This document discusses best practices for transradial interventions including performing Allen's test, minimizing radial artery occlusion, and reducing radiation exposure. It summarizes evidence that testing for collateral circulation is controversial, radial artery occlusion can be reduced through minimizing trauma, adequate anticoagulation, and patent hemostasis. Radial access is associated with higher radiation exposure but exposure can be decreased through experience, limiting fluoroscopy use, and left radial access.

1. TRI best practices: Allen’s test,
RAO, radiation exposure
Sunil V. Rao MD FACC, FSCAI
Slides courtesy of Samir Pancholy MD

2. Disclosures
• Teaching / Speaking honoraria: Terumo,
Medicines company
• Consultant: Terumo, The Medicines Company,
Zoll, Daiichi Sankyo Lilly, Astra Zeneca
• Research funding: Cordis Corporation, Ikaria

3. Tests for collaterals
• Logically makes good sense
• Is there any evidence?

4. Collateralization in UE is more than we
think
• Extensive interosseous collaterals
• Dynamic recruitable non-visible circuits.

5. Recruitable circulation
JACC Vol. 46, No. 11, 2005 December 6, 2005:2013–7

6. Abnormal Allen’s = ischemia?
JACC Vol. 46, No. 11, 2005 December 6, 2005:2013–7

7. Hand ischemia following TRI
Normal pre-procedure Allen’s test
Rhyne D, Mann T. CCI 2010

8. Should we be doing Allen’s test
• Probably not for assessing risk of ischemia
– Medicolegal issues?
• Should probably record a baseline
plethysmography to follow for post procedural
radial artery patency.

9. Radial Artery Occlusion
• An Achilles’ heel of TRI
• A function of:
– Radial artery trauma (sheath size, multiple access
attempts)
– Anticoagulation
– Nonocclusive hemostasis
– Spasm? Hydrophilic sheaths? Ulnar
compression?

10. Radial artery occlusion
• Prevalence of RAID in men and women
Saito S, CCI 1999

11. Radial Artery Occlusion
• 5F vs. 6F sheaths
– 171 patients undergoing TRI randomized
Dahm J, et. al. CCI 2002

12. Heparin and RAO
Incidence of RAO (%)
80
70
60
50
40
30 Incidence of RAO (%)
20
10
0
No 2000-3000 5000 I.U 2000 I.U 5000 I.U
Heparin I.U
Spaulding et al Bernat et al

13. Patent Hemostasis
14
P < 0.05
12
10
8
Usual Hold
%
6 Patent Hold
4
2
0
Early RAO Persistent RAO
Pancholy S et al, CCI 2008;72:335-40

14. Ulnar Artery Compression
Diagnostic Transradial Catheterization
2000 IU UFH 5000 IU UFH
N=222 N=243
Patent hemostasis ≤ 2 hrs
Radial U/S 3-4 hrs later
Radial Artery Occlusion
No Yes
Bernat I, et. al. AJC 2011
1 hour ulnar compression

15. Ulnar artery compression
Bernat I, et. al. AJC 2011

16. TALENT Study (CAG)
Am Heart J 2011;161:172-9.

17. TALENT Study (PCI)
Am Heart J 2011;161:172-9.

18. Age related differences
Am Heart J 2011;161:172-9.

19. Experience matters
Am Heart J 2011;161:172-9.

20. REVERE Trial
Randomized Evaluation of Vascular
Entry site and Radiation Exposure

21. REVERE trial
• 358 patients refereed for 5F diagnostic
coronary angiography
• 1:1 randomization to RRA, LRA and FA access
• Total patient and operator radiation exposure

22. Minimizing Radiation
• Don’t fluoro the J-wire going up the arm
unless there is resistance
• Don’t fluoro catheter exchanges
• Use Fluoro-Save as much as possible
• Operator experience matters
• Left radial may also help
– Distance
– Shorter procedures (less subclavian tortuosity)

23. Summary
• Best practices are essential to moving the radial field forward
– We are generating good data to support specific practices
• Testing for collateral circulation is controversial OUS
– No good data, but in the US, probably best to do it
• RAO is a major issue and can be considered a quality metric
– Minimize radial trauma, adequate anticoagulation, patent hemostasis
• Radiation exposure
– Radial consistently associated with higher exposure
– Need to use best practices
– Device evolution