1. Radial artery access is an alternative to femoral artery access for coronary procedures that offers advantages like lower bleeding risks and faster recovery times. 2. The radial artery anatomy and variations like tortuosity must be considered to select appropriate patients and techniques. 3. Radial artery puncture and navigation of wires and catheters through the arm requires specialized techniques to prevent complications like spasm or dissection. 4. Maintaining radial artery patency with anticoagulation, proper compression, and monitoring is important to prevent radial artery occlusion following the procedure.

1. RADIAL ARTERY ACCESS

2. CONTENT
• CHOOSING TRA
• ANATOMY OF RA
• ANOMALIES OF RADIAL ARTERY
• ALLEN AND BARBEU TEST
• RADIAL ARTERY PUNCTURE
• NAVIGATING THE UPPER EXTREMITY ARTERIAL SYSTEM
• COMPLICATIONS AND ITS MANAGEMEMNT

3. Reason for adopting TRA
• Less access site bleeding and vascular complications.(The flat, bony prominence of the radius provides
ease of compression and hemostasis after sheath removal)
In addition, TRA is associated with
• Early sheath removal,
• Improved patient comfort,
• Faster recovery, and
• Lower costs in comparison with transfemoral access .
• Vast collateralization - prevents ischemia of the hand;
• The puncture site - not on joint- motion of the hand or the wrist does not increase the risk
of bleeding
• No risk of neurologic sequelae – No adjacent nerve structures

4. Radial Bone

5. Against radial artery approch
• Relatively steep learning curve ,
• Increased radiation exposure (The mean operator dose was 107 µSv
for TRA and 74 µSv for TFA )
• Incompatibility of the radial artery with sheaths larger than 6F
required for
• Large rotablator burrs
• Complex bifurcation stenting,
• Higher access failure rates

6. ANATOMICAL
CONSIDERATIONS
• Diameter of
2 . 8 mm in females
3 . 1 mm in males
• The radial artery arises together with the ulnar artery
from the bifurcation of the brachial artery just below
the bend of the elbow.
• The radial artery passes along the lateral side of the
forearm from the neck of the radius to the forepart
of the styloid process in the wrist
• It then winds backward, around the lateral side of the
carpus.
• The distal portion of the artery in the forearm is
superficial, being covered by the integument and the
superficial and deep fascia ,
• Lying between the tendons of the brachioradialis
and flexor carpi radialis over the prominence of the
radius.

7. ULNAR ARTERY
• The ulnar artery is
Deep lying,
Mobile,
Adjacent to the ulnar nerve
consequently not ideal for first-line vascular access.

8. The Ideal Patient for NEW RADIALIST
Hemodynamically and clinically stable
Strong radial pulse
Simple coronary anatomy
Relatively young (< 70 years old)

9. Exclusion Criteria for New Radialists
Absence of radial artery pulse
Absence of functional collaterals between the radial and the ulnar arteries, as judged by the
Modified Allen's Test or alternative tests
Clinically unstable, e.g., acute coronary syndromes
Complex or problematic anatomy, e.g., bypass grafts, unprotected left main stenosis, chronic total
occlusions and peripheral vascular lesions
Elderly (> 70 years old), especially with hypertension (often have dilation and/or distortion of the aortic
arch that impedes entry into the ascending aorta)
Arteriovenous shunt for renal dialysis on the procedure forearm
Raynaud's phenomenon
Any procedure requiring > 8 Fr catheter

10. ANATOMIC
ANOMALIES
• Variations include
Tortuous radial configurations ,
Stenoses ,
Hypoplasia ,
Radioulnar loops,
Aberrant right subclavian artery (arteria lusoria) ,
and
Abnormal origin of the radial artery.
• These anomalies are usually unilateral, therefore
vascular access crossover to the left radial artery or
ipsilateral ulnar artery may be indicated in cases of
extreme tortuosity or angulated radial loops.

