
%ofPatients
<291
291-330
>330
Bertrand OF et al. Am J Cardiol 2009;104:1235 40
p=0.0040
p=0.20
ACT
n=1,234
Independent Predictors of MI

38. Procedure-Specific Measures of
Quality of Life
Cooper CJ et al. Am Heart J 1999;;138:430-­6
n=200
Measured on 0-­10 visual analog scales at 1 week after catheterization

39. Economics of Radial Access
Vascular complication
Prolonged hospital stay (~ 3 days)
Incremental cost: $6,400
Bleeding complication (Incremental cost)
GUSTO IIb
Mild/severe bleed $3,770
Transfusion $2,080
REPLACE-2
Major bleed $6,300
Diagnostic Cath
Radial Access saves $290 per case
Driven by lower nursing utilization and pharmacy costs
Nursing Workload
Femoral: 174 [134 218] min
Radial: 86 [58 126] min, ( p <0.001)
Kugelmass AD et al. Am J Cardiol 2006;;97:322-­7
Rao SV et al. Am Heart J 2008;;155:369-­74
Cohen DJ, et al. J Am Coll Cardiol 2004;;44:1792-­800
Cooper CJ et al. Am Heart J 1999;;138:430-­6
Amoroso G et al. Eur J Cardiovasc Nurs 2005;;4:234-­41

40. Why Radial? The Disadvantages
Catheter manipulation needed for coronary
cannulation
Learning curve ~ 100 cases
Failure to reach the ascending aorta
Vascular anomalies
Elderly hypertensive patients may have increased
tortuosity of the radial and subclavian arteries
Limited compatibility with larger (>2.0mm)
Rotablator burrs or other large devices

41. Learning Curve
<80 Patients >80 Patients
Access failure 14% 2%
Sheath insertion time 10.2 ± 7.6 min 2.8 ± 2.5 min
Procedure time 25.7 ± 12.9 min 17.4 ± 4.7 min
Spaulding et al. Cathet Cardiovasc Diagn 39:365-­70, 1996

42. Radiation: RAPTOR Trial
Dose Area Product Radiation Time
Femoral Radial p Femoral Radial p
Diagnostic 22.6 15 29.7 16 <0.01 4.4 5 6.4 5 <0.01
PCI RCA 27.1 19 27.8 23 0.5 8.6 8 6.4 5 0.7
PCI LCA 31.9 31 25.1 17 0.5 5.2 3 7 4 0.8
Schäufele TG et al. LBCT AHA 2009

43. New Guiding Catheter Technologies
Hydrophylic Sheathless Catheters
- 7.5 Fr Catheter: OD < 6 Fr Sheath
- 6.5 Fr Catheter: OD < 5 Fr Sheath
Mamas MA et al, CCI 2008;;72:357 364
Catheter external diameter: 2.49mm
6F Sheath external diameter: 2.62 mm

44. Contraindications?
There is only one contraindication
Abnormal Allen test
However, it is now questioned by some operators
No reports of hand ischemia/necrosis in more than 20
years
Most reports from critical care and anesthesiology
literature
Harvesting radial arteries for CABG is safe
Need for right heart catheterization is not an
excuse for not using the radial approach
RHC can be performed via the antecubital vein
(using a 5F 110 cm balloon-tipped catheter)

45. Variations of the
Superficial Palmar Arch
A. Typical radioulnar communication
(35%).
B. Formation of complete arch by the
ulnar artery (39%).
C. Completion of arch by ulnar and
median arteries (4%).
D. Joining of ulnar, median, and
superficial branches of the radial artery
(1%).
E. Incomplete arch; formation of the
proper digital arteries by the radial and
ulnar arteries without communication
between the radial and ulnar arteries
superficially (16%).
F. Contribution of ulnar, median, and
superficial branches of the radial artery
to the digital vessels, without
communication between the branches
at the superficial level (5%).

