Radial artery access
Updates to Article Attributes
Radial artery access is a minimally invasive approach for vascular access in interventional procedures. This route has widely been adopted since it reduced significantly the transfemoral-related complications. It is the recommended access route by the European Society of Cardiology for angiography and interventions in patients with ST-elevation myocardial infarctions1.
Advantages
Compared to transfemoral or transbrachial access, the radial approach decreases the incidence of complications such as2,3:
access site bleeding
pseudoaneurysm
arteriovenous fistula
Disadvantages
inability to use larger sheaths
risk of radial artery spasm
increased radiation exposure
potential need for crossover to femoral access
Radial access is a harder technique compared to the femoral approach and is associated with a higher cannulation failure rate4 because:
the distal radial artery has a small diameter
existence of anatomical variants
are more prone to thromoembolic disease than the femoral artery
Preprocedural assessment
Examination of radial pulse.
Confirm adequate collateral circulation to the hand, to ensure blood supply in case of radial artery spasm/occlusion by performing:
Allen test
Barbeau test
Ultrasound duplex assessement
measure the diameter of the radial artery, to select the correct sheath size. The Radial artery-to-sheath diameter should be <1
verify the patency of the radial and brachial artery and look for stenosis or thrombosis
Patient preparation
Monitoring with finger oximeter in the accessed hand to assess the integrity of blood supply to the hand.
Anxiolytics and nalgesics - to reduce the potential radial artery spasm.
Sterilise the area from the mid-forearm to the flexor crease.
The groins can be sterilised to facilitate femoral access in case of radial cannulation failiure or if a mechanical support is needed.
The arm should not be flexed (could block the advancement of catheters and wires) but rather extended, on a movable splint or armboard.
Material preparation
The material generally prepared consists of:
short 5-6F sheath catheter (10 to 11 cm in length) - the size depends on the radial artery diamater
20 G angiocath - if doublewall through-and-through approach is to be used or a micropuncture needle (19- 21G) for single-wall anterior puncture approach
-
"radial cocktail"5
1.25 mg of verapamil
100 μg of nitroglycerin
5,000 IU of heparin
Flush the sheath catheter and the tapered tip dilator. The access guidewire should be damped in heparnized saline.
Procedure
Local anaesthesia
lidocain 1% mixed with Isosorbide dinitrate - to promote arterial dilatation.
Ultrasound-guided puncture of artery
the distal artery is preferred over the proximal segment since it offers a better position for the patient and operator
doublewall through-and-through approach or single-wall anterior puncture
the needle tip should be headed towards the navigation direction (towards brachial artery), and should be at 45º from the skin surface.
the trasnducer is placed 2.5 - 5 mm from the needle tip
Access wire exchange
when the angiocath/needle tip is within the lumen of the artery, decrease the angle to the skin surface to allow the access wire to pass
Insertion of the access wire
advance the wire until it traverses the elbow
any resistance is abnormal and require visualisation under ultrasound/fluoroscopy.
The causes of guidewire resistance may be :
extra-arterial location
the wire is in a small branch
iI's in subintimal position
Placement of sheath catheter
slowly introduce the sheath over the wire
remove dilator
aspirate and flush heparnaized saline
the "radial cocktail" should be diluted with approximately 20 ml of aspirated blood and injected over one minute, to avoid patient discomfort during the injection6
Radial angiography
To confirm radial patency and to screen for loops and anomalies before introducing larger catheters.
Sheath fxation - optional
The sheath can be fixed with a transparent adhesive pad to prevent accidental removal during the procedure.
