Use and safety has been validated with large-scale randomized prospective studies comparing TFA and TRA Romangnoli et al (JACC 2012), Mehta et al (JACC 2012), and Valgimigli et al (Lancet 2015)

1. 1
Prone Transradial Access:
Approach and Uses
AIM RADIAL SYMPOSIUM 2018
RAVI N. SRINIVASA, M.D.
Associate Professor of Clinical Radiology
Ronald Reagan UCLA Medical Center

2. 2
• Disclosures:
• Teleflex Medical, Inc. – Consultant
• Guerbet, LLC – Paid Speaker
• Acknowledgements:
• Jeffrey Forris Beecham Chick, MD, MPH
INOVA Alexandria Hospital, Alexandria, VA
• Joseph J. Gemmete, MD, FSIR
University of Michigan, Ann Arbor, MI
• Anthony N. Hage, MD
Thomas Jefferson University, Philadelphia, PA
Disclosures and Acknowledgements

3. 3
• Use and safety has been validated with large-scale
randomized prospective studies comparing TFA and TRA
• Romangnoli et al (JACC 2012), Mehta et al (JACC
2012), and Valgimigli et al (Lancet 2015)
• IR: Chemoembolization, radioembolization, uterine
artery embolization, aortoiliac and peripheral arterial
interventions, renal and visceral interventions
• Raghuram et al (JVIR 2016), Staniloae et al (CCI 2010)
Supine transradial access

4. 4
• Allows combined procedures that would otherwise require
patient repositioning
• Minimizes downtime and potential complications
• Anesthesia considerations
• Procedure and room time
• Patient comfort
• Increased safety with simultaneous arterial access
• Puncture site complication if repositioned from TFA
Prone transradial access

5. 5
• Simultaneous transarterial and
posterior percutaneous access
• RCC embolization & Cryoablation
• AVM embolization
• Pelvic tumor embolization &
Cryoablation
Prone transradial access
Srinivasa RN, Chick JFB, Gemmete JJ, Majdalany BS, Hage A, Jo A, Srinivasa RN. Prone transradial catheterization for combined single-
session endovascular and percutaneous interventions: approach, technical success, safety, and outcomes in 15 patients. Diagn Interv
Radiol. 2018 Sep;24(5):276-282.

6. 6
• Simple to perform as forearm can be rotated at the
elbow to facilitate radial artery access in prone position
Approach
Chick JFB, Branach C, Majdalany BS, et al. Prone transradial catheterization for combined single-session transarterial embolization and percutaneous
posterior approach cryoablation of solid neoplasms. Cardiovasc Intervent Radiol. 2017;40:1026–1032.

7. 7
Approach
Use of the prone transradial technique to perform simultaneous embolization, ablation,
and nephrostomy placement in a hybrid CT and angiography suite
Chick JFB, Branach C, Majdalany BS, et al. Prone transradial catheterization for combined single-session transarterial embolization and percutaneous
posterior approach cryoablation of solid neoplasms. Cardiovasc Intervent Radiol. 2017;40:1026–1032.

8. 8
• Left transradial access most common with patient
prone for IR procedures
• Ergonomics may be easier in IR suites
• Standard pre-procedure preparation including
Barbeau, topical EMLA and nitroglycerin
• Arm board not necessary
• Tuck arm next to patient
Approach

9. 9
75-year-old male with rectal carcinoma status post
abdominoperineal resection and external beam
radiation complicated by radiation-associated pelvic
sarcomatoid carcinoma presented with pelvic pain.
Case #1
Chick JFB, Branach C, Majdalany BS, et al. Prone transradial catheterization for combined single-session transarterial embolization and percutaneous
posterior approach cryoablation of solid neoplasms. Cardiovasc Intervent Radiol. 2017;40:1026–1032.