12. • Significant subclavian or brachiocephalic tortuosity is present in
about 10% of cases and is usually associated with
• Advanced age,
• Short stature,and
• Long-standing history of hypertension.
• However, subclavian tortuosity is rarely a cause of procedural
failure because it can be easily negotiated by the use of deep
inspiration or supportive guidewires

13. • In rare cases ( < 1 % ) , the right
subclavian artery arises directly from
the distal segment of the posterior
aspect of the aortic arch and has a
retroesophageal course toward the right
upper extremity.
• This anomaly is known as arteria
lusoria and represents a formidable
challenge for advancing a catheter from
the subclavian artery to the ascending
aorta .

14. ALLENS TEST
• In 1929 , Edgar Van Nuys Allen introduced a
"compression test" to diagnose arterial occlusion
resulting from thromboangiitis obliterans or
Buerger disease
• The test consists of simultaneously compressing the
ulnar and the radial arteries at the level of the wrist
for approximately 1 or 2 minutes ,
• The patient closes the hand tightly to squeeze as
much blood out as possible,
• Then the operator releases compression of the
ulnar artery and waits for the hand to regain color.
• Than normal in about 5 to 9 seconds .
• The Allen's test is largely subjective and yields more
than 30% of falsely abnormal results

16. Interpretation of the Modified Allen's
Test
1. Normal (positive) Modified Allen's Test
Normal palm color returns within 7 seconds.
2. Abnormal (negative) Modified Allen's Test
a. Borderline abnormal
Delayed return of palm color, in 8 to 15 seconds.
b. Absolutely abnormal
No return of palm color until more than 15 seconds.

17. Inverse Allen's Test
• Patency of the radial artery.
• Test are similar to those in the Modified Allen's Test, except the radial
pulse is released instead of the ulnar pulse. The interpretation is the
same as in the Modified Allen's test.
• If the Inverse Allen's Test is abnormal, the radial artery is not suitable for the procedure.
Therefore, both the Modified Allen's Test and the Inverse Allen's Test should be normal
before the patient is selected for a transradial procedure

18. BARBEAU
TEST(attaching
a pulse
oximeter to the
thumb )
• Type A -No damping of the pulse waveform immediately after 2 minutes of radial compression, positive
oximetry, frequency 1 5 % ) ;
• Type B - Damping - complete recovery within 2 minutes of compression, (, frequency 75%) ;
• Type C - Loss of pulse waveform, negative oximetry, with partial progressive recovery of the pulse waveform
and oximetry within 2 minutes of compression (, frequency 5%) ;
• Type D -Loss of pulse waveform , negative oximetry, without recovery of either pulse waveform or oximetry after
2 minutes of compression (, frequency 5%)

20. RIGHT TRA VS LEFT TRA
• Right TRA the catheter has to pass through the
right subclavian artery and the brachiocephalic
trunk before reaching the aortic root .
• These two areas of bifurcation can increase
technical difficulty, especially when these vessels
are atherosclerotic, tortuous, and calcified.
• Left subclavian artery arises directly from the
aorta, in the left radial route the ascending aorta
is more straightforward, often resulting in less
complex catheter manipulation.
• Left TRA should be strongly considered in
patients who have undergone coronary artery
bypass grafting ( CABG ) , because it provides
direct access to the left internal mammary
artery (LIMA) .

21. Patient Positioning- Right Radial Access
• The patient's right arm is placed on the board
and abducted at a 30° angle.
• The right wrist is placed in a hyperextended
position using commercially available splints
or a rolled towel behind the wrist with the
fingers taped to the arm board.
• A pulse oximeter probe in the right thumb
for continuous monitoring of the circulation to
the hand throughout the procedure .