Complications
radial artery occlusion - higher risk when the ratio of radial artery inner diameter to sheath catheter outer diameter < 1 7
-
radial artery injuries
intimal tears
medial dissections
chronic intima-media thickening
- +<p><strong>Radial artery access</strong> is a minimally invasive approach for vascular access in interventional procedures. This route has widely been adopted since it reduced significantly the transfemoral-related complications. It is the recommended access route by the European Society of Cardiology for angiography and interventions in patients with ST-elevation myocardial infarctions<sup>1</sup>.</p><h5>Advantages</h5><p>Compared to transfemoral or transbrachial access, the radial approach decreases the incidence of complications such as<sup>2,3</sup>:</p><ul>
- +<li><p>access site bleeding</p></li>
- +<li><p>pseudoaneurysm</p></li>
- +<li><p>arteriovenous fistula</p></li>
- +</ul><h5>Disadvantages</h5><ul>
- +<li><p>inability to use larger sheaths</p></li>
- +<li><p>risk of radial artery spasm</p></li>
- +<li><p>increased radiation exposure</p></li>
- +<li><p>potential need for crossover to femoral access</p></li>
- +</ul><p>Radial access is a harder technique compared to the femoral approach and is associated with a higher cannulation failure rate<sup>4</sup> because:</p><ul>
- +<li><p>the distal radial artery has a small diameter</p></li>
- +<li><p>existence of anatomical variants</p></li>
- +<li><p>are more prone to thromoembolic disease than the femoral artery</p></li>
- +</ul><h5>Preprocedural assessment</h5><p>Examination of radial pulse.</p><p>Confirm adequate collateral circulation to the hand, to ensure blood supply in case of radial artery spasm/occlusion by performing:</p><ul>
- +<li><p>Allen test</p></li>
- +<li><p>Barbeau test</p></li>
- +</ul><p>Ultrasound duplex assessement</p><ul>
- +<li><p>measure the diameter of the radial artery, to select the correct sheath size. The Radial artery-to-sheath diameter should be <1</p></li>
- +<li><p>verify the patency of the radial and brachial artery and look for stenosis or thrombosis</p></li>
- +</ul><h5>Patient preparation</h5><p>Monitoring with finger oximeter in the accessed hand to assess the integrity of blood supply to the hand.</p><p>Anxiolytics and nalgesics - to reduce the potential radial artery spasm.</p><p>Sterilise the area from the mid-forearm to the flexor crease.</p><p>The groins can be sterilised to facilitate femoral access in case of radial cannulation failiure or if a mechanical support is needed.</p><p>The arm should not be flexed (could block the advancement of catheters and wires) but rather extended, on a movable splint or armboard.</p><h5>Material preparation</h5><p>The material generally prepared consists of:</p><ul><li><p>short 5-6F sheath catheter (10 to 11 cm in length) - the size depends on the radial artery diamater</p></li></ul><ul><li><p>20 G angiocath - if doublewall through-and-through approach is to be used or a micropuncture needle (19- 21G) for single-wall anterior puncture approach</p></li></ul><ul><li>
- +<p>"radial cocktail"<sup>5</sup></p>
- +<ul>
- +<li><p>1.25 mg of verapamil</p></li>
- +<li><p>100 μg of nitroglycerin</p></li>
- +<li><p>5,000 IU of heparin</p></li>
- +</ul>
- +</li></ul><p>Flush the sheath catheter and the tapered tip dilator. The access guidewire should be damped in heparnized saline.</p><h5>Procedure</h5><p><strong>Local anaesthesia</strong></p><ul><li><p>lidocain 1% mixed with Isosorbide dinitrate - to promote arterial dilatation.</p></li></ul><p><strong>Ultrasound-guided puncture of artery</strong></p><ul>
- +<li><p>the distal artery is preferred over the proximal segment since it offers a better position for the patient and operator</p></li>
- +<li><p>doublewall through-and-through approach or single-wall anterior puncture</p></li>
- +<li><p>the needle tip should be headed towards the navigation direction (towards brachial artery), and should be at 45º from the skin surface.</p></li>
- +<li><p>the trasnducer is placed 2.5 - 5 mm from the needle tip</p></li>
- +</ul><p><strong>Access wire exchange</strong></p><ul>
