Anticipating Failure:ROLE OF ARM IMAGING PRIOR TO       ARTERIAL ACCESS                  Sanjay Chugh      MD(Cal.),DM (AI...
Conflict of Interest StatementWithin the past 12 months, I or my spouse/partner have had a financial interest/arrangement ...
There`s been a paradigm shift in  interventional Cardiology to       transradial access           because of….    ↓ VASCUL...
BUT IF PATIENT INTEREST IS SUPREME             THEN……• IS A TRIAL & ERROR APPROACH by operators  on their Radial Learning ...
A SCIENTIFIC APPROACH TO        ↓TRIAL & ERROR               in      THE LEARNING CURVE& HENCE CROSS-OVER, RADIATION   TIM...
So What`s the trial & error about ?         In the `Learning Curve`                      which may lead to                ...
SIZE MATTERS……•PUNCTURING SMALL ARTERIES IS MORE   DIFFICULT!•SPASM IS MORE IN SMALLER ARTERIES                           ...
SHORT STATURE (OR:0.97; 95% CI: 0.95 to 0.99, p = 0.02) & AGE>75 (odds ratio [OR]: 3.86; 95%                           con...
OYE Let Go…Yeow**!                                                  RA Spasm   VARIABLE                  ALL 783       NO ...
Is it okay to shove any size Guiding       Catheter into any Radial artery ?eg   A 7F GUIDE INTO A 1.7 mm ARTERY ?
Of course not!    (SHEATH / GUIDING ) > 1:1 : (RA)                         initiates spasm SPASM MAKES CATHETER MANIPULATI...
HOW DO WE DECIDE IF THE ARTERY IS BIG ENOUGH TO SAFELY TAKE WHAT   YOU WANT TO SHOVE INTO IT ?            SIZE IT
RA Sizing                          ASE 2007SCAI 2011 Dr Sanjay Chugh. Guide Cath                                        13...
FAILURE:        (1) SMALL ARTERY SIZE AND SPASM :                   (2) LOOPS / ANOMALIES/ STENOSIS        •7% of procedur...
CAN WE ANTICIPATE FAILURE          & HENCEENHANCE SUCCESS BY AVOIDING  THESE BY PRE-PROCEDURE         IMAGING?
YES, BY KNOWING THE HAND      BEFORE-HAND ! ENHANCE SUCCESS BY ANTICIPATING            FAILURE
Feasibility and Utility of Pre-procedure Ultrasound Imaging ofthe Arm to facilitate Trans-Radial     Coronary Diagnostic a...
•   Pre-procedure ultrasound assessment of the Right and Left Radial, Ulnar, andBrachial arteries, using a linear probe in...
• Prospective Single center Registry• Consecutive patients undergoing diagnostic  and interventional procedures (2006 to 2...
Methods:
Linear, transducer with the frequency L 12-3 MHz (Philips Medical Systems,           IE 33 & HD7, USA)
MEASURING RADIAL ARTERY      DIAMETER
NORMAL BIFURCATION
PARALLEL RADIAL AND ULNAR
HIGH ORIGIN OF RADIAL FROM BRACHIAL: OFTEN RADIAL          ARTERY IS OF SMALL DIAMETER
HIGH ORIGIN OF RADIAL FROM BRACHIAL: OFTEN    RADIAL ARTERY IS OF SMALL DIAMETER
RADIAL ARTERY LOOP
While radial artery loops and tortuosity may beeasily traversed with 0.014” guidewires, doing soincreases procedure time a...
NORMAL TRIPHASIC FLOW
BIPHASIC FLOW MEANS UPSTREAM            BLOCK
Stenosis in upstream RA can cause      procedural delay or failure & crossover           (CAN BE PICKED UP BY DOPPLER PRE-...
NEVER NEEDED TO LOOK FOR UPSTREAM        OBSTACLES EXCEPT ONCEBECAUSE WE WERE IN AN ACCESSORY SMALL    RADIAL INSTEAD OF U...
Access Artery (Radial/Ulnar) Selection          for Angiogram or PCI            (BRACHIAL NEVER USED)• 5F in ≥ 1.6mm for a...
PREFERENCE ORDER FOR ACCESS SIDE• RIGHT SIDE PREFERRED IN MOST• LEFT ACCESS PREFERRED in PCI to Shepherd  crook/ tortuous/...
