Radial Basics. Samir B. Pancholy, MD, FACP, FACC, FSCAI. Program Director, Cardiology Fellowship, The Wright Center for Graduate Medical Center
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1 Radial Basics Samir B. Pancholy, MD, FACP, FACC, FSCAI Program Director, Cardiology Fellowship, The Wright Center for Graduate Medical Center Associate Professor of Medicine, The Commonwealth Medical College, Scranton, PA
2 Disclosures Consultant: Terumo, Medtronic Speaker: Pfizer Research: Accumed Radial Systems Sanofi, PHRI.
3 Radial Basics Preprocedural evaluation Technique Puncture (Palpation, Ultrasound) Sheath Cocktail
4 Oxymetry + Plethysmography The clamp sensor is applied to the thumb No damping of pulse tracing immediately after radial artery compression 15% Damping of pulse tracing 75% Loss of pulse tracing followed by recovery of pulse tracing within 2 minutes 5% Loss of pulse tracing without recovery within 2 minutes. 5% Barbeau et al. Am Heart J 2004;147:489 93
5 Radial Approach Ulnar artery Palm ar a rch Radial artery
6 Collateralization in UE is more than we think Extensive interosseous collaterals Dynamic recruitable non-visible circuits.
7 Recruitable circulation JACC Vol. 46, No. 11, 2005 December 6, 2005:2013 7
8 Abnormal Allen s = ischemia? JACC Vol. 46, No. 11, 2005 December 6, 2005:2013 7
9 RADAR Study N=203 patients Valgimigli M, et. al. JACC 2014
10 RADAR Study N=203 patients Valgimigli M, et. al. JACC 2014
11 RADAR Study N=203 patients Valgimigli M, et. al. JACC 2014
12 RADAR Study N=203 patients Valgimigli M, et. al. JACC 2014
13 RADAR Study N=203 patients Valgimigli M, et. al. JACC 2014
14 RADAR Study N=203 patients Valgimigli M, et. al. JACC 2014
15 RADAR Study N=203 patients Valgimigli M, et. al. JACC 2014
16 RADAR Study N=203 patients Valgimigli M, et. al. JACC 2014
17 RADAR Study N=203 patients Valgimigli M, et. al. JACC 2014
18 RADAR
19 RADAR
20 From this carefully performed mechanistic study, one can conclude that the AT and oximetryplethysmography are not reliable tests to predict distal ischemia, loss of strength, or discomfort after transradial catheterization. On the basis of the results of RADAR, we believe that the denial of radial access for diagnostic angiography or interventions solely on the basis of an abnormal AT or oximetryplethysmography curve is not warranted, because these tests are not scientifically predictive of pathologic rises in lactate levels, weakness in the hand, or persistent discomfort during or after transradial catheterization. The time has come to remove the AT from pre-procedural triage for transradial catheterization. We need to refocus our attention on the use of oximetry-plethysmography and other techniques to guide patent Hemostasis once the transradial procedure is completed to minimize RAO. JACC 2014;63(18):
21 Radial Artery Access Techniques TR vs. TF access smaller needle (20 or 16 ) bare-needle vs. teflon-sheathed needle or guidewire
22 Counterpuncture
23
24
25
26
27 Withdraw Teflon cannula parallel to skin
28 Kinking is prevented by constant pull
29 Upon entry into lumen from posterior wall, cannula straightens out
30 Upon entry into lumen from posterior wall, cannula straightens out
31 Upon entry into lumen from posterior wall, cannula straightens out
32 Anterior puncture / metallic needle users, enter at shallow angle
33 Anterior puncture / metallic needle users, enter at shallow angle
34 Anterior puncture / metallic needle users, enter at shallow angle
35 RATE trial Pancholy SB, Sanghvi KA, Patel TM. Catheter Cardiovasc Interv Aug 1;80(2):288-91
36 Predictors of RAO Dharma S, Kedev S, Patel T et al, CCI 2014
37 Predictors of RAO Dharma S, Kedev S, Patel T et al, CCI 2014
38 Courtesy A. Seto, MD Real-time Ultrasonography for Radial Access US Tips: Keep probe near/over needle Mark the center of the probe and line up artery with centerline marker of image Short jabs on the skin or tissue to identify needle tip Compress the skin to close the veins Note compression of artery