46. Oxymetry + Plethysmography

47. Oxymetry + Plethysmography
No damping of pulse tracing
immediately after radial artery
compression
Damping of pulse tracing
Loss of pulse tracing followed
by recovery of pulse tracing
within 2 minutes
Loss of pulse tracing without
recovery within 2 minutes.
The clamp sensor is applied to the thumb
Barbeau et al. Am Heart J 2004;;147:489 93
15%
75%
5%
5%

49. Right Heart Catheterization
via Antecubital Vein

50. Right Heart Catheterization
via Antecubital Vein

52. Rules
Radial is Different than Femoral
Precise puncture & never push (finesse over muscle)
Prophylactic antispasm medication is needed
Verapamil 3 mg
Anticoagulate to prevent (reduce) thrombosis
Heparin~5,000 U (50-70 U/Kg in lighter patients)
Hold on to hard won territory (exchange wire or jet-
catheter exchange technique)
Find a catheter series that works best for you
(practice makes perfect)
Remove the sheath at the end of the case

53. Hand Ischemia
Secondary to Radial Cath?

54. Lee KL et al. J Hand Surg [Br] 1995;; 20:493-­495
Wallach SG. Am J Crit Care. 2004;;13: 315-­319
Hand Ischemia Following Radial
Artery Cannulation

55. Radial Access may be Challenging!!
Significant Subclavian Tortuosity

56. Radial Loop

57. Radial Loop

58. Radial Loop

59. Radial Loop

60. Brachial Tortuosity

61. Brachial Tortuosity

62. Brachial Tortuosity

66. Forearm Hematoma

67. Challenging Anatomy

69. Perforation
Early recognition
Wrap potential bleeding
site
If seen on angiogram
If wire pushed too hard
Okay to wrap and finish
case
Forearm swelling not
related to hemostasis
device at any time,
consider wrap with elastic
bandage
Monitor for Compartment Syndrome
Elastoplast ® or
ACE ® bandage

70. Radial Spasm
Dieter RS et al. Catheter Cardiovasc Interv 2003;58:478-80

71. Prevention of Spasm
Multiple local agents used according to
Verapamil: 3 mg (caution with low EF patients)
Patient will complain of burning in the hand
Nitroglycerin Intra-arterial or Sublingual
Papaverine
Nicardipine
Sedation
Anxious patients have increased adrenergic tone
that can contribute to spasm
Switch to a 5F catheter
Look for anatomic variation (high radial origin from
the brachial artery)

72. Consider Ulnar Access in Selected
Cases

73. Radial Access Site Inflammation

74. Sterile Inflammation
Incidence 1.6%
Associated with
hydrophilic-coated
sheath
Absence of infectious
agent
Appears 2-3 wks post-
cath
Granulomatous
reaction
Kozak M, et al CCI 2003;;59(2):207-­13

75. Radial Artery Occlusion
Radial artery occlusion can occur in 5-10%
Prevented with anticoagulation
Avoid prolonged compression time with
hemostatic device
More frequent with larger catheters
Most radial occlusions are asymptomatic &
not an acute issue -may contribute to
chronic vessel injury
Most acute radial occlusion resolves over
time
Since syndrome is usually asymptomatic,
changes in treatment protocols need to be
monitored against objective measures of
radial perfusion

76. Prevention of Radial Occlusion
Patent Hemostasis
12
7
5
1.8
0
2
4
6
8
10
12
14
Early
Occlusion
(24h)
Persistent
Occlusion
(30d)
%ofPatients
P<0.05
P<0.05
Pancholy S, et al CCI 2008;;72:335-­40
Conventional Hemostasis
Band left in place for 2 hours
Patent Hemostasis
Loosen the pressure on the
radial artery while
compressing the ulnar artery
until return of
plesthymographic signal
n=436

77. Starting a Radial Program
Read the literature and attend a course if possible
Train your cath lab staff and nurses in the floor
Not used to see patients walking after cath
Select your patients well
Start with young male and large patients as their radial arteries
are more likely to be larger
ladies)
Never push! A limited angiogram will help you
Pain is not good Listen to your patient
Radial angiography is not a religion, you can convert a case
to femoral if you encounter difficulties
Wait until you feel more comfortable to do CABG patients
Use the left radial artery
Know your limitations!!

86. Scalpel
Dilator
Needle
Glidesheath®
Nitinol
Wire
Syringe
Access Kit One of Several
Teflon
Catheter
Complete
Needle
Assembly
SURFLO
Needle

92. a
b
c
d