Complications of Transradial Catheterization:What to Look For and How to Avoid Them              Amir Halkin        Tel Av...
Conflicts of interestNone to declare
Transradial Catheterization Complications                 Radial Artery Catheterization: The way to go                    ...
Transradial Catheterization Complications                 Radial Artery Catheterization: The way to go                    ...
Transradial Catheterization Complications                 Radial Artery Catheterization: The way to go                    ...
Transradial Catheterization Complications                 Radial Artery Catheterization: The way to go                    ...
Transradial Catheterization Complications:What to Look for and How to Avoid Them        Anatomical Considerations       Cl...
Transradial Catheterization Complications:What to Look for and How to Avoid Them        Anatomical Considerations       Cl...
Transradial Catheterization Complications:                       Anatomical Considerations  Congenital variants  Arterial ...
Transradial Catheterization Complications:                     Anatomical ConsiderationsCongenital anatomical variantsLoca...
Transradial Catheterization Complications:                     Anatomical ConsiderationsCongenital anatomical variantsLoca...
Transradial Catheterization Complications:                     Anatomical ConsiderationsCongenital anatomical variantsLoca...
Transradial Catheterization Complications:                       Anatomical ConsiderationsArterial tortuosityLocation     ...
Transradial Catheterization Complications:                       Anatomical ConsiderationsArterial tortuosityLocation     ...
Transradial Catheterization Complications:                       Anatomical ConsiderationsArterial tortuosityLocation     ...
Transradial complicationsAnatomical ConsiderationsClassification and IncidencePrevention and Management
Transradial Catheterization Complications:                     Classification and IncidenceKanei al. CCI 2011             ...
Transradial Catheterization Complications:                     Classification and IncidenceKanei al. CCI 2011             ...
Transradial Catheterization Complications:                                       Risk FactorsEvent                        ...
Transradial Catheterization Complications:                                       Risk FactorsEvent                        ...
Transradial Catheterization Complications:      Radial Occlusion and Critical Hand Ischemia      Case Report (I)Kanei et a...
Transradial Catheterization Complications:Critical Hand Ischemia
Transradial Catheterization Complications:Critical Hand Ischemia                      “Hand ischemia with necrosis has    ...
Transradial Catheterization Complications:                      Case Report (II)56 y.o. ♀Suspected troponin positive ACSUr...
Transradial Catheterization Complications:                      Case Report (II)Vascular surgery consult: heparin, analgesia
Transradial Catheterization Complications:         Case Report (II)            RAO         can result in  critical hand is...
Transradial complicationsAnatomical ConsiderationsClassification and IncidencePrevention and Management
Transradial Catheterization Complications:                             PreventionCase selectionAccessNegotiation of upper ...
Transradial Catheterization Complications:                             PreventionCase selection         •Age, gender      ...
Transradial Catheterization Complications:                             PreventionCase selection         •Age, gender      ...
Transradial Catheterization Complications:                              PreventionCase selection          •Age, gender    ...
Transradial Catheterization Complications:                              PreventionCase selection          •Age, gender    ...
Transradial Catheterization Complications:                              PreventionCase selection          •Age, gender    ...
Transradial Catheterization Complications:       Prevention: Palmar arch circulation                  •absent ulnar 0.01-0...
Transradial Catheterization Complications:               Prevention: Palmar arch circulation        Barbeau TestBarbeau et...
Transradial Catheterization Complications:                   Prevention: Patent hemostasisPancholy et al. PROPHET. CCI 200...
Transradial Catheterization Complications:                   Prevention: Patent hemostasisPancholy et al. PROPHET. CCI 200...
Transradial Catheterization Complications:                          Prevention and ManagementEvent                        ...
Transradial Catheterization Complications:                          Prevention and ManagementEvent                        ...
Transradial Catheterization Complications:Prevention and Management of Critical Hand Ischemia What should be done when rad...
Transradial Catheterization Complications:                       Prevention of Hand ischemia       Ulnar compression can r...
Transradial Catheterization Complications:                    Prevention of Hand ischemia       Ulnar compression can reso...
Transradial Catheterization Complications:                 Management of Hand ischemia        Early angiography and interv...
Transradial Catheterization Complications:                         SummaryThough generally very safe, serious potentialcom...