39 Number of Attempts 4 p< Attempts Courtesy A. Seto, MD N= 237 Palpation N= 236 Ultrasound
40 First Pass Success Rate 100% p< Percentage 80% 64.8% 60% 43.9% 40% 20% Courtesy A. Seto, MD N = 237 Palpation N = 236 Ultrasound
41 P=0.006 N = 351 Courtesy A. Seto, MD N = 347
42 18.6% P<0.001 P= % 3.7% 2.4% Palpation Ultrasound Courtesy A. Seto, MD Palpation Ultrasound
43 Clinical Outcomes Palpation Ultrasound N=351 N= (3%) 15 (4.3%) (1.1%) 5 (1.4%) (8 successful) N.A. N.A. Crossover to other site after successful sheath insertion Crossover to other site before sheath insertion / failed access Characteristic Spasm Pain score (0-10) Bleeding Crossover to ultrasound rescue attempts after >5 minutes Courtesy A. Seto, MD P-value
44 Role of Ultrasound Guidance Zaremski et al J Inv Cardiol 2013: 25(10);538
45 Zaremski et al J Inv Cardiol 2013: 25(10);538
46 Very important Any resistance to wire or catheter advancement
47 Very important Any resistance to wire or catheter advancement RADIAL ANGIOGRAM
48 Hydrophilic sheath Less spasm (Saito et al, Rathore et al), Increased comfort? Less entrapment? Less RAO
49 Radial Cocktail Vasodilators (prevent spasm) Nitrates (200 mcg IA) Calcium channel blockers Diltiazem 5 mg, Verapamil 2.5 mg IA
50 Anticoagulants Prevent radial artery occlusion
51 Anticoagulants Unfractionated heparin (5000 U bolus) at least 50 U/Kg (Spaulding et al, Leipzig study, Bernat et al) systemic effect, IA vs IV (Pancholy et al)
52 Anticoagulation Effect probably related to degree of anticoagulation (ACT 200 = < 5% RAO) Seen with Bivalirudin (Plante et al)
53 Warfarin anticoagulation RAO prevention not = any anticoagulation
54 Incidence of Radial Artery Occlusion in Patients Receiving Warfarin Compared to Heparin P = P = Warfarin 9.6 Heparin % Early RAO Late RAO Pancholy S et al Am J Cardiol 2014
55 Distal forearm anatomy
56 Goals Hemostasis
57 Goals Hemostasis Radial artery preservation
58 Radial Artery Hemostasis Well tolerated Highly effective
59 RAO: Flow cessation % P < RAO No RAO Sanmartin et al CCI 2007; 70: 185-9
60 Radial artery occlusion Maintaining radial artery patency reduces RAO Pancholy S et al. Catheter Cardiovasc Interv. 2008;72(3):
61 Patent hemostasis protocol
62 Apply pressure, remove sheath, release pressure, use least necessary pressure
63 Focal Occlusion of Ulnar to assess radial patency
64 Reverse Barbeau Plethysmography
65 Does duration matter * * * Pancholy S, Patel T, Cathet Cardiov Interv 2012
66 Duration of hemostasis Duration predicts RAO Once patency status entered in multivariable analysis, duration loses its significance as a predictor. If radial artery is patent during hemostatic compression, longer duration of compression is well tolerated. Pancholy S, Patel T, Cathet Cardiov Interv 2012
67 Role of Spasm Dharma S, Kedev S, Patel T et al, CCI 2014
68 Eliminate residual spasm Dharma S, Kedev S, Patel T et al, CCI 2014
69 Predictors of RAO Dharma S, Kedev S, Patel T et al, CCI 2014
70 Radial Artery Occlusion Rates Early Late 12 Pre-Patent hemostasis Post-Patent hemostasis % Patent hemostasis UFH u/kg UFH 70 u/kg No 0.8 Cubero Bernat NR NR Sanmartin Rathore Anticoagulation 1.1 No Plante UFH 70 u/kg Or Bivalirudin No Pancholy UFH 50u/kg UFH u/kg UFH 5000 u Yes Yes Yes + Ulnar compression
71 Probability of Success with Repeat TRA Abdelaal E Bertrand OF, AHJ 2012
72 Probability of Success with Repeat TRA No attention to Patent Hemostasis Abdelaal E Bertrand OF, AHJ 2012
73 Probability of Success with Repeat TRA No attention to Patent Hemostasis Abdelaal E Bertrand OF, AHJ 2012
74 Summary Micropuncture access Hydrophilic introducers Vasodilators / anticoagulants Patent hemostasis
75 Thank you
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For Personal Use. Copyright HMP 2014
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