10. 10
Computed tomography
Contrast-enhanced CT demonstrates enhancing tumor within the pre-sacral space
compatible with sarcomatoid carcinoma (arrows)

11. 11
Internal Iliac Artery Embolization
Selective left internal iliac arteriography from a
prone transradial transarterial approach
demonstrates tumoral arterial hypervascularity
(arrow); these branches were embolized with
particles

12. 12
Cryoablation
Fluoroscopic image after positioning of six cryoablation probes within the tumor under CT-guidance;
cryoablation probes are seen within the tumor during active cryoablation; ice-ball is visualized as a
hypodense sphere encompassing the tumor (arrow)

13. 13
Nephrostomy Placement
Due to obstructive nephropathy, a left nephrostomy tube was also able to be successfully
placed from a prone position without having to reposition the patient

14. 14
19 year old male with pelvic arteriovenous malformation
Case #2
Srinivasa RN, Chick JFB, Gemmete JJ, Majdalany BS, Hage A, Jo A, Srinivasa RN. Prone transradial catheterization for combined single-session endovascular and
percutaneous interventions: approach, technical success, safety, and outcomes in 15 patients. Diagn Interv Radiol. 2018 Sep;24(5):276-282.

15. 15
Venous aneurysm (arrow) of pelvic arteriovenous
malformation. Notably, the bladder, femoral vein,
and an internal iliac artery branch vessel are in
close proximity if the venous aneurysm were
approached from an anterior percutaneous
approach.
Prone transradial access digital subtraction arteriography in early and late arterial phases showing
the feeding branch from the anterior division of the internal iliac artery. There is early and late filling of
the venous aneurysm (arrows).
Simultaneous prone transradial arterial and posterior percutaneous
embolization of an arteriovenous malformation

16. 16
Needle is advanced into the venous aneurysm
from a prone posterior approach (arrow). A wire is
coiled within the aneurysm.
Direct percutaneous embolization of the venous
aneurysm is performed through a catheter
positioned in the venous aneurysm with coils
(arrow). Simultaneous embolization is performed
from a transarterial approach (arrowhead).
Post-embolization arteriography showing
devascularization of the pelvic arteriovenous
malformation.
Simultaneous prone transradial arterial and posterior percutaneous
embolization of an arteriovenous malformation

17. 17
65-year-old female with history of HCC and indeterminate right pelvic mass
Case #3
Srinivasa RN, Chick JFB, Gemmete JJ, Majdalany BS, Hage A, Jo A, Srinivasa RN. Prone transradial catheterization for combined single-session endovascular and
percutaneous interventions: approach, technical success, safety, and outcomes in 15 patients. Diagn Interv Radiol. 2018 Sep;24(5):276-282.

18. 18
Image through the liver demonstrating a hyper-
vascular mass in the right hepatic lobe (arrow).
Image demonstrating a calcified mass within the right pelvis (arrow)
of indeterminate etiology. There was question whether this
represented a fibrous tumor versus a vascular malformation.
Prone transradial
arteriography demonstrating
no evidence for arterial supply
to the mass. Delayed imaging
showed no venous filling to
suggest a venous
malformation.
Simultaneous prone transradial chemoembolization and posterior
percutaneous pelvic mass biopsy

19. 19
Image demonstrating a biopsy
needle entering from an
ultrasound-guided posterior
percutaneous approach
(arrow). Wire is seen within
artery (arrowhead).
Hepatic arteriography reveals the hyper-vascular mass within the liver (arrows) prior to
chemoembolization.
Simultaneous prone transradial chemoembolization and posterior
percutaneous pelvic mass biopsy

20. 20
66 year old male with cirrhosis, portal hypertension and adrenal
masses
Case #4
Srinivasa RN, Chick JFB, Gemmete JJ, Majdalany BS, Hage A, Jo A, Srinivasa RN. Prone transradial catheterization for combined single-session endovascular and
percutaneous interventions: approach, technical success, safety, and outcomes in 15 patients. Diagn Interv Radiol. 2018 Sep;24(5):276-282.

21. 21
Contrast-enhanced axial magnetic resonance image of the abdomen
demonstrates a 4 cm hypervascular mass within the left lobe of the liver
(arrow) compatible with hepatocellular carcinoma. Contrast-enhanced
axial magnetic resonance image at a slightly lower level demonstrates a
2.2 cm left adrenal mass (arrow). In- and out-of-phase imaging
demonstrated no evidence for microscopic or macroscopic fat.
Axial intraprocedural CT image
demonstrates a 17-gauge biopsy needle at
the periphery of the adrenal mass (arrow)
prior to biopsy.
Simultaneous prone transradial chemoembolization and posterior percutaneous adrenal mass biopsy

22. 22
A diagnostic catheter is seen entering
from a prone transradial approach into
the left hepatic artery (arrow). The
biopsy introducer needle is also seen
within the left adrenal mass
(arrowhead).
Subselective magnified diagnostic left hepatic arteriography demonstrates the
hypervascular mass within the left hepatic lobe. Following chemoembolization,
hepatic arteriography reveals the mass is appropriately devascularized.
Simultaneous prone transradial chemoembolization and posterior percutaneous adrenal mass biopsy

