TRANSRADIAL ACCESS.pdf

TRANSRADIAL ACCESS
Dr. Thiều Minh Sơn, MD
Interventional Cardiology Fellow at
Khánh Hòa Provincial General Hospital
Nha Trang, May 5th 2023

CONTENTS
1. Anatomy of the radial artery
2. Transradial access technique
3. Complications

UPPER EXTREMITY ARTERIES
Moscucci, M. (2013). Grossman & Baim's cardiac catheterization, angiography, and intervention. Lippincott Williams & Wilkins.
Subclavian Artery:
• Right side: arises from the brachiocephalic
trunk
• Left side: branches directly from the arch of
aorta
• Travels laterally towards the axilla
Axillary Artery:
• At the lateral border of the first rib, the
subclavian artery enters the axilla  renamed
the axillary artery.
Brachial artery:
• At the lower border of the teres major muscle
 the axillary artery is renamed the brachial
artery.

RADIAL ARTERY
• Radial artery (RA) arises together with the ulnar artery from
the bifurcation of the brachial artery (3cm below the bend
of the elbow)
• RA 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 is superfcial, lying between the tendons
of the brachioradialis and ﬂexor carpi radialis over the
prominence of the radius
• Average diameter is 2.8 mm in females and 3.1 mm in males
(compatible with 6F sheaths).

RADIAL ARTERY
• Flat, bony prominence of the radius 
ease of compression and hemostasis after
sheath removal
• Vast collateralization of the RA through the
palmar arch  prevents ischemia of the
hand
• Puncture site is not overlying a joint 
motion of the hand/wrist does not
increase the risk of bleeding
• Absence of major adjacent nerve
structures  no risk of neurologic
sequelae

Heart 2009;95:410–415. doi:10.1136/hrt.2008.150474
Normal radial artery anatomy (86.2%)
Access failure: 0.9%
• 1540 consecutive patients were studied, overall
incidence of radial artery anomaly was 13.8%
• Overall transradial procedural success was 96.8%.
• Procedural failure was more common in patients
with anomalous anatomy than in patients with
normal anatomy (14.2% vs 0.9%, p=0.001).
ANOMALOUS ANATOMY

Heart 2009;95:410–415. doi:10.1136/hrt.2008.150474
High-bifurcating radial artery (7.0%)

Heart 2009;95:410–415. doi:10.1136/hrt.2008.150474
Radial artery tortuosity (2.0%)
Radial artery loop (2.3%)

Catheterization and Cardiovascular Interventions 67:870–878 (2006). DOI: 10.1002/ccd.20732
Stenotic radial artery (1.7%)
Hypoplastic radial artery (7.7%)

Retroesophageal origin of subclavian artery
(0.45%) - Access failure: 40%

GIỚI THIỆU
JACC: CARDIOVASCULAR INTERVENTIONSVOL. 14, NO. 8, 2021. DOI: https://doi.org/10.1016/j.jcin.2021.02.033
HISTORY
OF TRA

RADIAL/FEMORAL
Circulation: Cardiovascular Interventions Volume 11, Issue 9, September 2018. - JACC: CARDIOVASCULAR INTERVENTIONS VOL. 14, NO. 8, 2021.

GIỚI THIỆU
JACC Cardiovasc Interv. 2016 Jul 25;9(14):1419-34. doi: 10.1016/j.jcin.2016.04.014.

Brilakis, E. (2020). Manual of percutaneous coronary interventions: a step-by-step approach. Academic Press.
2017 ESC Guidelines for the management of acute myocardial
infarction in patients presenting with ST-segment elevation
RADIAL/FEMORAL

EQUIPMENT
• Arterial sheath
• Dilator
• Guidewire 0.018-0.021’’
• Stainless-steel needle (2.5cm 21G) or
needle/microcatheter assembly
• BowTie (guide wire insertion device)
• Local anesthetic (lidocaine 2% 2ml)
• Sterile syringe (with needle)
• Disinfectants (Povidone-iodine,
Chlorhexidine)
• Sterile Drapes
• Sterile Gauze

POSITIONING
RIGHT ARM:
Place on the board abducted at
a 30° angle
LEFT ARM:
Rest on a large pillow placed
on a regular arm board that
guides the forearm towards the
midsection of the patient's
body, placing the left wrist on
top of the left groin .

POSITIONING
• The hand is hyperextended with use of a rolled towel behind the
wrist and tape holding the fingers or with use of a dedicated
positioning splint.