Transradial Catheterization Complications                       Radial vs. Femoral AccessRIVAL. LANCET 2011               ...
Transradial Catheterization Complications                     Radial vs. Femoral AccessRIVAL. LANCET 2011                 ...
Transradial Catheterization Complications:            Anatomical ConsiderationsRadial Anomaly        vs. No Radial anomaly...
Transradial Catheterization Complications:                             Prevention: Access            Hydrophilic sheath us...
Transradial Catheterization Complications:                              Prevention: Access    Route of heparin administrat...
Transradial Catheterization Complications:                    Prevention: Access      •Local anesthesia, liberal analgesia...
Transradial Catheterization Complications:Prevention: Upper Extremity Vessel Negotiation    •Minimize use of non-”J-tipped...
Transradial Catheterization Complications:Prevention: Upper Extremity Vasculature
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Complications of Transradial Catheterization: What to Look For and How to Avoid Them

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  1. 1. Complications of Transradial Catheterization:What to Look For and How to Avoid Them Amir Halkin Tel Aviv Medical Center Tel Aviv, Israel
  2. 2. Conflicts of interestNone to declare
  3. 3. Transradial Catheterization Complications Radial Artery Catheterization: The way to go MORTON KERN, 2009“The complications from radial artery access are trivial compared tofemoral, with <4% loss of radial artery pulse as the worst of it”http://www.cathlabdigest.com/articles/Radial-Artery-Catheterization-The-way-go
  4. 4. Transradial Catheterization Complications Radial Artery Catheterization: The way to go MORTON KERN, 2009“The complications from radial artery access are trivial compared tofemoral, with <4% loss of radial artery pulse as the worst of it”“Why do I persist with femoral artery access when complications fromradial access are so much lower?”http://www.cathlabdigest.com/articles/Radial-Artery-Catheterization-The-way-go
  5. 5. Transradial Catheterization Complications Radial Artery Catheterization: The way to go MORTON KERN, 2009“The complications from radial artery access are trivial compared tofemoral, with <4% loss of radial artery pulse as the worst of it”“Why do I persist with femoral artery access when complications fromradial access are so much lower?”“I left Quebec with the enthusiasm of a converted sinner, returning to UCIto begin our radial program ….”http://www.cathlabdigest.com/articles/Radial-Artery-Catheterization-The-way-go
  6. 6. Transradial Catheterization Complications Radial Artery Catheterization: The way to go MORTON KERN, 2009“The complications from radial artery access are trivial compared tofemoral, with <4% loss of radial artery pulse as the worst of it”“Why do I persist with femoral artery access when complications fromradial access are so much lower?”“I left Quebec with the enthusiasm of a converted sinner, returning to UCIto begin our radial program ….”http://www.cathlabdigest.com/articles/Radial-Artery-Catheterization-The-way-go
  7. 7. Transradial Catheterization Complications:What to Look for and How to Avoid Them Anatomical Considerations Classification and Incidence Prevention and Management
  8. 8. Transradial Catheterization Complications:What to Look for and How to Avoid Them Anatomical Considerations Classification and Incidence Prevention and Management
  9. 9. Transradial Catheterization Complications: Anatomical Considerations Congenital variants Arterial tortuosityLo et al. Heart 2009Rodriguez-Niedenfuhr et al. J Anatomy 2001
  10. 10. Transradial Catheterization Complications: Anatomical ConsiderationsCongenital anatomical variantsLocation VariantArm Superficial brachial Accessory brachialArm and Forearm Brachio-radial Brachio-ulnar Brachio-interosseous Brachio-median Superficial brachio-radial Superficial brachio-ulnar Superficial brachio-ulnoradialForearm Superficial radial Absent radial Absent ulnarRodriguez-Niedenfuhr et al. J Anatomy 2001
  11. 11. Transradial Catheterization Complications: Anatomical ConsiderationsCongenital anatomical variantsLocation VariantArm Superficial brachial Accessory brachial ≅2-3:1,000Arm and Forearm Brachio-radial ≅15:100 Brachio-ulnar Brachio-interosseous Brachio-median Superficial brachio-radial Superficial brachio-ulnar Superficial brachio-ulnoradialForearm Superficial radial Absent radial Absent ulnarRodriguez-Niedenfuhr et al. J Anatomy 2001