PREFERENCE ORDER FOR CHOICE OF           ACCESS ARTERY        (RRA >LRA>RUA>LUA)• RADIAL OVER ULNAR• ULNAR PREFERRED only ...
Aortic root 3.8 cm     LT RADIAL 1.8 Cm        ULNAR 2.1 CmRt Radial 1.8 cmUlnar 1.7 cm
Spasm was recorded as per the              following grades:• Grade-4: Severe pain and spasm disallowing any catheter move...
RESULTS
Illustration-5                                              N=6125                                           Presented for...
PATIENT DEMOGRAPHICS1.Sex                   1179(63%) M;                   693(37%) F2.Mean age (yrs)   51.6 (±23.7)RISK F...
CLINICAL DIAGNOSISStable Angina including    711(38%)Post MI *& patients with positiveStress testUnstable Angina/ACS      ...
ARM IMAGING (ULTRASOUND) TIME• The mean time (bilateral forearm )=  6.4 min ± 1.8min(95% confidence interval).
Our ultrasound strategy only required   a minimum of effort and time• 62% in the inpatient setting (Coronary care  Unit an...
Doppler assessment of anomaly was        accurate in all cases                onCOMPARISON WITH ANGIOGRAPHIC           ASS...
SIZE OF RADIAL & ULNAR         ARTERY ON THE 2 SIDESSIZE OF RADIAL & ULNAR ARTERY         MEANON THE 2 SIDES              ...
Table-II: +ve Correlations of Radial           artery with Ulnar artery size                                              ...
Table III- 9.8 %  Incidence of Anomalies in Radial Artery in the study                     populationAnomalies            ...
Illustration-4mm   mm 5F   mm 6F   mm 7F   mm 8F
SPASM• Insignificant spasm (≤grade -2) occurred in  19.5%,• while significant spasm (grade -3) occurred in  1.5%.• Spasm g...
Angiography( Transradial(85.8%);Transulnar(14.2%)      62%=right; 38%=left Access• Crossover : 1.3%• Radiation time :2.1mi...
VESSEL & LESION TYPE                                  (n=570)SVD*           MVD**                       LAD   RCA   LCX72%...
PCI TRANSRADIAL (90%);TRANSULNAR (10%)       55%=left; 45%=right access• CROSSOVER =2.4%• RADIATION TIME: 12.6 ± 9 mins (f...
We may have prevented failure, access site crossover,or patient discomfort in nearly 30% of our cases with           Pre-p...
Success & Crossover                 In our study• Left Access  55% PCI & 38% Angiograms• SUCCESS >97.6 % (> Success of 95%...
RIVAL                                TRI                                Radial     Femoral       P                        ...
ACCESS ARTERY SPASM ComparisonOur Study• Significant spasm (grade -3) = 1.5%.• PROCEDURE FAILURE B/O Spasm = 1 patient .• ...
LIMITATION-1• We did not randomize patients to an  ultrasound-based strategy or usual care;  therefore, our comparisons of...
A journey of a 1000 miles begins with           the 1st step…..• The purpose of our study was to describe our  experience,...
LIMITATION-2• One operator performed all of the ultrasound  procedures, and• One separate operator performed all of the  c...
COST IMPLICATIONS• Cost -effectiveness OF PRE-PROCEDURE ARM  IMAGING was not studied.• THE COST OF PRE PROCEDURE ULTRASOUN...
Impact on RA /UA Occlusion• not tested in our study,• is being done as a part of an on going study at  our Institution..
CONCLUSION
This single center prospective registry showsPRE-PROCEDURE ULTRASOUND IMAGING  OF ARM ARTERIAL STRUCTURES IS  *FEASIBLE,  ...
RANDOMIZED STUDY NEEDED        BUT…. WOULD I EVER DO A TRANSRADIAL WITHOUT PRE-PROCEDURE ARM           IMAGING;           ...