LOCAL ANESTHESIA
• Sterile preparation and draping of the wrist
• Use a syringe (usually 3 cc) loaded with local anesthetic and a needle (usually 31G)  insert in
the skin
• Aspiration to confirm that the tip of the needle is not within a vessel (intra-arterial
administration can cause seizures)  injection 1 cc of local anesthetic (larger amounts can
compress the radial artery  hinder obtaining access)

SELDINGER TECHNIQUE
1. Insert a needle
2. Pass a guidewire
3. Withdraw the needle
4. Insert a catheter over the wire
5. Withdraw the guidewire
SINGLE-WALL TECHNIQUE
vs
DOUBLE-WALL TECHNIQUE

SINGLE-WALL TECHNIQUE (1)
STEP 1:
• Use a short 2.5cm 21G stainless-steel needle
• Palpation of the radial pulse
• Insert the needle to the point of strongest pulse (usually 2cm above the flexor
crease, bevel facing up, angle 30-45 degrees and from lateral to medial) until it
enters the RA lumen

STEP 1:
• Blood return  indicates intraluminal needle position
• Rarely pulsatile or brisk

STEP 2:
• Advance a 0.018” short guidewire without resistance through the needle into the proximal RA
• Resistance to wire advancement  NEVER push hard (this may cause dissection, spasm,
perforation)
• Causes: suboptimal needle position, tortuosity of the radial artery, wire advancement into a side
branch, or radial artery spasm
• Remove the needle  left the guidewire in the RA lumen

STEP 3:
• Dip the sheath in saline
solution to activate the
hydrophilic coating
• Advance the sheath
over the 0.018”
guidewire until the hub
reaches the skin
• Remove the dilator and
guidewire.

DOUBLE-WALL TECHNIQUE (1)
STEP 1:
• Use a needle/microcatheter
assembly
• Palpation of the radial pulse
• Insert the needle to the point of
strongest pulse (usually 2cm
above the flexor crease, bevel
facing up, angle 30-45 degrees
and from lateral to medial)
• Presence of blood in the hub of
the needle  artery has been
punctured
• Advance the needle forward
through the back wall of the RA.

STEP 2:
• Once the tip of microcatheter and needle are through the back wall of the
RA  remove the needle and left the microcatheter in place across the
radial artery.

STEP 3:
• Retrive the microcatheter very slowly until the appearance of brisk pulsatile
blood return  confirms that the distal tip is in the lumen of the RA

STEP 4:
• Advance a short 0.018” wire without resistance through the microcatheter into the
proximal radial artery.
• Resistance  perform a limited angiogram through the microcatheter  verify the
intraluminal position and rule out the presence of vascular anomalies.

STEP 5:
• Remove microcatheter,
left the 0.018” guidewire
in the RA lumen
• Dip the sheath in saline
solution to activate the
hydrophilic coating
• Advance the sheath over
the guidewire until the
hub reaches the skin
• Remove the dilator and
guidewire.

Inability to advance sheath
Causes: skin resistance, spasm, small
radial artery size, tortuosity.
Solutions:
• Resistance at skin: use scalpel to
facilitate insertion.
• If spasm: administer sedation,
intra-arterial verapamil or
nitroglycerin, or subcutaneous
nitroglycerin.
• If small radial artery size: use
alternative arterial access (ulnar,
contralateral radial, or femoral). Skin nick to facilitate sheath insertion.

SHEATH ASPIRATION & FLUSHING
• The side arm of the sheath is aspirated (3-4 mL) and the aspirated blood is discarded  clear the
sheath
• One or more vasodilators (such as verapamil 2-3 mg, nicardipine 100-200 mcg, or nitroglycerin
100-200 mcg) are administered  prevent spasm
• Intravenous heparin is also administered (usually 50 units/kg up to 5000 units for diagnostic
catheterization, although a dose of 100 units/kg may be more effective)  prevent radial artery
occlusion.

SECURING
Goal?
• To prevent sheath movement.
How?
Movement of the sheath may be prevented
using one of several maneuvers:
• Clip the side arm of the sheath to the
drape with a hemostat.
• Use a plastic adhesive cover, such as a
Tegaderm.
• Suture the sheath to the skin.
• If the Stand Tall device (RADUX Devices,
LLC) is used for left radial access, use the
provided clasp that has adhesive backing Securing the radial sheath to the drape with a hemostat.