  12. 12. Transradial Catheterization Complications: Anatomical ConsiderationsCongenital anatomical variantsLocation VariantArm Superficial brachial Accessory brachial ≅2-3:1,000Arm and Forearm Brachio-radial ≅15:100 Brachio-ulnar Brachio-interosseous Brachio-median Superficial brachio-radial Superficial brachio-ulnar Superficial brachio-ulnoradialForearm Superficial radial Absent radial ≅3:10,000 Absent ulnar ≅ 1-2:10,000Rodriguez-Niedenfuhr et al. J Anatomy 2001
  13. 13. Transradial Catheterization Complications: Anatomical ConsiderationsArterial tortuosityLocation VariantRadial Loops TortuosityLo et al. Heart 2009
  14. 14. Transradial Catheterization Complications: Anatomical ConsiderationsArterial tortuosityLocation VariantRadial Loops ≅2.5:100 Tortuosity ≅2:100Lo et al. Heart 2009
  15. 15. Transradial Catheterization Complications: Anatomical ConsiderationsArterial tortuosityLocation VariantRadial Loops ≅2.5:100 Tortuosity ≅2:100 n=1,560 4.6% 37% 13% 23%Lo et al. Heart 2009
  16. 16. Transradial complicationsAnatomical ConsiderationsClassification and IncidencePrevention and Management
  17. 17. Transradial Catheterization Complications: Classification and IncidenceKanei al. CCI 2011 Event Rate Asymptomatic radial artery occlusion 2-18% Nonocclusive radial artery injury common Radial artery spasm 5-10% Sterile granuloma 2.8% Hand ischemia rare Perforation rare Pseudoaneurysm rare AV fistula rare Nerve damage rare Hemorrhge/transfusion rare
  18. 18. Transradial Catheterization Complications: Classification and IncidenceKanei al. CCI 2011 Event Rate Asymptomatic radial artery occlusion 2-18% Nonocclusive radial artery injury common Radial artery spasm 5-10% Sterile granuloma 2.8% Hand ischemia rare Perforation rare Pseudoaneurysm rare AV fistula rare Nerve damage rare Hemorrhge/transfusion rare
  19. 19. Transradial Catheterization Complications: Risk FactorsEvent Risk factors •Prolongedhigh pressure compressionAsymptomatic radial artery occlusion •↑Sheath/Artery diameter •Multiplepuncture attemptsNonocclusive radial artery injury •Tortuous anatomy •Radialartery occlusionHand ischemia •Negligent evaluation of palmar arch circulationRadial artery spasm •Small caliber vessel/large sheaths •Multiple catheter exchange •Inadequate premedicationPerforation •Tortuous anatomy •Aggressive wiringPseudoaneurysm •Multiple punctures •Excessive anticoagulation •Large sheathsAV fistula •Multiple puncturesSterile granuloma •Cook sheathsNerve damage •Multiple punctures
  20. 20. Transradial Catheterization Complications: Risk FactorsEvent Risk factors •Prolongedhigh pressure compressionAsymptomatic radial artery occlusion •↑Sheath/Artery diameter •Multiplepuncture attemptsNonocclusive radial artery injury •Tortuous anatomy Operator-related factors: •Radial artery occlusionHand ischemia •multiple punctures •Negligent evaluation of palmar arch circulation •inadequate “spasmolysis”/anticoagulationRadial artery spasm •Small caliber vessel/large sheaths •large caliber catheters•Multiple catheter exchange •multiple catheter exchanges premedication •Inadequate •Tortuous anatomy •aggressive wiringPerforation •Aggressive wiring •occlusive hemostasis •Multiple puncturesPseudoaneurysm •Excessive anticoagulation •Large sheathsAV fistula •Multiple puncturesSterile granuloma •Cook sheathsNerve damage •Multiple punctures
  21. 21. Transradial Catheterization Complications: Radial Occlusion and Critical Hand Ischemia Case Report (I)Kanei et al. CCI 2011
  22. 22. Transradial Catheterization Complications:Critical Hand Ischemia
  23. 23. Transradial Catheterization Complications:Critical Hand Ischemia “Hand ischemia with necrosis has never been reported during TRC with thorough pre-examination of intact collateral circulation…”
  24. 24. Transradial Catheterization Complications: Case Report (II)56 y.o. ♀Suspected troponin positive ACSUrgent TRC cath (negative Allen test) ⇒ NCASevere “hand pain”Physical exam reportedly normal, palpable radial pulse⇒ required opiatesDoppler study⇒ radial artery occlusion
  25. 25. Transradial Catheterization Complications: Case Report (II)Vascular surgery consult: heparin, analgesia
  26. 26. Transradial Catheterization Complications: Case Report (II) RAO can result in critical hand ischemia(i.e., tissue loss) despite dual palmar arch supply !!!
