The Impact of ultrasound guidance for transradial approach

1. The Impact of Ultrasound
Guidance for TRA
Jonathan Roberts, MD, FACC, FSCAI
Medical Director, Interventional Cardiology Research
and Education
Memorial Healthcare System
Hollywood, Florida, USA

2. • Disclosures: None

3. How Difficult is TRA?
• RIVAL Trial
• 7021 pts RA vs FA
• NonSTEMI – 5063
• STEMI – 1958
• 7.6% crossover RA  FA
Mehta, et al JACC 2012

4. How Difficult is TRA?
• US vs Palpation TRA¹
• 183 pts
• 13 % crossover RA  FA
• RIFLE-STEACS²
• 1001 pts RA vs FA
• 9.6% crossover RA  FA
• 21/47 (47%) RA access failure
¹Zaremski, Quesada JIC 2013 ²Romagnoli JACC 2012

5. How Difficult is TRA?
• 7020 pt meta-analysis RA vs FA¹
• 5.9% crossover RA  FA
• ______________________________
• 1609 consecutive RA PCIs²
• 1.8% crossover RA  FA
• 57% RA access failure
¹Jolly, Am Heart J 2009 ²Abdelaal, et al JACC Int 2013

6. How Difficult is TRA?
With Palpation Guided TRA:
• RA  FA Crossover ̴ 6 – 7%
• Inability to access the RA may be the
cause of up to 50% of crossovers
• Multiple attempts to access are associated
with radial artery spasm.1
1. Rosencher, CCI 2013

7. How difficult is it to stick the RA?
Radial Artery
ID 2.6 mm
Area 5.3mm2
Femoral Artery
ID 7 mm
Area 38 mm2
2mm
2mm
2mm
“Normal” two point discrimination is 2-4 mm at the fingertips. DeJong's neurologic examination

8. How difficult is it to stick the RA?
Radial Artery
ID 2.6 mm

9. Ultrasound for Arterial Access

11. Tips for US Guided TRA
• Do it often!
• Get to know your US equipment
• Place the center of the transducer
directly over the center of the RA
• Place introducer needle directly under
center of transducer, and advance
• Won’t always see the needle. With short
jabs/wiggles, will see soft tissue move

12. Radial Artery 1.6 mm diameter
Sheath/Catheter
Sizing

13. Radial Access
Yan ZX et al, Circ J 2010, 74:686-692
Radial tortuosity Ulnar tortuosity Radial stenosis

14. Radial Artery Access
Metaanalysis of First Pass Success
Shiloh, AL et al, Chest 2011 139(3):524-9

15. The Radial Artery access
with Ultrasound Trial
(RAUST)
Arnold Seto, MD, MPA
Jonathan S. Roberts MD, Mazen Abu-Fadel MD
Zoran Lasic MD
Vol. 8, No. 2
Feb 2015:283

16. RAUST Study
• Inclusion Criteria
 Adults with planned radial catheterization
 Functional ultrasound equipment and trained operator
• Training: > 15 ultrasound radial procedures and > 100 radial cath
• Attending physicians (13) and advanced interventional fellows (3)
• Exclusion Criteria
 Abnormal Barbeau’s (Class D) or Allen’s (>10sec) test
 Emergency procedure (STEMI, shock)
 ESRD on dialysis
 Prior ipsilateral radial puncture within 1 week

17. RAUST Study
Primary Endpoints
• First-pass success rate
• Number of attempts to access
 Forward motions separated by withdrawal of needle
 Short “wiggle” to visualize path of needle on skin/tissue
above plane of artery allowed
 Announced by operator / confirmed by observer/tech
• Time to access
 From first application of US or needle for puncture to
successful sheath insertion

18. RAUST Study
Secondary endpoints
• Difficult access procedures
1. ≥ 5 minutes
2. ≥ 5 attempts
• Crossover to ultrasound guidance
• Crossover to another access site
• Wrist pain (VAS 0-10) 1-4 hours after
procedure
• Radial spasm
• Vascular complications
 Hematoma >2cm, clinically evident RAO