Navigating the Upper Extremity
Arterial System
• Once arterial access is
obtained, a 0.035 inch
guidewire (1.5-mm-
radius J-tip ) and a
catheter of choice are
advanced into the
ascending aorta
traversing the upper
extremity arterial system

AHA SCIENTIFIC STATEMENT
Circ Cardiovasc Interv. 2018;11:e000035. DOI: 10.1161/HCV.0000000000000035

• A radial-first approach is strongly recommended in
all patients
• Noninvasive testing for collateral hand circulation
(Allen or Barbeau test) does not predict adverse
outcomes and should not be used for access site
triage
• Ulnar artery access is an alternative among
experienced operators for patients with prohibitive
RA anatomy
• Ultrasound guidance facilitates vascular access,
particularly in the setting of a weak pulse,
hypotension, cardiogenic shock, or transulnar access
• Low-profle hydrophilic sheaths should be used to
reduce patient discomfort and to prevent RA spasm

BARBEAU TEST
• The Barbeau Grading
System for assessment of
collateral circulation of the
palmar arch
• The presence of an arterial
waveform on
plethysmography (even if
delayed or with reduced
amplitude) and an oxygen
saturation above 90% (
Grades A, B, and C) confirm
the presence of dual
circulation to the hand.

ULTRASOUND
GUIDANCE

• Administration of local anesthesia, achievement of mild to moderate sedation,
and provision of a warm environment are interventions that reduce patient
anxiety, discomfort, and RA spasm
• Calcium channel blockers (verapamil 2.5–5 mg, diltiazem 2.5–5 mg, or
nicardipine 250–500 µg) and nitroglycerin (100–200 µg) reduce RA spasm and
should be administered intra-arterially after sheath insertion and possibly with
catheter exchanges or before sheath removal
• Caution should be exercised with the use of spasmolytics in patients with
cardiogenic shock, severely reduced ejection fraction, or severe aortic stenosis
• Intraprocedural anticoagulation (unfractionated heparin 50 U/kg up to 5000 U
or comparable doses of enoxaparin or bivalirudin) should be administered to
all patients to prevent RAO and should otherwise follow current guidelines in
ACS management.

• A 1.5-mm-radius J-tip 0.035-inch wire may safely navigate the
majority of peripheral tortuosity
• Deep inspiration and use of stiff-bodied J wires for catheter
exchanges may facilitate procedures in the presence of signifcant
aorto-subclavian tortuosity
• For diffcult upper extremity anatomy, use of a 0.014-inch wire with
subsequent exchange to a 0.035-in wire may be considered
• Balloon-assisted tracking and catheter-assisted tracking techniques
may also help navigate catheters traversing signifcant upper extremity
vascular tortuosity or spasm

EFFECT OF INSPIRATION
Richard Casazza (2018). “Blowout” Technique: Deep Expiration for Wire Navigation Into the Ascending Aorta With Severe Subclavian Tortuosity From the Right Radial Approach.
DEEP INSPIRATION: the diaphragm
lowers the heart  straightens the angle
(a)  more vertical direction toward the
ascending aorta.
EXPIRATION: more acute angle (a)
between the brachiocephalic trunk and
the ascending aorta  more horizontal
direction toward the descending aorta

“BLOWOUT” TECHNIQUE
Richard Casazza (2018). “Blowout” Technique: Deep Expiration for Wire Navigation Into the Ascending Aorta With Severe Subclavian Tortuosity From the Right Radial Approach.
DEEP INSPIRATION
• Aorta & right subclavian are distended
 straightening out  allowing for
catheters to pass into the AA
• Creates a rigid pathway for catheters
• Bias catheters towards the descending
aorta
DEEP EXPIRATION
• “Softens” the anatomy  slightly
increases the lumen size  improve the
entry angle into the AA.

0.014-INCH WIRE
A. The anatomy of a radial loop.
B. The loop can be negotiated by
advancing an 0.014 inch
coronary wire with the support
of a short 4F hydrophilic-coated
catheter.
C. The catheter has already been
advanced through the loop and
the coronary wire exchanged for
an 0.035 inch guidewire.
The loop usually straightens as
the 0.035 inch wire passes
through or with gentle pullback
and counterclockwise torque of
the entire system

BAT TECHNIQUE
Circ Cardiovasc Interv. 2019;12:e007386. DOI: 10.1161/CIRCINTERVENTIONS.119.007386
Baloon-assisted tracking (BAT) technique used to overcome tortuosity (example shown illustrates tortuosity in high
take-off radial artery), spasm, loops, or small arteries.

PAT TECHNIQUE
Catheterization and Cardiovascular Interventions 83:211–220 (2014), DOI: 10.1002/ccd.24959 - Indian Heart J. (2016), http://dx.doi.org/10.1016/j.ihj.2016.03.016
Pigtail-assisted tracking (PAT) technique
(a) Guide catheter loaded over 0.035 inch
guidewire. Note the wide free space
between the inner lumen of guide catheter
and guidewire. Sharp edge at guide catheter
tip works like a ‘‘razor blade’’
(b) Pigtail catheter fills this wide free space
and abolishes the ‘‘razor-blade’’ effect.
Additionally, it works like the dilator of EBU
guide catheter and helps in navigating the
complex forearm vasculature.
(c) ‘‘Pigtail catheter-EBU guide catheter
assembly’’; 5 Fr pigtail catheter inside the 6
Fr EBU guide catheter.

