Gilchrist IC 201111

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International Chair on Interventional Cardiology and Transradial Approach

This document provides information about accessing the upper extremity venous system for procedures. It discusses using the radial or ulnar veins to access the central venous system as a safer alternative to other approaches. Key points include: - The radial or ulnar veins can be used to safely access the right heart and central venous system. - Nurses can place a heparin lock in the forearm veins ahead of time to facilitate venous access in the catheterization lab and improve efficiency. - 5F right heart catheters between 105-110cm in length are typically used for left/right heart procedures but longer catheters may be needed. - Procedures done through the radial vein have shorter arterial

Health & Medicine Education

Upper Extremity Venous Access
&
Procedure
Ian C Gilchrist, MD, FACC, FSCAI
Professor of Medicine
Heart & Vascular Institute
Penn State/Hershey Medical Center
Hershey, PA

Arm Veins: Original Cardiac Access

Werner Forssmann

Forssmann Klinische Wochenschrift 1929;8(45)2085-7.

Provide a Safe Approach to the
Central Venous System

Access:
Radial artery
RIJ vein There is room for a safer
way to the right heart &
central venous system
Complication:
Pneumothorax

Icg/HMC cath lab

A New Playground
beyond the arterial tree

Right Heart Catheterization
Transvenous Pacemakers
Right Ventricular Biopsy
Venous Filters
Potentially any technology with the right length

Venous System: Typical Patterns

Radial (lateral)
veins lead equally to
either Cephalic or
Basilic veins
Ulnar (medial) veins
usually continue as
Basilic vein

Chun et al. Radiology. 2003;226:918-920.

Upper Venous Junction
Cephalic vein joins the Axillary
vein at a T-Junction.
– Defines start of the
subclavian & central venous
system
– Location most likely to cause
technical issues

Venous System Access
Before entering the cath lab

+ +

Nurse IV Catheter (20 g) Heparin Lock
Nurse places heparin lock in forearm for use in
the catheterization lab for venous sheath access.
• saves time
• improves cath lab efficiency
• fosters team building

Nurses unable to get access?

Try in cath lab ± tourniquet
°C
Inspect arm carefully
Ultrasound?
Levophase angiogram?
Don’t forget the other arm

Heparin Locks, Needles & Wires

Micropuncture needle impaled in Heparin Lock
(remove both in block off field for sterility)

Wire holder

Micropuncture needle
Heparin lock on angiocath

5F Right Heart Catheters
(4 F also available)
Edwards Lifescience TS105F5 Arrow Balloon Wedge AI-07124

105 cm 110 cm

Examples from Penn State Hershey Medical Center
Really need 125-cm , but industry not interested

Left/Right Heart Procedures
Femoral vs Radial
250 Procedural Time Arterial Time

75±5.4 70±5.0 45±6.3 35±4.2
200

Time 150
(minutes) Less radiation time
p<.001
100

50

0
Femoral Radial Femoral Radial
(n=175) (n=105) (n=175) (n=105)

Gilchrist IC. Cathet Cardiovasc Intervent 2006;67:585-588.

Contraindications/Cautions

Obstruction to drainage
 Radial breast surgery
 Trauma
 SVC disease
Prior brachial cutdown
EP devices
Ref (July 2006): http://assets.families. com/Encyclopedias/gea2_02_img0132.jpg
No visible veins

Summary

Finish with hemostasis just like removing an IV
Its simple & extends the potential of transradial

Learning both arterial and
venous techniques will make
you a better cardiologist

This document discusses radial artery access for cardiac catheterization procedures. It covers patient evaluation and setup, arterial access technique, options for venous access, hemostasis methods, and tips for salvaging failed access. The benefits of the radial approach include lower bleeding risks and more comfortable recovery for patients compared to femoral access. Radial access is now commonly used at many medical centers and continues to grow in popularity worldwide due to these advantages.

Halkin A

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This document discusses complications related to transradial catheterization. It begins by covering some anatomical considerations for complications, such as congenital variants of the arteries in the arm and forearm and arterial tortuosity. It then classifies and provides incidence rates for various complications including asymptomatic radial artery occlusion, radial artery spasm, and hand ischemia. Risk factors for different complications are also outlined. The bulk of the document focuses on prevention strategies such as careful case selection, use of small catheters and sheaths, spasmolytic cocktails, anticoagulation, and patent hemostasis techniques. Early detection and management of complications like perforation, pseudoaneurysm, and critical hand ischemia are also discussed.

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This document summarizes a presentation on techniques for transradial cardiac catheterization. It discusses common problems encountered such as unsuccessful puncture, radial artery spasm, and wire advancement issues. It provides tips for successful puncture including proper patient preparation, local anesthesia techniques, and treating spasm. Causes of failed wire advancement like radial loops and tortuosity are reviewed. Solutions emphasized are avoiding force, using contrast to understand the anatomy, hydrophilic wires, and external compression.

