Optimizing Transradial Interventions, Recognizing and Managing Complications Ramon Quesada, M.D., FACP, FACC, FSCAI Medical Director, Interventional Cardiology, Cardiac Research & Outcomes Baptist Cardiac & Vascular Institute Clinical Associate Professor of Medicine Herbert Wertheim College of Medicine at Florida International University
Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship CompanyGrant/Research Support NoneConsulting Fees/Honoraria Abbott, Cordis, St. Jude, W.L.Gore, NMT Medical, Terumo & Boston Scientific CorporationMajor Stock Shareholder/Equity NoneRoyalty Income NoneOwnership/Founder NoneIntellectual Property Rights NoneOther Financial Benefit None
How to Optimize TRA Be aware of anatomical considerations in patient selection Implement proper techniques to avoid failure Anticipate the possibility of common problems as well as rare complications
Stages of TRA: Possible Problems and Complications Subclavian & Coronary Cannulation Traversing Subclavian Tortuosity Anatomical Variations Rare but possible ComplicationsAnatomical Variations Radial Artery Spasm Perforation ACCESS Removal of Sheath/ Catheter Radial Artery Occlusion Hematoma / Pseudoaneurysm Bleeding/Compartment syndrome
How to Optimize TRA ~Access Be aware of anatomical considerations in patient selection Implement Proper Techniques to Avoid Techniques to Failure Avoid Failure Anticipate the possibility of common problems as well as rare complications
Forearm Normal Vascular Anatomy Fujii et al. J Invasive Cardiol 2010;22:536-40
Modified Allen Test Essentialsy To avoid ischemic hand complications, the percutaneous transradial approach is only performed in patients with patent hand collateral arteries, which is usually evaluated with the modified Allen’s test (MAT).y This qualitative test measures the time needed for maximal palmar blush after release of the ulnar artery compression with occlusive pressure of the radial artery
Combinedplethysmography (PL) and pulse oximetry (OX) testsSafe to proceed with TRA Avoid TRA Barbeau GR, Arsenault F, Dugas L, et al. Evaluation of the ulnopalmar arterial arches with pulse oximetry and plethysmography: comparison with the Allen’s test in 1,010 patients. Am Heart J. 2004;147:489-493.
Incidence and Implications of Arterial Anomaliesy Analysis and incidence of arterial anomalies completed by Fujii et al on 163 consecutive patients.y Classification of all anomalies and then stratification of the “difficulty” of transradial access for that anomaly was completed.y Overall it was concluded that 98.8% of patients were acceptable for TRA. Fujii et al. J Invasive Cardiol 2010;22:536-40
Anatomical Variations Fujii et al. J Invasive Cardiol 2010;22:536-40
Anatomical Variations Fujii et al. J Invasive Cardiol 2010;22:536-40
How to Optimize TRA ~ Accessy Be aware of anatomical considerations in patient selectiony Implement proper techniques to avoid failurey Anticipate the possibility of common problems as well as rare complications
Causes of Transradial Approach Percutaneous Coronary Intervention FailureRadial Artery Loop Guidewire-induced Severe Spasm not relieved Severe Subclavian Tortuosity Dissection by inter-arterial nitro & verapamil Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064
TRA Failure in Low (8%) to Intermediate (42%) Volume Operators N = 2,100 Overall Failure rate: 4.7% No Hydrophilic sheaths & no specialty design radial guide cathetersDehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1
Multivariate Predictors of TR-PCI Failure TR-PCI FailureStratified by Patient Height Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064
Transradial Procedure July 1, 1998 - April 30, 2001Diagnostic 722Converted to femoral 67 (9.3%)Intervention 403 Ad Hoc 232 (57.6%)Converted to femoral 31 (7.7%)Right Radial Approach 94%
Transradial: Aborted or Converted Cases due to Access ProblemsTortuousity Radial artery 36 Brachial artery 9 Subclavian artery 12 Ascending aorta 2Unable to Cannulate LCA 8 RCA 3 SVG 4 IMA 5Other Lack of back up 8
Are the Right and Left Radial Arteries Equal in Ease of Access?