  27. 27. Transradial complicationsAnatomical ConsiderationsClassification and IncidencePrevention and Management
  28. 28. Transradial Catheterization Complications: PreventionCase selectionAccessNegotiation of upper extremity vasculatureHemostasis
  29. 29. Transradial Catheterization Complications: PreventionCase selection •Age, gender •Co-operative patient •Palmar arch circulationAccessNegotiation of upper extremity vasculatureHemostasis
  30. 30. Transradial Catheterization Complications: PreventionCase selection •Age, gender •Co-operative patient •Palmar arch circulationAccessNegotiation of upper extremity vasculatureHemostasis
  31. 31. Transradial Catheterization Complications: PreventionCase selection •Age, gender •Co-operative patient •Palmar arch circulationAccess •Liberal anesthesia, analgesia & sedation •Small caliber catheters •Spasmolytic cocktail •Hydrophilic sheaths •Anticoagulation (i.v.=i.a., weight adjusted dose)Negotiation of upper extremity vasculatureHemostasis
  32. 32. Transradial Catheterization Complications: PreventionCase selection •Age, gender •Co-operative patient •Palmar arch circulationAccess •Liberal anesthesia, analgesia & sedation •Small caliber catheters •Spasmolytic cocktail •Hydrophilic sheaths •Anticoagulation (i.v.=i.a., weight adjusted dose)Negotiation of upper extremity vasculature •Avoid non-J-tipped 0.035” wires >> 0.014” •Liberal fluoroscopic guidance •Anticipate spasm and adverse anatomic featuresHemostasis
  33. 33. Transradial Catheterization Complications: PreventionCase selection •Age, gender •Co-operative patient •Palmar arch circulationAccess •Liberal anesthesia, analgesia & sedation •Small caliber catheters •Spasmolytic cocktail •Hydrophilic sheaths •Anticoagulation (i.v.=i.a., weight adjusted dose)Negotiation of upper extremity vasculature •Avoid non-J-tipped 0.035” wires >> 0.014” •Liberal fluoroscopic guidance •Anticipate spasm and adverse anatomic featuresHemostasis •“Patent hemostasis”
  34. 34. Transradial Catheterization Complications: Prevention: Palmar arch circulation •absent ulnar 0.01-0.03% •radial/ulnar atherosclerosis 1%Not every routine practice is supported by a RCT:e.g.,Antibiotics for pneumococcal pneumonia,Jumping out of an aeroplane with a parachute Just Test It!!!