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International Chair on Interventional Cardiology and Transradial Approach

This document summarizes recent literature on the trans-radial approach for cardiac catheterization and percutaneous coronary intervention. It discusses the RIVAL trial, which found lower rates of bleeding with radial access compared to femoral. It notes subgroups in RIVAL that had particularly large differences, such as patients with STEMI. The document also discusses the importance of operator experience for radial procedures. Overall, it highlights evidence that radial access reduces bleeding complications compared to femoral, especially for certain high-risk patients and when performed by experienced operators.

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This document discusses surgical techniques for debranching the aortic arch in hybrid procedures to treat aortic arch aneurysms. It describes how open surgery is used to reroute blood flow from the supra-aortic vessels before placing an endograft. Various zones of the aortic arch are defined based on the vessels involved, and the specific bypass procedures for each zone are outlined. The hybrid approach aims to reduce risks compared to open surgery alone by combining debranching with endovascular exclusion of the aneurysm. While outcomes are promising, mortality and morbidity rates are still significant and patient fitness must be considered.

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Bernat I

International Chair on Interventional Cardiology and Transradial Approach

This document discusses techniques for performing transradial cardiac catheterization and preventing radial artery occlusion (RAO). It presents data showing that using a higher dose of heparin (5000 units vs 2000-3000 units) and perfused hemostasis can reduce rates of RAO. The document also proposes that transient ulnar artery compression may treat subacute RAO by increasing blood flow through collateral vessels. Studies are presented demonstrating improved radial artery flow after one hour of manual ulnar compression. In conclusions, the document advocates for perfused hemostasis and higher dose heparin as best practices, and endorses transient ulnar compression as an effective method for treating early diagnosed RAO.

Addad F

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This document describes the case of an 82-year-old man with chest pain and pulmonary edema who was found to have multi-vessel coronary artery disease including a distal left main lesion. Due to his advanced age and high surgical risk, percutaneous coronary intervention (PCI) was chosen over coronary artery bypass grafting (CABG). The staged PCI procedure involved initially stenting the right coronary artery, followed by a complex multi-stent strategy including a mini-crush stent for the left main lesion and additional stents in the circumflex and left anterior descending arteries. The final result demonstrated successful revascularization.

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Gilchrist IC - AIMRADIAL 2015 - Right heart catheterization

Cohen MG - Transradial access - 201507

Demystifying clinical electrocardiography august, 2013

Prosthatic vales_.pptx

Segev A

Difficult Coronary Sinus Lead Implantation

Radial artery

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Quesada R

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PCI & AimRadial 2018 | Innovation in Cardiovascular Medicine - Tim A. Fischell

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes Tim Fischell's presentation on innovation in cardiovascular medicine. It discusses Fischell's history of medical device innovations, including the Arrow-Fischell sheath, brachytherapy devices, stents, and the AngelMed Guardian system. It provides guidance on developing new ideas into real innovations, including evaluating intellectual property, regulatory pathways, prototype testing, and clinical trials. Fischell emphasizes the importance of understanding unmet clinical needs and having a team approach to translating ideas into impactful new technologies.

PCI & AimRadial 2018 | A novel stent concept for South America - Ramses Galaz

International Chair on Interventional Cardiology and Transradial Approach

This document discusses opportunities for developing and manufacturing medical devices in Latin America, including coronary stents with an estimated $500M annual market. It outlines the roadmap needed to design, test, manufacture, and gain regulatory approval for a novel stent concept, including requirements for structure and flow, deployability and patency, and clinical performance. Design considerations are discussed such as structural rigidity, flexural rigidity, surface finish, and hemodynamic simulations. The potential for low-cost manufacturing and animal studies are also mentioned.

PCI & AimRadial 2018 | Biomechanics of biodegradable stents: a primer for car...

International Chair on Interventional Cardiology and Transradial Approach

PCI & AimRadial 2018 | Radial vs Femoral: Review of the Evidence in 2018 - Ia...

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes the evidence from multiple randomized clinical trials that support a Class IA recommendation for the use of radial artery access (TRA) over femoral artery access (TFA) for cardiac catheterization procedures. The data show that TRA is associated with lower rates of major vascular complications and major bleeding compared to TFA, with numbers needed to treat of 21 and 47 respectively. TRA may also reduce mortality in patients with acute coronary syndrome, with a number needed to treat of 100. Both the 2018 AHA guidelines and ESC/EACTS guidelines were updated to strongly recommend a radial-first approach in light of the overwhelming data demonstrating benefits of TRA over TFA.