• In addition to previously recommended
MOPH (maintenance of patent
hemostasis) and full procedural
anticoagulation, simultaneous
prophylactic ulnar artery compression
may be considered to prevent RAO
• Simultaneous ulnar artery compression
and systemic anticoagulation may also
be used to treat RAO
• Major vascular complications after TRA
are uncommon, and their consequences
are generally benign when recognized
early and managed appropriately.

PATENT HEMOSTASIS

• Distal pulse, plethysmography signal,
forearm pain and tenderness, and skin
temperature and color should be monitored
during the postprocedural observation
period
• The presence of forearm pain should raise
suspicion of hematoma. Early recognition of
hematomas and venous congestion is critical
to avoid more signifcant complications.
• Bed rest should be avoided, and early
ambulation needs to be encouraged.

COMPLICATIONS

COMPLICATIONS
Catheterization and Cardiovascular Interventions 78:840–846 (2011). DOI 10.1002/ccd.22978

RADIAL ARTERY PERFORATION
Am Coll Cardiol Case Rep 2019;1:737–41. DOI: https://doi.org/10.1016/j.jaccas.2019.10.016
• Rare complication (0.08%)
• Perforation  hematoma  compartment syndrome
• Balloon-tracking techniques (BAT)  advance guiding catheter  complete procedure

RADIAL
ARTERY
PERFORATION

RADIAL ARTERY PERFORATION
Am Coll Cardiol Case Rep 2019;1:737–41. DOI: https://doi.org/10.1016/j.jaccas.2019.10.016
(A) Balloon tamponade
failed to occlude the
radial recurrent branch
(2.5-15 mm semi-
compliant balloon, with
2 episodes of 10-min
inflations
(B) Covered stent
reduced the flow but did
not stop it completely
(C) After post-dilatation
of covered stent with a 4-
mm non-compliant
balloon, the radial
recurrent branch was
sealed completely.

FOREARM
HEMATOMA

FOREARM HEMATOMA
Management with the pressure bandage Management with the sphygmomanometer

FOREARM
HEMATOMA
J Vasc Interv Radiol 2017;29(3):1–6. DOI: https://doi.org/10.1016/j.jvir.2017.11.010

COMPARTMENT SYNDROME
J Interven Cardiol 2008;21:380–384. DOI: 10.1111/j.1540-8183.2008.00361.x
• One of the most feared complications
• Definition: increase in tissue pressure (normal
up to 9 mmHg) within a non-expandable space
• Mechanism: Elevated pressure  impedes the
normal capillary flow & lymphatic drainage 
progressive tissue edema & increased
interstitial pressure (vicious circle)  muscular
and nervous damage
• Diagnosis is based on symptoms, not imaging
or other diagnostic tests
• Acute pain and tumefaction
• Distal sensitivity disturbances & distal
pallor with preserved radial and ulnar
pulses
• “5P’s” (pain, pallor, painful stretching of
muscles, paresthesia, and pulselessness)

COMPARTMENT
SYNDROME
• Management:
• Surgical fasciotomy of the forearm
• Prevention:
• Circumferential compression to the
forearm, using an elastic bandage or a
blood pressure cuﬀ inflated up to 15
mmHg below the systolic blood
pressure, until the coagulation
parameters return to normal values,
usually after 1 or 2 hours
• A pulse oximeter should be placed in
the ipsilateral thumb to monitor for
hand ischemia

RADIAL ARTERY SPASM (RAS)
• Defined as a temporary, sudden
narrowing of the radial artery
• After several unsuccessful puncture
attempts  radial pulse disappears
due to spasm
• Management:
 Reassess the sedation status of the
patient
 Consider administering 200 to 400 mcg of
subcutaneous nitroglycerin at the site of
the lost radial pulse
 Wait for 5 to 10 minutes until the pulse
reappears before attempting a new
puncture Catheterization and Cardiovascular Interventions 68:389–391 (2006). DOI 10.1002/ccd.20881

• RAS is one of the most common
TRA complication and a frequent
reason for access failure
• Causes:
• Smaller caliber
• Large muscular media
• Higher receptor-mediated
vasomotion
• Manifestations:
• Severe forearm pain
• Difficult manipulation of the
catheters and the sheath