23. 23
65 year old male with chronic left flank pain, hydronephrosis,
and recurrent urinary tract infections
Case #5
Chick JFB, Osher ML, Castle JC, Malaeb BS, Gemmete JJ, Srinivasa RN. Prone Transradial Renal Arteriography and Interventional Nephroscopy for the Visualization and Retrieval
of Migrated Renal Embolization Coils Causing Flank Pain and Hydronephrosis. J Vasc Interv Radiol. 2017 Sep;28(9):1314-1316.

24. 24
Olympus OTV-S7ProH
Simultaneous prone transradial arteriography and posterior percutaneous nephroscopy
(A) Coronal computed tomography image showing migrated embolization coils (arrows) extending
from the renal artery into the proximal renal collecting system (arrow). (B) Corresponding
fluoroscopic image showing coils within the renal collecting system and proximal ureter (arrows)
with one coil within a greater than third order segmental renal artery (dashed arrow).
Prone transradial digital subtraction arteriogram
demonstrating embolization coils within a segmental
branch of the left lower pole renal artery (dashed arrow)
as well as migrated coils in the lower pole infundibulum,
renal pelvis, and proximal ureter (arrows).

25. 25
(A) Fluoroscopic image demonstrating the rigid endoscope (arrow) and grasping
forceps (dashed arrow) removing the migrated embolization coils. (B and C)
Intraprocedural photographs showing the prone transradial and nephroscopy setup.
Simultaneous prone transradial arteriography and posterior percutaneous nephroscopy

26. 26
Endoscopic images obtained through a rigid nephroscope
demonstrating (A) an embolization coil within the renal
collecting system with adherent debris (B) grasped and
removed with forceps.
Simultaneous prone transradial arteriography and posterior percutaneous nephroscopy

27. 27
(A) Gross photograph showing the retrieved embolization
coils. (B) Post-procedure fluoroscopic image showing the
nephroureteral stent in good position.
Simultaneous prone transradial arteriography and posterior percutaneous nephroscopy

28. 28
54 year old female with flank pain and recurrent UTIs
Case #6
Srinivasa RN, Chick JFB, Hage A, Ramamurthi A, Wolf JS Jr, Gemmete JJ, Dauw CA. Erosion of Embolization Coils into the Renal Collecting
System: Removal with Prone Transradial Renal Arteriography and Nephroscopy. J Endourol. 2017 Oct;31(10):1019-1025.

29. 29

30. 30
• 15 patients underwent PTRA
• 13 (87%) Barbeau A, 2 (13%) Barbeau B
• Mean sheath size was 4 French (Range: 4-6 F)
• 11 (73%) GETA, 4 (27%) MAC
Retrospective study
Srinivasa RN, Chick JFB, Gemmete JJ, Majdalany BS, Hage A, Jo A, Srinivasa RN. Prone transradial catheterization for combined single-session endovascular and
percutaneous interventions: approach, technical success, safety, and outcomes in 15 patients. Diagn Interv Radiol. 2018 Sep;24(5):276-282.

31. 31
Patient Age/Gender Arterial intervention Posterior percutaneous intervention
1 35/F Transarterial embolization of renal angiomyolipoma Renal mass biopsy
2 66/M Transarterial chemoembolization of hepatocellular carcinoma Adrenal mass biopsy
3 78/M Renal cell carcinoma embolization Cryoablation of renal mass, and contralateral renal mass
biopsy
4 37/F Lower extremity arteriogram Sclerotherapy of calf venous malformation
5 65/M Renal arteriogram Nephroscopic foreign body retrieval of coils eroded into
renal collecting system and nephro-ureteral stent
placement
6 75/M Transarterial embolization of presacral sarcomatoid carcinoma Cryoablation of presacral sarcomatoid carcinoma and
percutaneous nephrostomy placement
7 45/F Transarterial embolization of pelvic malignant peripheral nerve sheath tumor Cryoablation of pelvic malignant peripheral nerve sheath
tumor
8 62/M Embolization of pelvic arteriovenous malformation Bilateral percutaneous nephrostomy placement
9 54/F Intercostal arteriogram Intracavitary antifungal injection of lower lobe mycetoma
10 47/F Lumbar arteriogram Radiofrequency ablation and cementoplasty of L4 cystic
lesion
11 19/M Iliac arteriogram Sclerotherapy of pelvic arteriovenous malformation
12 55/F Renal arteriogram and embolization Nephroscopic foreign body retrieval of coils eroded into
renal collecting system
13 65/F Transarterial chemoembolization of hepatocellular carcinoma Pelvic mass biopsy
14 56/M Transarterial embolization of renal mass Renal mass biopsy
15 66/M Transarterial embolization of renal mass Renal mass biopsy and microwave ablation

