SHA24/020001

Introduction to Transradial Approach

Mohammed Balghith, MD, FACC,FRCPC,FACP Director of Cath Lab King Abdulaziz Cardiac Center National Guard, Riyadh

Fundamentals of A Transradial Program

Comparison of Femoral and Radial Access

Conditions strongly Favoring A Radial Approach

Patient Selection •All patients who have a normal type A or B Allen’s test are candidates for the radial approach with 5 and 6 F sheaths and catheters

•PATIENT CONDITIONS TO AVOID: • 1) Those on HD with(A-V) fistulae or who may need dialysis); •2) Very small, elderly, female patients who are more likely to have spasm. It is a balance between difficulty and benefit

Contraindications • a. Patients with an abnormal Allen’s test (impaired oximetric wave type C • b. Patients who require support devices like an IABP or other equipment requiring >7 F sheaths [Rotoblator (≥7F), kissing stents, etc.].

• c. Patients with known upper extremity vascular disease (Buerger’s or Reynaud’s, or other peripheral vascular disease).

Relative considerations for using the femoral approach • a. Patients with LIMA grafts (if only right-side access is available). • b. Patients who may need CABG and their physicians contemplate using the radial artery as a conduit

Radial Program • The risk of radial occlusion ranges from 2% to 5%, however, it is asymptomatic in patients with a normal Allen's test • Advantages. Patient comfort due to the ease of radial compression, ambulation is almost immediate, local complications is almost nil. Same day discharge.

• Finally, with use of GP IIb/IIIa inhibitors, sometimes in combination with thrombolysis in the treatment of STEMI • The radial approach could become the preferred approach in this setting

Patient Preparation • a. Sedation • The patient should be well sedated and comfortably positioned.

• Sedation options include 1-2 mg midazolam (Versed) with 2550 mcg fentanyl. Allow time for the sedation to work.

• b. Positioning the arm • Several positioning techniques have been suggested.

• The arm is abducted at a 70-degree angle on an arm board.

After sheath placement, the arm is moved next to the femoral access site • c. Sterile draping of the hand and arm

Oximetric Allen's test. Before radial or ulnar artery compression, pulse oximeter waveform is normal

Pulse waveform is normal when only ulnar is released. Radial artery is still compressed. This .is a type A response. Type B is blunted waveform and type C is flattened wave

.Waveform is flat when both radial and ulnar arteries are compressed

Draping of the hand with sterile towels

The radial pulse is palpated (right arrow). The point of puncture should be 2-3 cm cranial to the bony prominence of the distal radius (left arrow).

Radial Approach Preparation

(A) Picture of the cath lab with back table and prepared arm board. Right arm is positioned extended on arm board

A tray near the extended arm, showing the layout of needles, micro-puncture set, and syringes.

Radial Program • It is preferable to perform at least 25% of all procedures, through this approach before setting up a radial program • Patients with contraindications to the femoral approach (anticoagulation or GP IIb/IIIa inhibitors, obesity, aneurysm of the abdominal aorta, or vessel disease of the lower limbs, etc.) should be selected

Radial Program • With operator experience, puncture failure is extremely rare and the technical failure rate is around 1%, mainly due to the anatomic variations of the radial artery (antebrachial and humeral loops) • Apart from the difficulties associated with the learning curve, the radial approach has few limitations. • The procedure and x-ray exposure times are slightly longer for coronary angiography but not for angioplasty

Thank You