• Management:
• Additional doses of intraarterial vasodilators,
sedation
• Using smaller 4F to 5F catheters to complete the
procedure
• No improvement  limited upper extremity
angiography to rule out vascular anomalies
• Catheter or sheath entrapment due to spasm 
warm wet compresses can be applied over the
skin of the upper extremity  remove slowly
• Prevention:
• Using a hydrophilic-coated sheath
• Injection of a single vasodilator or a cocktail of
vasodilators through the sidearm immediately
after obtaining access
Catheterization and Cardiovascular Interventions 78:840–846 (2011).DOI 10.1002/ccd.22978

BP indicates blood
pressure; IA, intra-
arterial; NTG,
nitroglycerin; PO, oral;
PRN, as needed; SL,
sublingual; and SQ,
subcutaneous

CATHETER KINKING/TWISTING
IHJ Cardiovascular Case Reports (CVCR) 2 (2018) S62eS65. DOI: https://doi.org/10.1016/j.ihjccr.2018.08.010
Twisted catheter at elbow level How it might have twisted

EXTERNAL COMPRESSION
Catheter kink management using external compression (sphygmomanometer): external
fixation can be achieved externally using a sphygmomanometer that fixes the catheter (A) and
allows untwisting of the knot (B and C)

MOTHER & CHILD TECHNIQUE
(A) Complex catheter kink withdrawn to
brachial artery above the elbow
(B) Cutting of catheter close to hub (C)
Withdrawal of existing short sheath over
the cut catheter  advance a longer 6F
sheath over the catheter and wire using
the sheath dilator for assistance
(D) Catheter kink in brachial artery and
original sheath at level of mid radial
artery
(E) Longer sheath advanced to level of
brachial artery
(F) Kinked catheter straightened within
long sheath and can be removed,
avoiding trauma to radial artery
Technique for catheter kink management via swallowing
with long sheath.

CATHETER KINKING/TWISTING
IHJ Cardiovascular Case Reports (CVCR) 2 (2018) S62eS65. DOI: https://doi.org/10.1016/j.ihjccr.2018.08.010
MANAGEMENT:
1. Rotating the catheter in opposite direction
2. Use 0.035” guidewire pass through the
catheter to straighten the loop
3. Use of a stiff 0.014” guidewire to cross the
kinked segment
4. Mother and child technique
5. External compression (apply a
sphygmomanometer cuff to the upper arm 
inflated at 20 mmHg pressure above SPB to
secure the upper end of catheter  rotate to
untwist the catheter)
6. Gooseneck snare from femoral access 
untwist catheter

RADIAL ARTERY OCCLUSION (RAO)
Catheter Cardiovasc Interv. 2018;92:860–861. DOI: https://doi.org/10.1002/ccd.27937
RAO is the most frequent post-
procedural complication of TRA
Etiology:
• Endothelial injury from sheath
placement  thrombus formation
Rate:
• Range 1–10%
Manifestation:
• Intact collateral palmar circulation
 asymptomatic (mostly)
• No require further treatment
• Restricting the use of the same
radial artery for future procedures
and as a conduit for CABG or AVF

RADIAL ARTERY OCCLUSION (RAO)

RAO PREVENTION

ROLE OF HEPARIN?
Am J Cardiol 2012;110:173–176. DOI: 10.1016/j.amjcard.2012.03.007

DISTAL RADIAL ACCESS
JACC Cardiovasc Interv. 2022 Jun 27;15(12):1191-1201. doi: 10.1016/j.jcin.2022.04.032. Epub 2022 May 17.
Recently, distal radial access
(DRA) has emerged as a
promising alternative access to
minimize RAO risk.
Anatomical landmarks of
transradial artery access (TRA):
• Conventional TRA: puncture
site at wrist level
• DRA: punctures sites in the
anatomical snuffbox and in
the dorsum of the hand.

site at wrist level
• Distal TRA: punctures sites in
the anatomical snuffbox and
in the dorsum of the hand.

JACC Cardiovasc Interv. 2022 Jun 27;15(12):1191-1201. doi: 10.1016/j.jcin.2022.04.032. Epub 2022 May 17.
site at wrist level
• Distal TRA: punctures sites in
the anatomical snuffbox and
in the dorsum of the hand.

CONCLUSIONS
1. A radial-first approach is strongly recommended in all patients
2. Using single-wall technique or double-wall technique
3. Administration of local anesthesia, mild sedation to reduce patient anxiety,
discomfort, and RA spasm
4. Maintenance of patent hemostasis (MOPH), using full procedural
anticoagulation and prophylactic ulnar artery compression to prevent RAO
5. Major complications of TRA are uncommon, and generally benign when
recognized early and managed appropriately.

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