22. Algorithm for selecting radial access and crossing over
to other vascular access
1 F - 0.33 CM

23. RADIAL PUNCTURE
• Micropuncture needle, a short 0.018
to 0.021 inch wire, and an arterial
sheath with or without hydrophilic
coating of shorter ( 1 0 to 13 Cm) or
longer (23 em) length.
• hydrophilic coating allows easier
sheath removal and is clearly
associated with less spasm and
patient discomfort

24. • Locally anesthetized with
lidocaine using 25G needle

25. RADIAL PUNCTURE AND APPROACH
TWO TYPES OF PUNCTURE
• anterior wall puncture
• posterior wall puncture
TWO TYPES OF RADIAL APPROACH
• Proximal radial artery approach
• Distal radial artery approach

26. Transradial access technique-front wall technique
( Step 2 ) short 2.5 Cm 21 G stainess-still
needle is used t o p u n ctu re t h e rad i a l a rte ry.

27. Ultrasound guidance for radial access
• The ultrasound is positioned over the radial
artery.
• The arrow on the probe marks the centerline
and the place where the needle should enter
the skin (A).
• The radial artery is round and pulsatile,
accompanied by two radial veins that are
easily compressible (B and C).
• The puncture needle is entering the radial
artery (D)

28. FRONT WALL PUNCTURE
• Transradial access technique-
front wall technique ( Step 3 )

29. POSTERIOR WALL PUNCTURE
• Tra n s ra d i a l a ccess tech n i q u e- back-
wall technique ( Step 3 )

30. • The microcatheter is retrieved very slowly
until the appearance of brisk pulsatile
blood

31. • A short 0.018 inch wire is advanced without
resistance through the microcatheter into the
proximal radial artery.
• In case of resistance, a limited angiogram
can be performed through the microcatheter
to verify the in traluminal position and rule out
the presence of vascular anmalies.

32. Trans radial access
technique the sheet
preferably hydrophilic
coated is advanced over
wire

33. • A. The arm is kept in a semiprone position for distal trans radial approach.
• B. The sterile puncture site is anesthetized using approximately 1 to 2 cc of 1% lidocaine in a small syringe.
• C. The arterial puncture is performed using a 21G needle with plastic cannula.
• D. The introducer sheath is placed in usual fashion.
• E. The arm is kept in a semiprone position comfortable for the patient and operator.
• F. An commercial pneumatic compression device is placed for hemostasis.
DISTAL TRANS RADIAL APPROACH

34. Spasmolytic Cocktail Administration
• Slight burning sensation with administration of the cocktail.
• Aspirate blood into the syringe before injecting the spasmolytic cocktail
through the side arm of the sheath. (Mixing blood with the spasmolytic
cocktail buffers the pH of the mixture closer to that of blood and attenuates
the burning sensation.)
•

35. Navigating the Upper Extremity Arterial
System
• 0.035 in guidewire and a catheter of choice are advanced into the
ascending aorta traversing the upper extremity arterial system.
• A J-tipped wire may follow the path of larger vessels and not selectively
enter small radial or brachial branches.
• The tip of a regular J wire has a radius of 3 mm, which is larger than the
diameter of the radial artery and may cause vasospasm.
• A small J tip wire (“Baby-J”) with a radius of 1.5 mm is better suited to
navigate the upper extremity vasculature.
• Stiff shafts are ideal for negotiating tortuous anatomy, especially in the
subclavian artery and brachiocephalic trunk.
• Wires need to be advanced under close fluoroscopic surveillance,
sometimes inadvertently enter into and perforate small branches of
the radial or brachial arteries.

36. Navigating the Upper Extremity Arterial
System

37. • Due to the relatively small size of the upper extremity arterial system, the
operator should never force any equipment against resistance because of
the risk of vessel injury, dissection, or reactive spasm
• A limited retrograde angiographic assessment should be performed to
identify a vascular anomaly or unusual tortuosity, plan a strategy, and avoid
complications.
• Techniques such as balloon-assisted tracking (BAT), “Mother-in-Child”
technique, important for effective navigation.