TALENT TRIAL: Fluoroscopy Time and DAP per Operator’s ExperienceSubgroup analysis of fluoroscopy time and DAP for fluoroscopy according to the operators skill (seniors compared with fellows). Results are expressed as median (squares) and IQR (bars). Sciahbasi, A, Am Heart J 2011;161:172-9.
How to Optimize TRA ~ Accessy Be aware of anatomical considerations in patient selectiony Implement proper techniques to avoid failurey Anticipate the possibility of common problems as well as rare complications 26
Technical Tips for Successful Transradial Cannulation y Use a 21 G x 2.5 cm thin wall needle to cannulate the radial artery y Advance a 0.025 inch guidewire through the needle y After the introducer is inserted, give “cocktail” of Verapamil 2 mg, lidocaine 2% (1 cc) diluted in saline, followed by 50 units/kg heparin bolus and 100-200 mcg of nitroglycerine. Quesada et al, “Transradial Coronary Interventions”, Interventional Cardiology Secrets, 2003, pp. 203-210
Sedation and Verapamil Virtually Eliminate the Spasm ProblemBefore After
Severe vasospasm can lead to avulsion of the radial artery- rare but preventable Severe spasm can lead to eversion of the radial artery. The best therapy is prevention: •Hydration •Sedation •Vasodilator Cocktail •Hydrophilic SheathRadial artery seen protruding from the radialartery access site. Dieters, RS, Catheterization and Cardiovascular Interventions 58:478–480 (2003)
The radial artery is a thick-walled vessel composed mainlyof smooth-muscle cells arranged in concentric layers. Thismarked muscular component of the artery, together with the high density of alpha1-receptors, make this vessel especially susceptible to spasm Journal of Cardiothoracic and Vascular Anesthesia, Vol 22, No 3 (June), 2008: pp 428-430
The branching point of the axillary artery where Catheter Entrapment papaverine was injected. (A) The transradial catheter, (B) Tip of the transfemoral catheter,The transfemoral catheter deviating away (C) The abnormal high origin of the profunda brachiifrom the transradial catheter in the axillary artery, artery. (D) The anterior circumflex humeral artery, and (E) The posterior circumflex humeral artery.
Impact of Length and Hydrophilic Coating of theIntroducer Sheath in Radial Artery Spasm during TRAy There was significantly less radial artery spasm and less discomfort in patients with hydrophilic coated sheaths compared to non-hydrophilic coated . Hydrophilic Non-hydrophilic P RAS (Spasm) 19% 39.9% <0.001 Discomfort 15.1% 28.5% <0.001Sterile Abscess 5% 0.3% 0.001RAO(Occlusion) 8.9% 10.0 0.624 • J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S , V O L . 3 , N O . 5 , 2 0 1 0 MAY 2 0 1 0 : 4 7 5 – 8 3 Rathore et al. Impact of Sheath on Radial Artery Spasm
Impact of Length and Hydrophilic Coating of theIntroducer Sheath in Radial Artery Spasm during TRA There was no significant difference in the incidence of spasm (RAS), discomfort, or RAO (Occlusion) based on length of introducer. Long Short P RAS (Spasm) 27.9% 30.8% 0.389 Discomfort 21.5% 22.2% 0.414 RAO 8.3% 5.3% 0.42 (Occlusion) y No patients received vasodilators • J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S , V O L . 3 , N O . 5 , 2 0 1 0 MAY 2 0 1 0 : 4 7 5 – 8 3 Rathore et al. Impact of Sheath on Radial Artery Spasm
Sterile Abscess After Hydrophilic-Coated Radial Artery Sheath Gilchrist, I. C. et al. J Am Coll Cardiol Intv 2010;3:484-485
Adjunctive Tools for TRAy For tortuosity at the radial brachial level, and anatomical variations, 0.014 coronary floppy wires are sufficient.