19. RAUST Study
Design
DESIGN: Prospective, multicenter
randomized study
OBJECTIVE: To evaluate the
accuracy of ultrasound vs. palpation
guidance for radial access.
SITE LEAD INVESTIGATORS:
Arnold Seto, Jonathan Roberts,
Mazen Abu-Fadel, Zoran Lasic
SITES:
Jamaica / Lenox Hill Hospital (357)
Long Beach VA / UC-Irvine (193)
Miami Baptist (98)
Oklahoma VA (50)
698 patients with nonemergent radial
angiography enrolled and randomized
between December 2011 and March 2013
114 Censored*
Palpation
(n = 351)
Procedural / Clinical outcomes
Ultrasound
(n=347)
Palpation #attempts
(n = 237)
Ultrasound #attempts
(n=236)
111 Censored*
* First 225 patients from Jamaica Hospital censored due to first-pass success (96.5% P and 97.3% US) counted by # punctures

20. Patient Population
Characteristic
Palpation
N=351
Ultrasound
N=347
P-value
Age, years 62.3 61.5 0.80
Male 262 (75%) 254 (73%) 0.66
Outpatient 141 (40%) 139 (40%) 0.98
Body mass index (BMI) 30.2 30.4 0.64
Obesity (BMI >30) 153 (44%) 149 (43%) 0.86
Hypertension 305 (87%) 292 (84%) 0.30
Hypercholesterolemia 265 (75%) 254 (73%) 0.49
Diabetes Mellitus 151 (43%) 149 (43%) 0.98
Tobacco 107 (30%) 128 (37%) 0.07
PVD 16 (5%) 14 (4%) 0.73
Barbeau’s Class B or C 54 / 149 (36%) 56 / 149 (38%) 0.81

21. Procedural Characteristics
Characteristic
Palpation
N=351
Ultrasound
N=347
P-value
Intervention 63 (18%) 73 (21%) 0.30
5F Sheath 193 (55%) 185 (53%) 0.66
Single wall technique 306 (87%) 295 (85%) 0.41
Right radial access 323 (92%) 328 (95%) 0.19
Verapamil (≥2.5mg) 340 (97%) 342 (99%) 0.20
Nitroglycerin (≥100mcg) 271 (77%) 278 (80%) 0.35
Lidocaine IA (5mg) 167 (48%) 170 (49%) 0.71
TR band Closure 225 (64%) 229 (66%) 0.60
D-stat band 114 (33%) 111 (32%) 0.89
Heparin 322 (92%) 321 (92%) 0.71
Heparin dose 3487 U 3700 U 0.16
GPIIb/IIIa 13 (4%) 14 (4%) 0.82
Bivalirudin 51 (15%) 50 (14%) 0.96
P2Y12 Inhibitor 193 (55%) 200 (58%) 0.48

22. 3.05
1.65
0
1
2
3
4
Attempts
Palpation
Number of Attempts
p<0.0001
Ultrasound
N = 237 N = 236

24. 0
30
60
90
120
150
Seconds Time to access
UltrasoundPalpation
108
88
N = 351 N = 347
P=0.006

25. 0
10
20
Percent Difficult Access
≥ 5 attempts ≥ 5 minutes
UltrasoundPalpation UltrasoundPalpation
18.6%
6.8%
2.4%
3.7%
351 347237 236
P=0.07P<0.001

26. Clinical Outcomes
Characteristic
Palpation
N=351
Ultrasound
N=347
P-value
Spasm 12 (3%) 15 (4.3%) 0.56
Pain score (0-10) 0.71 0.69 0.85
Bleeding 4 (1.1%) 5 (1.4%) 0.75
Crossover to ultrasound rescue
attempts after >5 minutes
10 (8
successful)
N.A. N.A.
Crossover to other site after
successful sheath insertion
5 2 0.45
Crossover to other site before
sheath insertion / failed access
7 3 0.34
Failure of sheath insertion with
original technique
15 3 0.007
Any crossover 20 5 0.004

27. Summary Conclusions
1. Routine ultrasound guidance increases accuracy
and reduces time for transradial access
2. Ultrasound guidance reduces the incidence of
difficult access procedures, and is a useful rescue
technique for palpation guided access
3. Ultrasound guidance decreases crossover –
technique and/or vascular access site
Arnold Seto, MD MPARadial Artery access with Ultrasound Trial