- +<li><p>when the angiocath/needle tip is within the lumen of the artery, decrease the angle to the skin surface to allow the access wire to pass</p></li>
- +<li><p>Insertion of the <a href="/articles/access-guidewires" title="Access wire">access wire</a></p></li>
- +<li><p>advance the wire until it traverses the elbow</p></li>
- +<li><p>any resistance is abnormal and require visualisation under ultrasound/fluoroscopy.</p></li>
- +</ul><p>The causes of <a href="/articles/guidewires" title="Guidewires">guidewire</a> resistance may be :</p><ul>
- +<li><p>extra-arterial location</p></li>
- +<li><p>the wire is in a small branch</p></li>
- +<li><p>iI's in subintimal position</p></li>
- +</ul><p><strong>Placement of sheath catheter</strong></p><ul>
- +<li><p>slowly introduce the sheath over the wire</p></li>
- +<li><p>remove dilator</p></li>
- +<li><p>aspirate and flush heparnaized saline</p></li>
- +<li><p>the "radial cocktail" should be diluted with approximately 20 ml of aspirated blood and injected over one minute, to avoid patient discomfort during the injection<sup>6</sup></p></li>
- +</ul><p><strong>Radial angiography</strong></p><p>To confirm radial patency and to screen for loops and anomalies before introducing larger catheters.</p><p><strong>Sheath fxation - optional</strong></p><p>The sheath can be fixed with a transparent adhesive pad to prevent accidental removal during the procedure.</p><h5>Complications</h5><ul>
- +<li><p>radial artery occlusion - higher risk when the ratio of radial artery inner diameter to sheath catheter outer diameter < 1 <sup>7</sup></p></li>
- +<li>
- +<p>radial artery injuries</p>
- +<ul>
- +<li><p>intimal tears</p></li>
- +<li><p>medial dissections</p></li>
- +<li><p>chronic intima-media thickening</p></li>
- +</ul>
- +</li>
- +</ul>
References changed:
- 1. Bernat I, Horak D, Stasek J et al. ST-Segment Elevation Myocardial Infarction Treated by Radial or Femoral Approach in a Multicenter Randomized Clinical Trial: The STEMI-RADIAL Trial. J Am Coll Cardiol. 2014;63(10):964-72. <a href="https://doi.org/10.1016/j.jacc.2013.08.1651">doi:10.1016/j.jacc.2013.08.1651</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24211309">Pubmed</a>
- 2. Nathan S & Rao S. Radial Versus Femoral Access for Percutaneous Coronary Intervention: Implications for Vascular Complications and Bleeding. Curr Cardiol Rep. 2012;14(4):502-9. <a href="https://doi.org/10.1007/s11886-012-0287-5">doi:10.1007/s11886-012-0287-5</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/22733412">Pubmed</a>
- 3. Baklanov D, Kaltenbach L, Marso S et al. The Prevalence and Outcomes of Transradial Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction: Analysis from the National Cardiovascular Data Registry (2007 to 2011). J Am Coll Cardiol. 2013;61(4):420-6. <a href="https://doi.org/10.1016/j.jacc.2012.10.032">doi:10.1016/j.jacc.2012.10.032</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/23265340">Pubmed</a>
- 4. Kiemeneij F, Laarman G, Odekerken D, Slagboom T, van der Wieken R. A Randomized Comparison of Percutaneous Transluminal Coronary Angioplasty by the Radial, Brachial and Femoral Approaches: The Access Study. J Am Coll Cardiol. 1997;29(6):1269-75. <a href="https://doi.org/10.1016/s0735-1097(97)00064-8">doi:10.1016/s0735-1097(97)00064-8</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/9137223">Pubmed</a>
- 5. Shivaraju A & Shroff A. Radial Artery Spasm: Pick the Right Cocktail and Relax. J Invasive Cardiol. 2011;23(10):405-6. - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21972157">Pubmed</a>
- 6. Basics of Radial Artery Access - Cardiac Interventions Today. Cardiac Interventions Today.
- 7. Saito S, Ikei H, Hosokawa G, Tanaka S. Influence of the Ratio Between Radial Artery Inner Diameter and Sheath Outer Diameter on Radial Artery Flow After Transradial Coronary Intervention. Catheter Cardiovasc Interv. 1999;46(2):173-8. <a href="https://doi.org/10.1002/(SICI)1522-726X(199902)46:2<173::AID-CCD12>3.0.CO;2-4">doi:10.1002/(SICI)1522-726X(199902)46:2<173::AID-CCD12>3.0.CO;2-4</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/10348538">Pubmed</a>
Sections changed:
- Interventional Radiology
Systems changed:
- Interventional