Perforationy Early recognition is the most important factory If a perforation occurs, although I treated with vascular glue,other approaches would include : – Limited angio if the wire is across the main vessel you can attempt balloon sealing (perforations usually occur because you have entered a small side-branch or because of extreme tortuosity) – If you feel resistance -- Never Push! – Application of an elastic bandage – Arm elevation to prevent compartment syndrome
Compartment Syndrome PresentationThere are classically 5 “Ps” associated with Compartment Syndrome1. PAIN (out of proportion to expected)2. Paresthesia3. Pallor4. Paralysis5. Pulselessness6. Poikilothermia (failure to thermoregulate) Of these, only the first two are reliable in the diagnosis of compartment syndrome
J Neurol Neurosurg Psychiatr2005;76: 1465 Compartment Syndrome post Transradial Access Leeches were effective in treating a massive hematoma causing right forearm compartment syndrome. The patient had been treated with anticoagulants before cardiac catheterization via the radial artery. Hardening and discoloration of the forearm was followed by motor and sensory deficits of the hand. Thirteen leeches removed about 145 ml of blood, with resolution of symptoms and signs. J Neurol Neurosurg Psychiatr2005;76: 1465Example of a forearm wrapped with anelastic bandage at the site of a suspectedmicropuncture in the midportion of theforearm. The standard hemostasis device isseen in place in the foreground. There wasno visible or measurablehematoma after removal of the elastic wrapthat had been placed during the initialaccess procedure Gilchrist, I. CARDIAC INTERVENTIONS TODAY JANUARY/FEBRUARY 2008 pp 39-42
How to Optimize TRA ~ Subclavian & Coronaryy Be aware of anatomical considerations in patient selectiony Implement Proper Techniques to Avoid Failurey Anticipate the possibility of common problems as well as rare complications 40
How to Optimize TRA ~ Subclavian & Coronaryy Be aware of anatomical considerations in patient selectiony Implement Proper Techniques to Avoid Failurey Anticipate the possibility of common problems as well as rare complications 41
How do you deal with tortuousity?y Use a Benson or Wholey wire into the ascending aorta. If there is significant tortuousity in the subclavian artery, switch to a stiff exchange 0.035 or 0.038 Cook or Amplatz wire.y Pull the wire into the shaft of the catheter in order to facilitate torquing for coronary cannulation. Quesada et al, “Transradial Coronary Interventions”, Interventional Cardiology Secrets, 2003, pp. 203-210
Commonly Used Guiding Catheter ShapesLeft Arm Approach Right Arm ApproachFor Lesions in LCA For Lesions in LCA - XB 3.5 - XB 3.0 - JL 4 - JL 3.5 - Kimny - KimnyFor Lesions in RCA For Lesions in RCA - JR 4 - JR 4 - AL I or AL II - AL I - Castillo 1 & 2 - Barbeau - Kimny - Kimny
New Diagnostic Radial Catheters TIG-MOD 4.0 Ikari RightIkari Left
Arch Aortogram and MRA of the Major Arteries of the Upper BodyAbnormal origin of right (RT) subclavian artery arising directing from the descending aorta instead of the right innominate artery Yiu, K.-H. et al. J Am Coll Cardiol Intv 2010;3:880-881
Dissection as a result ofarteria lusoria Forms an acute angle (70°) with the proximal aortic archaberrant right subclavian artery the false lumen with retained contrast medium Huang, I, J Chin Med Assoc • July 2009 • Vol 72 • No 7
During the diagnostic procedure, because of evident tortuosity of the rightsubclavian and innominate arteries, a supportive angiographic guide and an accurate manipulation were needed to advance and rotate catheters.Several minutes after the procedure, the patient developed a cardiovocal syndrome with dysphonia, perceived as hoarseness and breathiness. Subsequently an important dysphagia affecting her feeding pattern occurred.