PCI & AimRadial 2018 | Best practices in same day discharge - Ivo Bernat

International Chair on Interventional Cardiology and Transradial Approach

This document discusses best practices for same day discharge after cardiac procedures. It provides an overview of the history and evidence supporting same day discharge. Key points include: - Same day discharge has been shown to be safe and effective in studies dating back to the 1990s. - Dedicated lounges and infrastructure improve outcomes for same day discharge by allowing for close monitoring and care in the immediate post-procedure period. - The author's hospital has successfully performed over 7,000 same day discharge procedures over 10 years using a dedicated radial lounge with trained nursing staff who provide care and arrange discharge. Complication rates are low with their protocol.

PCI & AimRadial 2018 | Even the big boss fail - Zoltán Ruzsa

International Chair on Interventional Cardiology and Transradial Approach

This document describes a case of critical hand ischemia treated through multiple endovascular interventions over several years. Initially, the patient underwent brachial artery recanalization and stenting from left radial access, but presented two days later with stent thrombosis. A second procedure recanalized the stent and treated a brachial dissection with another stent. However, two years later the patient returned with re-occlusion of arm vessels and iliac arteries. Further interventions were needed to recanalize stenosed iliac and brachial arteries over time. In conclusion, long term patency of arm interventions is unknown, and stent CTO recanalization in the arms poses similar challenges to the legs.

PCI & AimRadial 2018 | Contemporary Transradial Access Practices: Results of ...

International Chair on Interventional Cardiology and Transradial Approach

PCI & AimRadial 2018 | A Growing Population in the Cath Lab: Patient Identifi...

International Chair on Interventional Cardiology and Transradial Approach

This document discusses expanding the FDA indication for protected PCI procedures using the Impella heart pump. Key points include: 1. A study of 891 patients found that those with mildly/moderately reduced ejection fraction (LVEF >35%) undergoing protected PCI had favorable outcomes similar to those with severely reduced LVEF, despite being older with more comorbidities and complex coronary disease. 2. Protected PCI with Impella led to improved LVEF and quality of life in multiple studies. The Protect II trial showed Impella reduced MACCE by 29% compared to IABP at 30 days. 3. Guidelines recommend protected PCI for patients with severe/moderate/mild reduced LVE

PCI & AimRadial 2018 | Treating Cardiogenic Shock with Impella with Escalatio...

International Chair on Interventional Cardiology and Transradial Approach

PCI & AimRadial 2018 | LEFT MAIN PCILessons from the BCIS registry - Jim Nolan

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes the findings of a study analyzing 19,482 left main stem percutaneous coronary intervention (LMS-PCI) procedures from the British Cardiovascular Intervention Society National Database between 2007-2014: 1) Use of radial artery access for LMS-PCI increased significantly over time and radial access was associated with reduced vascular complications, major bleeding, and shorter hospital stays. 2) Radial access was independently associated with lower in-hospital mortality and major adverse cardiac and cerebrovascular events (MACE) compared to femoral access. 3) Independent predictors of 12-month mortality following LMS-PCI included acute kidney injury, older age, chronic renal failure, acute coronary syndrome presentation, and

PCI & AimRadial 2018 | Left Ventricular Endomyocardial Biopsy by Transradial...

International Chair on Interventional Cardiology and Transradial Approach

PCI & AimRadial 2018 | Right Heart Access by Radial - Ian C Gilchrist

International Chair on Interventional Cardiology and Transradial Approach

This document discusses accessing the right heart and central venous system through the radial vein as a safer alternative to traditional femoral access. It provides tips for establishing venous access through the forearm, including using ultrasound or no-touch technology to locate veins and heparin locks to improve efficiency. Challenges like low venous pressure, valves, and junctions are addressed. Images demonstrate techniques for navigating the radial artery into the right atrium, including using flushes of saline. Potential contraindications like arm trauma or breast cancer are noted. The document argues learning both arterial and venous radial techniques will improve cardiologist skills and safety.

PCI & AimRadial 2018 | Radial Artery Puncture - Ian C Gilchrist

International Chair on Interventional Cardiology and Transradial Approach

This document discusses techniques for radial artery puncture for cardiovascular procedures. It notes that the radial artery is smaller in diameter than the femoral artery. Successful radial access requires correctly positioning and securing the wrist. Ultrasound guidance can help find and access the radial artery, especially for trainees. The initial puncture approach can be anterior wall only or use a counterpuncture technique. Sheath size, length, and coating impact radial artery spasm and occlusion. Cocktails including nitroglycerine and calcium channel blockers are commonly used but acid in the cocktail may damage the artery if felt by the patient.

