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.

1. Radial Artery Puncture
Ian C Gilchrist, MD, FACC, FSCAI
Professor of Medicine
Penn State’s Hershey Medical Center
Heart & Vascular Institute
Hershey, PA
USA

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Radial Realities
Size differences
Greater tendency to spasm shut
More likely to be damaged from sheath
Common femoral diameter
8 mm
Radial/Ulnar diameter
2.25 mm
Efficient radial access = great likelihood of short & long term success

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Allen’s Test
Although assessment of the RA pulse is important, performing
an Allen or Barbeau test to confirm the patency of dual
arterial circulation to the hand & intact palmar arch system is
only of historical interest.
Mason PJ, Shah B, Gilchrist IC, et al. Circ Cardiovasc Interv. 2018;11:e000035.
AHA 2018 Statement

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Positioning for Success
Radial or Ulnar Access Dorsal Radial
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A little extra effort to correctly position and secure wrist will simplify the procedure

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Can You Find It?
Peters RM, et al. The Journal of Neuroscience 2009; 29(50):15756 –15761
Spatial resolution of 1-2 mm for finger
Typical radial diameter = 2.5 mm
Smaller fingers have greater spatial resolution

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If in Doubt, Use Ultrasound
Get your fingers out of the way!
Davies RE, Gilchrist IC. Cardiovasc Revasc Med. 2017; pii: S1553-8389(17)30336-6.
Find it
Measure It
Stick it the first time
New trainees are very familiar with
ultrasound & its use should be
supported.
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Seldinger’s Technique?
Seldinger’s Technique
1. Anterior wall puncture
2. Original sheathless approach
Modified-Seldinger’s Technique
1. Anterior wall puncture
2. Introduces vascular sheath
From Eisenberg RL. Radiology: an illustrated history.
St Louis: Mosby–Year Book; 1992, p. 442
Seldinger has nothing to do with
thru & thru techniques or counter-
puncture techniques

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Initial Approach
Anterior Wall Only Approach
(53%)
Schroff AR, et al. Catheter Cardiovasc Interv. 2018 Nov 19. doi: 10.1002/ccd.27989
Images from Samir Pancholy

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Counter Puncture Technique
40% of operators preference
Schroff AR, et al. Catheter Cardiovasc Interv. 2018 Nov 19. doi: 10.1002/ccd.27989
Images from Samir Pancholy

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Hybrid Approach
Steel Needle
Let Go
Images modified from Samir Pancholy

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Sheaths
Diameter (↑diameter → ↑radial artery occlusion)
Length (protect or hurt endothelium, spasm)
Hydrophilic coating
Thinness of sheath (↓wall thickness → ↑ potential to kink
Sheathless?
Sheath insertion should be a relatively smooth & painless process,
otherwise stop & trouble shoot

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Cocktails
13% operators don’t bother
Most popular:
40% Nitroglycerine
45% Verapamil
4% Diltiazem
6% Nicardipine
5% other
Buffer with blood. If the patient feels the injection, the acid in
the cocktail has probably injured the endothelium
Schroff AR, et al. Catheter Cardiovasc Interv. 2018 Nov 19. doi: 10.1002/ccd.27989

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Thank you