38. Balloon-assisted tracking (BAT)
• An inflated coronary balloon is partially protruded through the distal end of a guide catheter or a diagnostic catheter
and deployed at 3 or 6 atmospheres.
• 5F catheters, a balloon of 1.5 mm. 6F guide catheters, a balloon of 2.0 mm A balloon length of 10 mm or 15 mm .
• The entire assembly is advanced over a soft-tipped 0.014″ in coronary wire,
• Anatomical situations that may require BAT include a
• Very small caliber radial artery (diameter less than 1.5 mm),
• Tortuous radial or brachial artery,
• Severe and resistant radial spasm,
• Atherosclerotic disease,
• Complex loops,
• Severe subclavian tortuosity, and
• Subclavian stenosis.

39. • Schematic representation of “Razor” effect and “balloon-assisted tracking (BAT).” A. Guiding catheter edge
leading to “Razor” effect in tortuous segment. B. Smooth tracking of guide catheter without “Razor” effect in
tortuous segment. C. Severe RA tortuosity. D. Catheter is advanced using BAT

40. Mother-in-Child” technique
• The “consists of telescoping a long
125 cm 5-Fr multipurpose or JR4 catheter
through a 6- or 7-Fr guiding catheter to
create a smooth transition between the
wire and the guiding catheter eliminating a
leading edge.
• It can be useful for navigating a guiding
catheter through complex vascular
anatomy without significant trauma or
local pain.

42. COMPLICATION AND
MANGEMENT
procedural Post procedural
Bleeding Nonbleeding Bleeding Non bleeding
Radial artery
perforation
Radial spasm Forearm
hematoma
Radial artery occlusion
Catheter
entrapment
Compartment
syndrome
Pseudoaneurysm
Radial dissection AV fistula
Catheter kink Regional pain
syndrome
Infection

43. RADIAL ARTERY OCCLUSION

44. Procedural attributes
• Systemic anticoagulation with heparin (50
U/kg up to 5,000 U either IV or IA, minimizes
the incidence of RA occlusion.
• Sheath-to-artery ratio of > 1 is associated
with an increased risk of RA occlusion.
• Adequate cocktail (antispomotics) to prevent
radial artery spasm
Post-procedural attributes
• Maintaining RA patency during hemostatic
compression after transradial catheterization is
associated with a lower incidence of RA occlusion.
• Consider the use of prophylactic ipsilateral ulnar
artery compression
• Shorten the duration of radial artery compression
(Radial band can be loosened 30 minutes after
diagnostic procedures and 90–120 minutes after
interventional procedures)
Attributes to Prevent Radial Artery Occlusion

45. Conclusions-—RAO is a common complication of transradial access. Maintenance of radial patency should be
an integral part of all procedures undertaken through the radial approach. High-dose heparin along with shorter
compression times and patent hemostasis is recommended in reducing RAO

47. In the PROPhylactic Hyperperfusion
Evaluation Trial II (PROPHET)
• 3,000 patients undergoing cardiac catheterization were randomized to standard patent
hemostasis versus patent hemostasis and prophylactic ipsilateral ulnar compression.
• RAO at 24 hours and 30 days was significantly reduced with ulnar compression from
4.3% to 1.0% and 3.0% to 0.9%, respectively (P = .0001 for both comparisons).72
• Hence, with
Intense procedural anticoagulation,
Meticulous patent hemostasis,
Careful vigilance for early RAO managed with ulnar compression, and
Shorter hemostasis duration.
The RAO incidence can be reduced to less than 1%.

48. Strategies Asociated with a Reduced Risk for Radial Artery
Oclusion

49. Definition of patency
RA patency is defined as the presence of plethysmographic signal with
ulnar artery occlusion and the amplitude of that plethysmographic signal
should be at least 33% of the amplitude noted at baseline.
WEAK(< 33%) UNDULATION OF PLETHYSMOGRAM SHOULD NOT BE
ACCEPTED AS EVIDENCE OF PATENCY.