32. 32
• Arterial intervention technical success 100% (15/15)
• Posterior-approach intervention technical success was
100% (15/15)
• All biopsies were diagnostic
• Mean procedure time 167 minutes
• Mean fluoroscopy time 29 minutes
• No major or minor complications related to PTRA
Results
Srinivasa RN, Chick JFB, Gemmete JJ, Majdalany BS, Hage A, Jo A, Srinivasa RN. Prone transradial catheterization for combined single-session endovascular and
percutaneous interventions: approach, technical success, safety, and outcomes in 15 patients. Diagn Interv Radiol. 2018 Sep;24(5):276-282.

33. 33
• Decreased complications
• Improved patient satisfaction and recovery time
• Allows single-session embolization, ablation, and completion
of genitourinary procedures and others that require prone
positioning
• Fusion procedures may be more effective
• Decreased procedure time
• Overall increased procedural efficiency and decreased
financial cost
Prone transradial access

34. 34
1. Raghuram P, Biederman DM, Patel RS, et al. Transradial approach to noncoronary interventions: a single-center review of safety and feasibility in the first
1500 cases. J Vasc Interv Radiol. 2016;27:159–166.
2. Staniloae CS, Korabathina R, Yu J, Kurian D, Coppola J. Safety and efficacy of transradial aortoiliac interventions. Catheter Cardiovasc Interv. 2010;75:659–
662.
3. Chick JFB, Branach C, Majdalany BS, et al. Prone transradial catheterization for combined single-session transarterial embolization and percutaneous
posterior approach cryoablation of solid neoplasms. Cardiovasc Intervent Radiol. 2017;40:1026–1032.
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;18:58–65.
5. Barbeau GR, Arsenault F, Dugas L, Simard S, Larivière MM. Evaluation of the ulnopalmar arterial arches with pulse oximetry and plethysmography:
comparison with the Allen’s test in 1010 patients. Am Heart J. 2004;147:489–493.
6. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the
RIFLE-STEACS (radial versus femoral randomized investigation in ST-elevation acute coronary syndrome) study. J Am Coll Cardiol. 2012;60:2481–2489.
7. Mehta S, Jolly SS, Cairns J, et al. Effects of radial versus femoral artery access in patients with acute coronary syndromes with or without ST-segment
elevation. J Am Coll Cardiol. 2012;60:2490–2499.
8. Valgimigli M, Gagnor A, Calabró P, et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a
randomised multicentre trial. Lancet. 2015;385:2465–2476.
9. Srinivasa RN, Chick JFB, Gemmete JJ, Majdalany BS, Hage A, Jo A, Srinivasa RN. Prone transradial catheterization for combined single-session endovascular
and percutaneous interventions: approach, technical success, safety, and outcomes in 15 patients. Diagn Interv Radiol. 2018 Sep;24(5):276-282.
10. Srinivasa RN, Chick JFB, Hage A, Ramamurthi A, Wolf JS Jr, Gemmete JJ, Dauw CA. Erosion of Embolization Coils into the Renal Collecting System: Removal
with Prone Transradial Renal Arteriography and Nephroscopy. J Endourol. 2017 Oct;31(10):1019-1025.
11. Chick JFB, Osher ML, Castle JC, Malaeb BS, Gemmete JJ, Srinivasa RN. Prone Transradial Renal Arteriography and Interventional Nephroscopy for the
Visualization and Retrieval of Migrated Renal Embolization Coils Causing Flank Pain and Hydronephrosis. J Vasc Interv Radiol. 2017 Sep;28(9):1314-1316.
References

35. 35
Thank You
Ravi N. Srinivasa, MD Jeffrey Forris Beecham Chick, MD, MPH
medravi@gmail.com jeffreychick@gmail.com
@medravi @CHICKVIR