PCI & AimRadial 2018 | Post-PCI FFR: Time is coming - Olivier F. Bertrand

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes a presentation given by Dr. Olivier Bertrand on post-PCI FFR measurement. It discusses studies showing that a post-PCI FFR of 0.90 or higher is associated with lower rates of re-PCI and major adverse cardiac events. It then outlines the proposed PREDICT randomized study to evaluate whether routine post-PCI FFR measurement can guide PCI strategy and completion. The study would measure FFR after successful PCI in all-comers and randomize patients to clinical follow-up alone or with guidance from the post-PCI FFR results. The goal is to establish if physiology-guided PCI optimization can improve outcomes and reduce costs.

PCI & AimRadial 2018 | Lessons from iFR-SWEDEHEART and DEFINE-FLAIR - Hitoshi...

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes lessons learned from the DEFINE-FLAIR and iFR-SWEDEHEART clinical trials. The trials found: 1) Decision-making based on instantaneous wave-free ratio (iFR) was non-inferior to fractional flow reserve (FFR) for guiding revascularization and reducing major adverse cardiac events over 1-2 years. 2) iFR-guided decisions resulted in significantly less revascularization procedures compared to FFR. 3) Subgroup analysis found increased event rates among diabetic patients evaluated with FFR compared to iFR. 4) iFR has been upgraded to a Class IA recommendation in European Society of Cardiology guidelines based on these trials

PCI & AimRadial 2018 | Use of physiology in ACS - Colin Berry

International Chair on Interventional Cardiology and Transradial Approach

1. The document discusses the use of physiology in acute coronary syndrome (ACS) patients, including trials evaluating fractional flow reserve (FFR) and index myocardial resistance (IMR) measurements. 2. Several trials showed that FFR-guided revascularization in multivessel disease STEMI patients reduced major cardiac events compared to culprit-only PCI or medical therapy. Ongoing trials are further evaluating FFR in ACS. 3. IMR predicts mortality and heart failure in STEMI patients and adversely remodeling post-STEMI. 4. Incomplete revascularization is common in ACS and associated with worse outcomes; FFR may help guide more complete revascularization. The clinical utility of physiology in ACS

PCI & AimRadial 2018 | FFR using 4Fr catheters: Can Slender Technique Work He...

International Chair on Interventional Cardiology and Transradial Approach

This document discusses the potential use of 4 French (4F) catheters for fractional flow reserve (FFR) measurements as a less invasive alternative to larger catheters. It notes that 4F catheters have a smaller profile but can lack the ability to directly perform percutaneous coronary intervention if needed. The document outlines key considerations for using 4F catheters, including ensuring the catheter lumen is well flushed and the pressure transducer is not damped. It concludes that improvements are still needed, such as reducing friction between the pressure wire and catheter, in order to maximize the benefits of using the smallest catheter size possible.

PCI & AimRadial 2018 | FFR in Left Main Disease - William F. Fearon

International Chair on Interventional Cardiology and Transradial Approach

This document discusses using fractional flow reserve (FFR) to evaluate ambiguous left main coronary artery disease. It presents a case of an 82-year-old woman with chest pain and a recent stent in the circumflex artery. FFR measurements of the left main and left anterior descending artery were 0.64, indicating significance. Intravascular ultrasound also suggested significance. The left main and proximal left anterior descending artery were stented, and post-procedure FFR measurements improved. The document reviews evidence that FFR can safely guide decisions about revascularization of ambiguous left main lesions.

PCI & AimRadial 2018 | FFR-CT - Colin Berry

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes a presentation on CT-derived fractional flow reserve (FFR-CT). It discusses how FFR-CT increases the positive predictive value of coronary CT angiography (CTCA). Several landmark studies are summarized that evaluated the diagnostic accuracy of FFR-CT compared to CTCA. The PACIFIC trial findings showing high diagnostic accuracy of FFR-CT are described. Ongoing and upcoming clinical trials using FFR-CT like PRECISION and DECISION are mentioned. Novel applications of FFR-CT for biomechanics analysis and PCI planning are presented. Finally, new methods like user-generated CT-FFR that may reduce processing time are introduced, though accuracy needs further evaluation.

PCI & AimRadial 2018 | Image based FFR during coronary angiography - Hitoshi...

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes the results of a study evaluating the diagnostic accuracy of quantitative flow ratio (QFR) compared to fractional flow reserve (FFR) as the reference standard. The study included 317 lesions in 273 patients. Key results included: - QFR showed superior sensitivity and specificity for detecting functionally significant lesions compared to 2D quantitative coronary angiography. - QFR values correlated well with invasive FFR measurements. - QFR could be computed within a similar time frame as FFR measurements. - A hybrid approach using QFR and FFR may allow pressure wire-free assessment in 68% of lesions while maintaining high diagnostic accuracy.

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