An ear nose and throat physical examination with fiberoptic laryngoscopy revealed right hemi laryngeal palsy without intra laryngeal edema, likely due to right recurrent laryngeal nerve (RLN) stupor. Fig. 1. The figure shows the right vocal fold fixed in abduction during respiration (A) and phonation (B) (images obtained during the videoendoscopic exam with Digital Video Stroboscopy System, by Kay Elemetrics Corporation). Intravenous steroid therapy was started and the nerve dysfunction complete recovered as shown by a second laryngoscopy. At discharge, despite thecomplete symptom resolution, a vocal rehabilitation period was recommended.
Scheme showing the course of therecurrent laryngeal nerves. The RLNon the right side hooks aroundbehind the subclavian artery, whileon the left side this nerve passesaround behind the aortic arch beforeascending in the neck
Basal extreme tortuosity of right subclavian and innominate arteries preventing any catheter manipulation.
Subclavian and innominatearteries straightening after diagnostic catheter introduction; a supportive angiographic guide was required to rotate andadvance the catheter in the coronary ostium. The straightening determined by the catheter introduction in the tortuous right subclavian andinnominate arteries likely caused an unfavorable anatomical change leading to a temporary compression/stretch of right RLN
Vascular injury resulting in a small leak in the branchesof the innominate artery is a possible complication of the transradial approach.
A 61 year-old male patient with diabetes mellitus. Diagnostic coronary angiography via the radialapproach showed eccentric intermediate stenosisof the LAD ostium and a focal 99% tight stenosis in the distal LCx followed by segmental 70% stenosis. Approximately 30 min after the diagnostic procedure, the patient complained of severe anterior chest pain—no EKG change- unrelieved by Nitro- returned to cath lab for urgent PCI – 2 stents placed in left circumflex post procedure patient still complaining of painECHO done – negative- Chest X-ray showed widening of mediastinum
A chest CT scanshowing a largehematoma in theanterior mediastinumaround the aortic arch. Follow up chest CT scan after recurred chest pain showing increased hematoma in the anterior mediastinum.
Second case is similar to the firstA. Coronary angiogram (APcaudal projection) showingtight stenosis in the leftcircumflex coronary artery.B. Chest X-ray (AP view) C. Chest CT scan showing ahuge mediastinal hematomalocated left of the aortic arch. D. Follow up chest CTshowing almost completeresorption of the previoushematoma.
Mediastinal Hematoma– From the two cases presented here, vascular injury resulting in a small leak in the branches of the innominate artery is a possible complication of the transradial approach.– Therefore, extra caution and careful maneuvering of the guidewire is warranted during the transradial approach. In addition, the use of anticoagulation seems to be important in continuous extravasation after the initial break in vascular integrity.
How to Optimize TRA ~ Removal of Sheath & Cathetery Be aware of anatomical considerations in patient selectiony Implement proper techniques to avoid failurey Anticipate the possibility of common problems as well as rare complications 60
Transradial Access Site Complicationsy Radial artery occlusiony Midforearm hematomay RA Pseudoaneurysmy Bleeding with resultant Compartment Syndrome
Prevention of Radial Artery Occlusion—Patent Hemostasis Evaluation Trial (PROPHET Study): Randomized Comparison of Traditional Versus Patency Documented Hemostasis After Transradial Catheterization ‘‘Patent Hemostasis’’ Procedure • The sheath was pulled out 4–5 cm and a plastic band ‘‘Hemoband’’ was placed around the forearm at the site of entry. • The needle cap and gauze composite was placed over the site of entry. • A pulse oximeter sensor was placed over the index finger, the hemoband was tightened, and the sheath was removed. • Ipsilateral ulnar artery was occluded and the hemoband was loosened till plethysmographic signal returned (confirming radial artery patency) or bleeding occurred. Samir Pancholy, et al Catheterization and Cardiovascular Interventions 72:335–340 (2008)*
Devices used for radial compressionHemoband TR Band
Samir Pancholy, et al Catheterization and Cardiovascular Interventions 72:335–340 (2008)
Samir Pancholy, Journal of Invasive Cardiology 21: 101-104 (2009)
How to Optimize TRAy Be aware of anatomical considerations in patient selectiony Implement proper techniques to avoid failurey Anticipate the possibility of common problems as well as rare complications 71