28. The Impact of Ultrasound
Guidance for TRA
Jonathan Roberts, MD, FACC, FSCAI
Medical Director, Interventional Cardiology Research
and Education
Memorial Healthcare System
Hollywood, Florida, USA

29. Frederic Baumann MD
Jonathan S. Roberts MD

30. 1000 Consecutive Radials
• Single Center
• Single Operator
• Retrospective
• Observational Trial
• 100% had Ultrasound Guided Vascular
Access of Wrist Arteries

31. 1000 Consecutive Radials
• 1162 consecutive pts Jan 2012 – April
2014
• 1000 consecutive RA/UA
• 162 planned FA
• Crossover to contralateral wrist 3/1000
• Radial loop, Brachial loop, vessel injury
• No crossover to FA

32. 1000 Consecutive Radials
• Pre access SL NTG
Pre SL NTG, RA = 2.6 mm¹ Post SL NTG, RA = 2.8 mm¹
¹Roberts JIC Dec 2013

33. 1000 Consecutive Radials
• Pre access SL NTG
• Intraprocedural Ultrasound assessment
of RA and UA

34. Intraprocedural Ultrasound assessment
of RA and UA
• 59 yo woman with unstable angina
• Which artery would you want to access?

35. Intraprocedural Ultrasound assessment
of RA and UA
• 76 yo man with unstable angina
• Which artery would you want to access?

36. Intraprocedural Ultrasound Evaluation of Both the Radial and Ulnar Artery and Its Implication to Improve Success of Arterial Access
from the Wrist: Anatomical Evaluation of a Consecutive Series of 565 Patients Undergoing Cardiac Catheterization and/or
Percutaneous Coronary Intervention
Frederic Baumann, MD 1 and Jonathan S. Roberts, MD 2
1 Miami Cardiac & Vascular Institute, Baptist Hospital of Miami, Miami FL, USA
2 Memorial Cardiac & Vascular Institute, Memorial Regional Hospital, Hollywood FL, USA
Introduction
Arterial access from the wrist is almost exclusively obtained from the radial artery (RA). Crossover
to secondary femoral arterial (FA) access was observed in up to 7.6% 1, 2, 3 in randomized
multicenter trials utilizing palpation guided RA access. The benefit of ultrasound guidance to
obtain arterial access from the RA was recently demonstrated in the RAUST trial, including
significantly fewer crossovers to alternative access 4.
To obtain anatomic and morphologic features of the RA and ulnar artery (UA) including:
• Diameters
• Presence of a dual (parallel running) artery
Based on these ultrasound findings, it is hypothesized that of the two wrist arteries (RA/UA), one
may be more suitable (larger) for puncture, and accessing this artery may improve the success rate
of arterial access from the wrist.
Intraprocedural ultrasound evaluation of the RA and UA was performed in a
consecutive series of patients undergoing Cardiac Catheterization and/or Percutaneous
Coronary Intervevention with arterial access from the wrist. A difference (Δ) of 20% in
diameter was defined as significant. In the case of a dual artery, measurements of the
dual arteries and the more proximal confluens were obtained.
A total of 566 RA/UA measurements were analysed (patients: n=565, female: n=201 35.5%, mean
age: 66.5 years). Overall, the RA measured 3.03  0.57 mm and the UA 2.70  0.57 mm (P< 0.01).
The RA was larger (Δ ≥20%) in 210 (37.1%) and the UA was larger in 37 (6.5%) measurements. A
dual RA was present in 25 (4.4%) measurements. In those patients (pts), the mean diameters of
the smaller and larger of the dual RAs were 1.82  0.37 mm and 2.59  0.36 mm (P< 0.01). The
corresponding proximal confluens measured 3.10  0.40 mm. No dual UA was observed.
In 15 pts, the RA diameter was <2.0 mm (mean RA diameter of 1.6 + 0.28mm). The corresponding
ipsilateral UAs were significantly larger (mean diameter of 2.6 + 1.02 mm , P = 0.0012). In 12/15
pts, the UA was larger than the RA, in 3/15 pts the UA was smaller.
In 10.9 % of patients, a larger UA or a dual RA with a more accessible confluens was observed. This information can only be obtained using ultrasound and may improve arterial access from the wrist if the
larger UA or RA confluens is accessed instead of blind palpation guided RA access. Future trials will be needed to validate this concept.
Results
Female
N=201
Male
N=364
P-Value
Age, mean  SD 68.4 (12.1) 65.5 (12.0) 0.01
Height cm, mean  SD 161.2 (7.2) 176.2 (8.4) <0.01
Weight kg, mean  SD 76.4 (18.2) 91.8 (19.4) <0.01
BMI kg/m2, mean  SD 29.3 (6.4) 29.6 (6.1) 0.66
Radial Artery, mean  SD 2.7 (0.45) 3.2 (0.56) <0.01
Ulnar Artery, mean  SD 2.4 (0.47) 2.8 (0.57) <0.01
Dual Radial Artery, n (%) 10 (5.0) 15 (4.1) 0.67
Dual Ulnar Artery, n (%) 0 (0.0) 0 (0.0) 1.0
Total
N=566
Female
N=201
Male
N=365
P-Value *
RA > UA ( 25%), n
(%)
170 (30.0) 57 (28.4) 113 (31.0) 1.0
UA > RA ( 25%), n
(%)
30 (5.3) 12 (6.0) 18 (4.9) 0.70
RA > UA ( 15%), n
(%)
261 (46.1) 91 (45.3) 170 (46.6) 1.0
UA > RA ( 15%), n
(%)
61 (10.8) 20 (10.0) 41 (11.2) 0.67
Demographics and Characteristics
Conclusion
1 Mehta et al. JACC. 2012 2 Rao et al. JACC Interv. 2014 ³ Romagnoli et al. JACC. 2012 4 Seto et al. JACC
Purpose
Methods
Illustration of dual RA with proximal confluens Alternative Diameter Cutoff Thresholds Comparing RA / UA