Thanks
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Chugh S 201111

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Anticipating Failure: Role of Arm Imaging Prior to Arterial Access

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Chugh S 201111

  1. 1. Anticipating Failure:ROLE OF ARM IMAGING PRIOR TO ARTERIAL ACCESS Sanjay Chugh MD(Cal.),DM (AIIMS), MRCP(I), FACC, FSCAI(USA) Principal Consultant, Interventional Cardiology, Fortis Escorts Heart Institute, New Delhi, India
  2. 2. Conflict of Interest StatementWithin the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliationwith the organization(s) listed below.Physician Name Company/Relationship NONE NONE
  3. 3. There`s been a paradigm shift in interventional Cardiology to transradial access because of…. ↓ VASCULAR COMPLICATIONS ↑PATIENT COMFORT
  4. 4. BUT IF PATIENT INTEREST IS SUPREME THEN……• IS A TRIAL & ERROR APPROACH by operators on their Radial Learning Curve justified even at the expense of ↑ procedure failure, complications and patient inconvenience?
  5. 5. A SCIENTIFIC APPROACH TO ↓TRIAL & ERROR in THE LEARNING CURVE& HENCE CROSS-OVER, RADIATION TIME, PATIENT DISCOMFORT & PROCEDURE FAILURE Is therefore needed
  6. 6. So What`s the trial & error about ? In the `Learning Curve` which may lead to TR Procedure failure (~5%)• ACCESS RELATED 52.6%(Guedes et al, J INVASIVE CARDIOL 2010;22:391–7)• Inability to advance guide catheter to ascending aorta 51% ( Dehghani P et al(JACC Cardiovasc Interv. 2009 ;2(11):1057-64.)• RADIAL ARTERY SPASM 38% (Circ Cardiovasc Interv. Ball WT, et al2011e pub)
  7. 7. SIZE MATTERS……•PUNCTURING SMALL ARTERIES IS MORE DIFFICULT!•SPASM IS MORE IN SMALLER ARTERIES “ predictors of failure= "small radial artery" size (OR 2.6, 95% CI 1.4 to 5.0; p = 0.003) or a "difficult access" (OR 2.5, 95% CI 1.3-4.9; p = 0.006)”. Guedes et al, 1.7 mm Radial artery RA spasm J INVASIVE CARDIOL 2010;22:391–397
  8. 8. SHORT STATURE (OR:0.97; 95% CI: 0.95 to 0.99, p = 0.02) & AGE>75 (odds ratio [OR]: 3.86; 95% confidence interval [CI]: 2.33 to 6.40, p = 0.0006) = INDEPENDENT PREDICTORS OF FAILURE 142 cm 36 kg 1 mm; R Ao root 1.2 mm U 2.4cm 1.4 mm R; 1.5 mm U SCAI 2011 Dr Sanjay Chugh. Guide Cath selection for Transradial PCI
  9. 9. OYE Let Go…Yeow**! RA Spasm VARIABLE ALL 783 NO RAS RAS 230 P 553 Female 202 (25.) 115 (20.) 87 (37.8) <0.001 Diabetes 155 (19.8) 97 (17.5) 58 (25.2) 0.018 Height, cm 168.84 ± 9.7 169.6 ± 9.7 166.8 ± 9.5 <0.001 6 Weight, kg 83.65 ± 16.3 85 ± 16.24 80.3 ± 16.32 <0.001 9 BMI, kg/m2 29.27 ± 4.87 29.48 ± 4.95 28.76 ± 4.64 0.05 Wrist 17.24 ± 1.20 17.37 ± 1.17 16.92 ± 1.19 <0.001 circumferen ce, cm (Rathore S, JACC Cardiovasc Interven 2010;3(5):475)
  10. 10. Is it okay to shove any size Guiding Catheter into any Radial artery ?eg A 7F GUIDE INTO A 1.7 mm ARTERY ?
  11. 11. Of course not! (SHEATH / GUIDING ) > 1:1 : (RA) initiates spasm SPASM MAKES CATHETER MANIPULATION DIFFICULT---> Saito et al.CCI 46, 1999:173 LEADS TO RADIAL OCCLUSION
  12. 12. HOW DO WE DECIDE IF THE ARTERY IS BIG ENOUGH TO SAFELY TAKE WHAT YOU WANT TO SHOVE INTO IT ? SIZE IT
  13. 13. RA Sizing ASE 2007SCAI 2011 Dr Sanjay Chugh. Guide Cath 13 selection for Transradial PCI
  14. 14. FAILURE: (1) SMALL ARTERY SIZE AND SPASM : (2) LOOPS / ANOMALIES/ STENOSIS •7% of procedural failure& CROSSOVER (Jolly SS, et alAm Heart J. 2009 Jan;157(1):132-40 in transradial intervention is due to radial artery tortuosity, loops, or stenosis (Dehghani P ,et al.JACC Cardiovasc Interv. 2009 BRACHIAL Nov;2(11):1057-64.) ULNAR RADIAL•Inability to advance the wire or catheter through the brachial artery accounts forup to 73% of procedural failure (Guedes et al, JIC 2010).