50. PATENT HEMOSTASIS

51. DIAGNOSIS OF RAO
Plethysmographic technique
Absence of plethysmographic waveform with manual occlusive compression of
the ulnar artery.
Duplex-Doppler evaluation
Absence of antegrade flow in the radial artery distal to the radial puncture site,
as evidenced by reversal of the flow signal in the radial artery where it crosses over
and dives into the palm, using pulse-Doppler technique.
Audible Doppler signal is frequently preserved in the radial artery proximal and distal to
the occluded segment and, hence, the presence of an audible Doppler signal is not of
value in evaluating radial artery patency
Radial pulse and radial artery occlusion
The presence of radial artery pulsation is not a sign of radial artery patency.Decrease
in pulsation volume or a gap in radial pulsation around the entry site is frequently
seen in radial artery occlusion.

53. PATENT HEMOSTASIS
Frequency of monitoring Duration of compression Removal of hemostatic device
• RA flow should be monitored
every 15 minutes after initial
hemostatic pressure application.
• If radial flow is evident by
plethysmography, the status
should be re-evaluated in 15
minutes.
• If radial flow is interrupted,
hemostatic pressure should be
decreased, unless bleeding
occurs.
• Manual hemostatic
compression should be performed
until hemostasis is evident, the
duration of which is determined
by repeated assessment
• When hemostatic compression
is performed using a dedicated
device, approximately 2 hours
may be required.
• Longer compression duration
is associated with a higher
risk of RA occlusion.
• Devices must be removed very
carefully to avoid tenting of the
skin that may have adhered to the
band.
• Application of a thin film of
lubricant (e.g., antibiotic
ointment or saline) to the point
of pressure usually eliminates this
problem

55. RAO TREATMENT
• Conservative
• Pharmacological
• Ulnar compression
• Percutaneous Intervention
• Combined approach
• Surgery

56. Ulnar artery compression
• Ulnar artery compression is simple, safe and easily reproducible
method.
• In case of early RAO, occurring on the same day of the
procedure and/or before discharge, applying 1 hour of ulnar
artery occlusive compression with a balloon-based
hemostatic device can increase peak velocity flow into the radial
artery with reestablishment of forward flow.

57. • COMBINED APPROACH
• Empiric short courses of 1 to 4 weeks of low molecular weight
heparin led to late recanalization in the majority of patients
• Combination of RA balloon angioplasty + abciximab is new and
perspective but has to be validated in prospective large study

58. Radial artery spasm
• It occurs in 5–10% of all cases, with a higher incidence associated with
• smaller diameter radial arteries,
• female gender,
• multiple catheter exchanges,
• larger sheath size,
• radial artery anomalies
• operator inexperience
• The radial artery has a prominent medial layer dominated by alpha-1
adenoreceptor function. Thus, adequate local anesthesia and sedation to
control circulating catecholamine activity can help to prevent arterial
spasm

60. • DIAGNOSIS :
Radial spasm - severe forearm pain and unusually difficult
manipulation of the catheters and the sheath.
• TREATMENT :
Additional doses of intraarterial vasodilators,
Sedation, and
Downsizing to smaller 4- to 5-Fr catheters
• If after these measures the patient still complains of substantial pain
and the catheters are difficult to manipulate, a limited upper
extremity angiography is recommended.
• Anatomical variations, particularly the anomalous origin of the
radial artery from high brachial or axillary artery and radio-brachial
loops are commonly misinterpreted as RA spasm.