37. Intraprocedural Ultrasound assessment
of RA and UA
• 565 pts
• UA larger (≥ 20%) than RA in 6.5%
• 15 pts RA < 2.0 mm
• ‘Dual RA’ in 4.4%
• Smaller = 1.82 mm
• Larger = 2.59 mm
• Confluens = 3.10 mm

38. Intraprocedural Ultrasound assessment
of RA and UA
Dual Radial Arteries

39. Intraprocedural Ultrasound assessment
of RA and UA
Dual
Confluens

40. Intraprocedural Ultrasound assessment
of RA and UA
• 565 pts
• UA larger (≥ 20%) than RA in 6.5%
• ‘Dual RA’ in 4.4%
________________________________
• 10.9% of pts, a larger UA or a Dual
RA was observed

41. 1000 Consecutive Radials
• Pre access SL NTG
• Intraprocedural Ultrasound assessment
of RA and UA

42. 1000 Consecutive Radials
• Pre access SL NTG
• Intraprocedural Ultrasound assessment
of RA and UA
• US guidance of RA/UA access

43. 1000 Consecutive Radials
• Pre access SL NTG
• Intraprocedural Ultrasound assessment
of RA and UA
• US guidance of RA/UA access

44. 1000 Consecutive Radials
• Pre access SL NTG
• Intraprocedural Ultrasound assessment
of RA and UA
• US guidance of RA/UA access
• “Knuckle wire” technique to negotiate
arterial loops

45. “Knuckle Wire Technique”
0.014 inch Prowater™
Coronary Guidewire
Customized ‘Knuckle’ or
Umbrella Handle End

46. “Knuckle Wire Technique”

47. “Knuckle Wire Technique”

48. “Knuckle Wire Technique”

49. The Impact of Ultrasound
Guidance for TRA
“Seeing “ the RA is better than “feeling”
the RA
You will see things you can not feel
With UGRAA, I believe one can
PREDICTABLY DECREASE
RA CROSSOVER to < 1%!

50. The Impact of Ultrasound
Guidance for TRA
 Predictably Decrease Crossover to < 1%
 Allow access of the most appropriate (larger)
vessel – RA vs UA
 Allow access of the most appropriate
position on the vessel
 Use of appropriate sized sheath
 FASTER, EASIER, more predictable access

51. The Impact of Ultrasound
Guidance for TRA
Predictably Decrease Crossover to < 1%
Predictably Reduce RAO to < 1 %

52. The Impact of Ultrasound
Guidance for TRA
Thank you for listening!
jonathanroberts@mhs.net

53. March/April 2013
Cardiac
Interventions
Today