  15. 15. CAN WE ANTICIPATE FAILURE & HENCEENHANCE SUCCESS BY AVOIDING THESE BY PRE-PROCEDURE IMAGING?
  16. 16. YES, BY KNOWING THE HAND BEFORE-HAND ! ENHANCE SUCCESS BY ANTICIPATING FAILURE
  17. 17. Feasibility and Utility of Pre-procedure Ultrasound Imaging ofthe Arm to facilitate Trans-Radial Coronary Diagnostic and Interventional Procedures. TCT 2011 (In Press)
  18. 18. • Pre-procedure ultrasound assessment of the Right and Left Radial, Ulnar, andBrachial arteries, using a linear probe in all patients.• Endpoints: Incidence and Correlates of : * Arterial anomalies * Procedure success * Crossover to alternate access * Fluoroscopy time * Ultrasound assessment time.• Patient Demographics, Medical history, and Procedural characteristics , angiographic assessment of arm arteries were recorded
  19. 19. • Prospective Single center Registry• Consecutive patients undergoing diagnostic and interventional procedures (2006 to 2011).• Institutions: Fortis Escorts Heart Institute New Delhi, (including Fortis Escorts Kalyani Heart Centre, Gurgaon) India,
  20. 20. Methods:
  21. 21. Linear, transducer with the frequency L 12-3 MHz (Philips Medical Systems, IE 33 & HD7, USA)
  22. 22. MEASURING RADIAL ARTERY DIAMETER
  23. 23. NORMAL BIFURCATION
  24. 24. PARALLEL RADIAL AND ULNAR
  25. 25. HIGH ORIGIN OF RADIAL FROM BRACHIAL: OFTEN RADIAL ARTERY IS OF SMALL DIAMETER
  26. 26. HIGH ORIGIN OF RADIAL FROM BRACHIAL: OFTEN RADIAL ARTERY IS OF SMALL DIAMETER
  27. 27. RADIAL ARTERY LOOP
  28. 28. While radial artery loops and tortuosity may beeasily traversed with 0.014” guidewires, doing soincreases procedure time and radiation exposureto the patient and operator, and also may result insignificant spasm and discomfort for the patient.
  29. 29. NORMAL TRIPHASIC FLOW
  30. 30. BIPHASIC FLOW MEANS UPSTREAM BLOCK
  31. 31. Stenosis in upstream RA can cause procedural delay or failure & crossover (CAN BE PICKED UP BY DOPPLER PRE-PROCEDURE)PLETHYSMOGRAPHY MAYNOT PICK THIS UP! Stenosis in Radial artery------------------ Why diversify ?
  32. 32. NEVER NEEDED TO LOOK FOR UPSTREAM OBSTACLES EXCEPT ONCEBECAUSE WE WERE IN AN ACCESSORY SMALL RADIAL INSTEAD OF ULNAR ARTERY
  33. 33. Access Artery (Radial/Ulnar) Selection for Angiogram or PCI (BRACHIAL NEVER USED)• 5F in ≥ 1.6mm for angio; 6F≥1.8 mm for PCIKnowledge of the arm anatomy allowed us to choose :• The Biggest artery• Without anomaly/abnormality
  34. 34. PREFERENCE ORDER FOR ACCESS SIDE• RIGHT SIDE PREFERRED IN MOST• LEFT ACCESS PREFERRED in PCI to Shepherd crook/ tortuous/ calcific RCA• Access opposite to arm with previous injuryscar/fracture /Venous cannula/phlebitis
  35. 35. PREFERENCE ORDER FOR CHOICE OF ACCESS ARTERY (RRA >LRA>RUA>LUA)• RADIAL OVER ULNAR• ULNAR PREFERRED only IF *LOOP OR PARALLEL RADIAL & ULNAR *IF BOTH RADIALS WERE SMALL (PROVIDED ULNAR CONSIDERED EASY TO COMPRESS MANUALLY FOR HEMOSTASIS)• Groin was used if both arteries in both arms were unsuitable because of small size or anomaly.