  35. 35. Transradial Catheterization Complications: Prevention: Palmar arch circulation Barbeau TestBarbeau et al. AHJ 2004 2 separate series: n=1,010 n=7,049 No cases of acute hand ischemia
  36. 36. Transradial Catheterization Complications: Prevention: Patent hemostasisPancholy et al. PROPHET. CCI 2008 n=436conventional patent 12% hemostasis “Barbeau test” 7% radial artery patency @ 24-hr, 30-d 5% 1.8% 1.8%
  37. 37. Transradial Catheterization Complications: Prevention: Patent hemostasisPancholy et al. PROPHET. CCI 2008 n=436conventional patent 12% hemostasis “Barbeau test” 7% radial artery patency @ 24-hr, 30-d 5% 1.8% 1.8% “Patent hemostasis” reduces risk of radial occlusion
  38. 38. Transradial Catheterization Complications: Prevention and ManagementEvent Prevention/Management •AnticoagulationRadial artery occlusion •Patent hemostasisNonocclusive radian artery injury •Careful evaluation prior to harvesting for CABGHand ischemia •Careful examination of palmar circulation •Smallcaliber sheaths/cathetersRadial artery spasm •Hydrophilic catheters •Premedication •Avoid 0.035” hydrophilic wires/fluoroscopy guidancePerforation •Early detectionPseudoaneurysm •Compression •Thrombin injectionAV fistula •SurgerySterile granuloma •Removal of hydrophillic coatingNerve damage •Supportive care
  39. 39. Transradial Catheterization Complications: Prevention and ManagementEvent Prevention/Management •AnticoagulationRadial artery occlusion •Patent hemostasisNonocclusive radian artery injury •Careful evaluation prior to harvesting for CABG Prevention:Hand ischemia •Verify functionality of •dual examination arch supply Careful palmar of palmar circulation (Allen, Barbeau tests) •Small caliber sheaths/cathetersRadial •Technique and dedicated devices artery spasm •Hydrophilic catheters •Patent hemostasis •Premedication •Avoid 0.035” hydrophilic wires/fluoroscopy guidancePerforation •Early detectionPseudoaneurysm •Compression •Thrombin injectionAV fistula •SurgerySterile granuloma •Removal of hydrophillic coatingNerve damage •Supportive care
  40. 40. Transradial Catheterization Complications:Prevention and Management of Critical Hand Ischemia What should be done when radial occlusion is detected? Recognize the potential consequences Avoid nihilismUlnar artery compression for radial artery occlusionsEarly angiography and intervention for CHI
  41. 41. Transradial Catheterization Complications: Prevention of Hand ischemia Ulnar compression can resolve early radial occlusionBerant et al. AJC 2011 n=465 i.v. heparin i.v. heparin 2000u 5000u TR hemostatic band 3-4 hour duplex RAO 1-hr ulnar occlusion
  42. 42. Transradial Catheterization Complications: Prevention of Hand ischemia Ulnar compression can resolve early radial occlusionBerant et al. AJC 2011 n=465 i.v. heparin i.v. heparin 2000u 5000u TR hemostatic band 3-4 hour duplex RAO 1-hr ulnar occlusion
  43. 43. Transradial Catheterization Complications: Management of Hand ischemia Early angiography and intervention for critical hand ischemiaKawarada et al. CCI 2010
  44. 44. Transradial Catheterization Complications: SummaryThough generally very safe, serious potentialcomplications of TRC should be recognizedMost complications are easily avoided by simplepreventive measures (case selection, technique anddedicated devices, patent hemostasis)Early detection and intervention should may preventpermanent radial occlusion and critical hand ischemia
  45. 45. Transradial Catheterization Complications Radial vs. Femoral AccessRIVAL. LANCET 2011 4.0% 3.7% p=0.9 CURRENT sub-study n=7,021 10: death/MI/CVA/non CABG bleed femoral radial 0.5% 3,514 3,507 p=0.23 0.3% 20: non CABG bleed
  46. 46. Transradial Catheterization Complications Radial vs. Femoral AccessRIVAL. LANCET 2011 Radial Femoral p=0.23
  47. 47. Transradial Catheterization Complications: Anatomical ConsiderationsRadial Anomaly vs. No Radial anomaly Lo et al. Heart 2009
  48. 48. Transradial Catheterization Complications: Prevention: Access Hydrophilic sheath use reduces radial spasmRathore et al. JACC CArdiovasc Interv 2010 n=790 hydrophilic no coat 13cm 23cm
  49. 49. Transradial Catheterization Complications: Prevention: Access Route of heparin administration has no impact on radial occlusion ratesPancholy SB et al. AJC 2009 n=500
  50. 50. Transradial Catheterization Complications: Prevention: Access •Local anesthesia, liberal analgesia & sedation •Small caliber catheters •Spasmolytic cocktail •Hydrophilic sheaths •AnticoagulationHydrophilic sheath use reduces radial spasmRathore et al. JACC CArdiovasc Interv 2010Route of heparin administration has no impact on radialocclusion ratesPancholy SB et al. AJC 2009
  51. 51. Transradial Catheterization Complications:Prevention: Upper Extremity Vessel Negotiation •Minimize use of non-”J-tipped” 0.035” wires •Fluoroscopic guidance/road mapping •Anticipate spasm/adverse anatomy
  52. 52. Transradial Catheterization Complications:Prevention: Upper Extremity Vasculature

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