Puncture, Radial Spasm and Wire Progression: Remaining Problems in Transradial Approach

1. Rencontres Interventionnelles - Transradial Approach RITA
Prague, Czech Republic,
Thursday 29th & Friday 30th September 2011
Puncture, radial spasm and
wire progression:
remaining problems in TRA?
Jacques Monségu, MD
Val-de-Grâce Military Hospital, Paris
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2. Puncture, radial spasm and wire progression
Radial failure predictors
A multivariate analysis of a large serie: 6,962 TRA (94-98)
Causes of the 475 TRA failures (7%):
- unsuccessful puncture (69%)
- difficult anatomy (16%),
- brachial artery spasm (8%),
- unsuccessful canulation (5%)
- miscellaneous (2%)
G.Barbeau AHA 1999

3. Puncture, radial spasm and wire progression
Premedication with
hydroxyzine The puncture
dichlorhydrate
Patient information
Good installation
of the arm
A dedicated sheath
Quiet atmosphere
Local anesthesia:
EMLA® and
xylocaïne
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4. Puncture, radial spasm and wire progression
EMLA® vs Local Infiltration Anesthesia
for Radial Artery Cannulation
EMLA Lidocaïne p
n 269 269
Pain during Puncture 2 (1-3) 7 (6-8) 0.0001
Additional Lidocaïne (%) 7 34 <0.0001
Failure of Cannulation (%) 4 10 0.006
Radial Spasm (%) 1 4 0.002
Time to Sheath Insertion (min) 4 (3-5) 6 (2-12) 0.0002
Joly Anesth Analg 1998; 87:403-06
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5. Puncture, radial spasm and wire progression
Subcutaneous 500 μg Nitroglycerin
for Radial Artery Cannulation
NTG + NTG - p
Number of patients 33 / 42 30 / 42
Number of puncture 1.27 / 1.16 1.43 / 1.5 0.29 / < 0.05
Radial Spasm (%) 1 4 0.002
Time to Cannulation (sec) 75 / 146 132 / 213 < 0.001 / < 0.05
Pulse improvement 79% 10% 0.005
Candemir J Vasc Interv Radiol 2009; 20:1151-6
Ouadhour Cath Cardiov Interv 2008; 72:343-6
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6. Puncture, radial spasm and wire progression
Sometimes falsy missing «Atrophic» Radial Artery
Dorsal Carpal Branch
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7. Puncture, radial spasm and wire progression
How to recover a radial ?
Ø Subcutaneous nitrates
Ø High blood pressure level
Ø Hyperemia by brachial compression:
NO release
Ø Avoid pain
Ø And espacially be quiet and patient…
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8. Puncture, radial spasm and wire progression
A good flow, but the wire
don’t advance!
Reasons ?
Radial posterior wall ?
Small branch ?
Loops ?
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9. Puncture, radial spasm and wire progression
A good flow, but the wire
don’t advance!
Solutions
Ø Never force
Ø Flow verification
Ø Needle rotation
Ø Perform a «J » to the wire or use
a J specific wire
Ø Cannulation with venous needle
and inject contrast to understand
Ø New puncture higher, with bare
needle possibly
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10. Puncture, radial spasm and wire progression
Radial spasm
Multivariate Analysis
127 pts with spasm /637 pts without
OR 95% CI
Anatomical anomalies 5.1 2.1 - 11.4
Use of > 3 catheters 3.0 1.9 – 4.7
Moderate-to-severe pain during 2.6 1.4 – 4.9
radial artery cannulation
The use of phentolamine as 1.8 1.1 – 2.9
spasmolytic
Post vasodilation radial diameter 0.98 0.98 – 0.99
R.J Ruiz-Salmeron
Rev Esp Cardiol 2005;85(5):504-11
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11. Puncture, radial spasm and wire progression
How to treat spasm ?
PREVENTION:
Ø A good « cocktail »: Verapamil
+/- nitrates and Heparin
Ø No pain: Emla®, Xylocaine…
Ø A quick puncture
Ø The least catheters
Ø Long hydrophilic sheath?
Ø Anesthesiologist??
TREATMENT:
Ø Vasodilators…
Ø Sedation…
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12. Puncture, radial spasm and wire progression
ANesthesia In Trans-radial Approach
RESULTS: Spasm
P < 0.0001
visual analogic
scale
Benamer H, ANITA Study TCT 2006
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13. Puncture, radial spasm and wire progression
0.035’’ wire don’t advance!
1533 Normal High Radial Radial Other
patients anatomy bifurcations loops tortuosities anomalies
No. of 1321 (86%) 108 (7%) 35 (2.3%) 30 (2%) 39 (2.5%)
patients
Female % 28 29 49 50 33
Age 63.0±11.0 65.5±10.8 69.8±10.4 72.2±7.7 65.1±11.8
Procedure 41.3±21.5 45.2±23.2 49.4±17.1 41.0±12.7 42.1±19.2
time (min)
X-ray time 9.7±8.0 9.3±6.5 10.0±6.6 10.7±6.5 9.6±7.1
(min)
Failure % 0.9 4.6 37.1 23.3 12.9%
Lo, Heart 2009; 95: 410-5
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14. Puncture, radial spasm and wire progression
0.035’’ wire don’t advance!
ACTIONS: To avoid…
Ø Never force +++
Ø Contrast injection
Ø Take an hydrophilic wire
Ø External side-compression
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15. Puncture, radial spasm and wire progression
Hydrophilic wire use
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16. Puncture, radial spasm and wire progression
With a 0.014’’ !

17. Puncture, radial spasm and wire progression
But, be careful …
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