  36. 36. Aortic root 3.8 cm LT RADIAL 1.8 Cm ULNAR 2.1 CmRt Radial 1.8 cmUlnar 1.7 cm
  37. 37. Spasm was recorded as per the following grades:• Grade-4: Severe pain and spasm disallowing any catheter movement necessitating crossover.• Grade-3: Moderate pain and spasm restricting catheter movement & necessitating a pause in procedure and > 2 doses of additional intra- arterial Diltiazem or Verapamil> 5mg and/ or > 1 mg of intravenous Midazolam .• Grade-2: Mild pain and spasm not restricting catheter movement ; no pause in procedure but > 1 dose of (additional) intra-arterial Diltiazem (or Verapamil) of 5mg and / or 0.5 mg of intravenous Midazolam .• Grade-1: Mild pain and spasm not restricting catheter movement ; no pause in procedure and only 1 dose of either or both intra-arterial Diltiazem (or Verapamil) of 5mg and/or > 0.5 mg of intravenous Midazolam.
  38. 38. RESULTS
  39. 39. Illustration-5 N=6125 Presented for Angiogram/PCI* (2006- 2011) 2344 Complete ultrasound data on arm arteries 12.9% (n=279) unsuitable 8.9% (n=193) unsuitable for trans- radial / trans- for even for an angiogram Remaining 1872 patientsulnar PCI*(because of small underwent a transradial / because of small radial &diameter of bilateral radial transulnar procedure Ulnar arteries and ulnar arteries) *PCI=Percutaneous Coronary Intervention
  40. 40. PATIENT DEMOGRAPHICS1.Sex 1179(63%) M; 693(37%) F2.Mean age (yrs) 51.6 (±23.7)RISK FACTORS1.Diabetic 569(30.4%)2.Tobacco abuse 624(33%)3.Hypertensive 649(34.6%)4.Dyslipidemia 702(37.5%)•
  41. 41. CLINICAL DIAGNOSISStable Angina including 711(38%)Post MI *& patients with positiveStress testUnstable Angina/ACS 1161(52%)
  42. 42. ARM IMAGING (ULTRASOUND) TIME• The mean time (bilateral forearm )= 6.4 min ± 1.8min(95% confidence interval).
  43. 43. Our ultrasound strategy only required a minimum of effort and time• 62% in the inpatient setting (Coronary care Unit and Wards);• in 33% patients our protocol could be implemented on the day of the procedure in the pre-procedure area.• 5% of the ultrasound studies were performed in the clinic setting
  44. 44. Doppler assessment of anomaly was accurate in all cases onCOMPARISON WITH ANGIOGRAPHIC ASSESSMENT
  45. 45. SIZE OF RADIAL & ULNAR ARTERY ON THE 2 SIDESSIZE OF RADIAL & ULNAR ARTERY MEANON THE 2 SIDES Diameter (mm)Left Radial Artery Male 1.8±0.29 Female 1.7±0.26Left Ulnar Artery Male 1.8±0.30 Female 1.7±0.3Right Radial Artery Male 1.9±1.12 Female 1.7±0.29Right Ulnar Artery Male 1.8±0.30 Female 1.6±0.28
  46. 46. Table-II: +ve Correlations of Radial artery with Ulnar artery size Left Radial Artery Left Ulnar ArteryLeft Radial Artery Pearson Correlation 1 .404(**) Sig. (2-tailed) 0.000Left Ulnar Artery Pearson Correlation .404(**) 1 Sig. (2-tailed) 0.000 **. Correlation is significant at the 0.01 level (2-tailed). Right Radial Artery Right Ulnar Artery Right Radial Artery Pearson Correlation 1 .416(**) Sig. (2-tailed) 0.000 Right Ulnar Artery Pearson Correlation .416(**) 1 Sig. (2-tailed) 0.000
  47. 47. Table III- 9.8 % Incidence of Anomalies in Radial Artery in the study populationAnomalies Radial ArteryIntimal thickness 3.6%Parallel Radial and Ulnar suggesting 4.7%possibility of high origin of radialfrom Brachial or Radioulnar loop orsimilar anomalyLoop seen at Cubital Fossa 0.9%Blocked artery 0.6%
  48. 48. Illustration-4mm mm 5F mm 6F mm 7F mm 8F
  49. 49. SPASM• Insignificant spasm (≤grade -2) occurred in 19.5%,• while significant spasm (grade -3) occurred in 1.5%.• Spasm grade-4 occurred in 1 patient .