61. Stepwise Approach Algorithm for Treatment of Radial Sheath Entrapment:
Pharmacologic
• Systemic Vasodilators (nitroglycerin and/or verapamil)
• Sedation (IV midazolam and fentanyl)
Non-Pharmacologic
• Warm Compresses
• Forearm Heating
• Flow Mediated Vasodilatation Technique ("Clamp and Release")
Deep Conscious Sedation / General Aneasthesia
• IV Propofol
• Endotrachial Intubation
Inavsive / Surgical
• Regional Nerve Block
• Endarterectomy

62. NON PHARMACOLOGICAL

63. Hematoma and Bleeding Forearm
bleeding and hematoma formation
• Presence of significant pain and swelling during or after the procedure.
• Early detection in the catheterization laboratory or the recovery area are important to
prevent compartment syndrome, one of the most feared TRA complications.
• Small hematomas are usually managed conservatively with
• Ice,
• Analgesics,
• Arm elevation, and
• Light compression.

64. Hematoma and Bleeding Forearm
bleeding and hematoma formation
• Large hematomas are managed with
cessation/ reversal of anticoagulants,
circumferential compression of the forearm with an
elastic bandage or blood pressure cuff, and
aggressive blood pressure control.
• A pulse oximeter should be placed in the ipsilateral thumb to
monitor for hand ischemia.
• In extreme cases, compartment syndrome can develop with the
need for surgical fasciotomy of the forearm

65. Radial Artery Perforation
• Rare but serious complication of TRA with an incidence of <1%.
• Risk factors for vascular perforation include
anatomic variations, such as
radial artery tortuosity or looping,
high radial-ulnar bifurcation, and
short ascending aorta,
• aggressive wire manipulation (hydrophilic wires in particular),
• female sex,
• short stature,
• hypertension, and
• excessive anticoagulation.
• leading edge of a guiding catheter sliding over a wire can create a “razor effect”
that causes injury and perforation to tortuous or anomalous radial arteries.

66. Radial Artery Perforation
• Confirmed with a limited radial angiogram.
• Perforations need to be recognized and managed immediately to avoid progression to
hematoma or compartment syndrome.
• Place a catheter across the perforation, with similar outer diameter to the radial lumen, to
occlude the vessel and “tamponade” the perforation to prevent further blood
extravasation.
• It usually takes 20 minutes for the perforation to be sealed.
• If the radial artery cannot be traversed with a catheter or continued extravasation is noted,
external compression with elastic bandage or a blood pressure cuff for approximately
20 to 30 minutes is recommended.
• Vascular surgery can be consulted after all these maneuvers fail.
• The use of polytetrafluoroethylene-covered stent grafts to seal radial perforations has
been reported.

67. RADIAL ARTERY PERFORATION

68. Radial Artery Pseudoaneurysm
• Incidence of radial pseudoaneurysm requiring intervention of
less than 0.02% in patients treated for ACS.
• Pseudoaneurysms usually develop as a consequence of
inadequate hemostasis with persistence of turbulent flow
between the adventitia and the media, which over time
creates a cavity surrounded by fibrous tissue connected to the
arterial lumen through a neck
• Clinically, a pseudoaneurysm can be recognized as a painful,
tender, pulsatile mass days to weeks postprocedure.

69. Radial Artery Pseudoaneurysm
• Independent risk factors include systemic
anticoagulation and elevated body mass
index.
• Diagnosis is made by duplex
ultrasound, and the treatment depends
on the size of the pseudoaneurysm.
• Options include compression with a
radial hemostasis device, ultrasound-
guided compression, thrombin injection,
or surgical repair.

71. • Both the Modified Allen's Test and the Inverse Allen's
Test should be normal before the patient is selected
for a transradial procedure
• Aspirate blood into the syringe before injecting the
spasmolytic cocktail through the side arm of the sheath
• Wires need to be advanced under close fluoroscopic
surveillance, sometimes inadvertently enter into and perforate
small branches of the radial or brachial arteries
• never force any equipment against resistance because of the risk of vessel
injury, dissection, or reactive spasm

72. • Consider the use of prophylactic ipsilateral ulnar artery
compression: a compression band is placed over a piece of
gauze applied over the ipsilateral ulnar artery in Guyon’s canal,
and once plethysmography confirms ulnar artery compression,
the radial sheath is removed and the TR Band is inflated using
the patent hemostasis protocol.