  50. 50. Angiography( Transradial(85.8%);Transulnar(14.2%) 62%=right; 38%=left Access• Crossover : 1.3%• Radiation time :2.1min for TRCA/TUCA (R=1.9min;L=2.3min)• Successful : 98.7%
  51. 51. VESSEL & LESION TYPE (n=570)SVD* MVD** LAD RCA LCX72% 28% 42% 32% 26% A+B1 B2 C*SVD=SINGLEVESSEL 58% 32% 10%DISEASE**MVD= ACC/AHA LESION TYPEMULTI-VESSELDISEASE
  52. 52. PCI TRANSRADIAL (90%);TRANSULNAR (10%) 55%=left; 45%=right access• CROSSOVER =2.4%• RADIATION TIME: 12.6 ± 9 mins (for 1V TRI) (Left radial:14.4 min Right Radial: 11.1 min; P<0.01).• Success= 97.6%
  53. 53. We may have prevented failure, access site crossover,or patient discomfort in nearly 30% of our cases with Pre-procedure Arm Imaging
  54. 54. Success & Crossover In our study• Left Access 55% PCI & 38% Angiograms• SUCCESS >97.6 % (> Success of 95% in RIVAL)• Crossover = 2.4%( <7.6%in RIVAL & = crossover from Femoral to arm (2%)!)
  55. 55. RIVAL TRI Radial Femoral P (n=3507) (n=3514) PCI Success 95.4 95.2 0.83 Access site Cross-over (%) 7.6 2.0 <0.0001 PCI Procedure duration (min) 35 34 0.62 Fluoroscopy time (min) 9.3 8.0 <0.0001 Preference (%) 90 49 <0.0001
  56. 56. ACCESS ARTERY SPASM ComparisonOur Study• Significant spasm (grade -3) = 1.5%.• PROCEDURE FAILURE B/O Spasm = 1 patient .• PROCEDURE FAILURE B/O SPASM=38%(Circ Cardiovasc Interv. Ball WT, et al2011e pub )
  57. 57. LIMITATION-1• We did not randomize patients to an ultrasound-based strategy or usual care; therefore, our comparisons of radiation times , procedure success and access site crossover are with the published literature rather than direct comparison
  58. 58. A journey of a 1000 miles begins with the 1st step…..• The purpose of our study was to describe our experience, which is the first using a routine pre-procedure ultrasound evaluation of the arm arterial structures.
  59. 59. LIMITATION-2• One operator performed all of the ultrasound procedures, and• One separate operator performed all of the coronary procedures.• It is difficult to generalize our results to other operators who may have varying levels of experience with ultrasound imaging or radial procedures.
  60. 60. COST IMPLICATIONS• Cost -effectiveness OF PRE-PROCEDURE ARM IMAGING was not studied.• THE COST OF PRE PROCEDURE ULTRASOUND MAY BE OFFSET BY REDUCTION IN RADIATION TIME, PROCEDURAL COMPLICATIONS & FAILURE
  61. 61. Impact on RA /UA Occlusion• not tested in our study,• is being done as a part of an on going study at our Institution..
  62. 62. CONCLUSION
  63. 63. This single center prospective registry showsPRE-PROCEDURE ULTRASOUND IMAGING OF ARM ARTERIAL STRUCTURES IS *FEASIBLE, **REQUIRES MINIMUM TIME AND EFFORT, ***PROVIDES INFORMATION ON ARTERIAL SIZE AND ANATOMICAL VARIANTS ****THUS FACILITATING TR & TU PROCEDURES & REDUCING SPASM, CROSSOVER, PROCEDURE FAILURE & PT .DISCOMFORT
  64. 64. RANDOMIZED STUDY NEEDED BUT…. WOULD I EVER DO A TRANSRADIAL WITHOUT PRE-PROCEDURE ARM IMAGING; NEVER !
  65. 65. Thanks

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