Hemostasis and Radial Artery Patency

1. Hemostasis and radial artery
patency
Samir B. Pancholy, MD, FACP, FACC, FSCAI
Program Director, Cardiology Fellowship,
Wright Center for Graduate Medical Center
Associate Professor of Medicine,
The Commonwealth Medical College, Scranton, PA

2. Disclosures
• Medtronic, The Medicines company, Terumo
Teaching honoraria

3. Radial hemostasis
• The easiest part of the procedure.
• The main reason for attractiveness of TRA

4. Radial artery hemostasis
• Radial artery lies on the flat portion of radius
• No major neurovascular structures
• Ulnar collateralization prevents ischemia
• Well tolerated

5. Distal forearm anatomy

6. Radial artery hemostasis
• Manual pressure
• Dedicated devices

7. Getting to Hemostasis
Sheath is removed and Hemoband / TR band is applied
Patient can sit up immediately after the procedure
Ambulation can occur as soon as patient steady.

8. Radial artery hemostasis
• Most significantly affecting radial artery
outcomes

9. Radial artery hemostasis
• Most significantly affecting radial artery
outcomes
• Most CAD patients will need more than one
procedure

10. Radial artery Hemostasis
Prevention of radial artery occlusion

11. Radial artery hemostasis
Absent radial flow
70
60
50
40
30
20
10
0
At application At removal
Sanmartin et al CCI 2007; 70: 185-9

12. Radial artery hemostasis
• Interruption of radial flow highly predictive of
subsequent radial artery occlusion.
100
90
80
70
60
50
40
30
20
10
0
RAO No RAO
Sanmartin et al CCI 2007; 70: 185-9

13. RAO HAPPENS
• 10.5% at 1 week follow-up (Sanmartin et al)
• 6.8% at 4-6 months (Rathore et al)
• 7% at 4-8 weeks (Plante et al)
• 7% at 4 weeks ( Pancholy et al)

14. Radial artery occlusion
Pancholy SB. J Invasive Cardiol. 2009 Mar;21(3):101-4

15. Active radial hemostasis
Attention to hemostasis
Attention to radial artery patency at onset
Periodic monitoring of radial artery patency

16. Active radial hemostasis
Attention to hemostasis
Attention to radial artery patency at onset
Periodic monitoring of radial artery patency
Buy in from cath lab staff

17. Patent hemostasis
• Maintaining radial artery patency (flow)
during hemostatic compression

18. 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

19. Patent Hemostasis

20. Patent Hemostasis

21. Patent Hemostasis

22. Plethysmography

23. Titration of hemostatic pressure

24. Ideal Hemostasis

25. Does duration matter
(6h)
(2h)
Pancholy S, Patel T, CCI, 2011 May 16. doi: 10.1002/ccd.22963

26. What if patency and hemostasis not
feasible ?

27. Ulnar compression

28. Ulnar compression
UA
UA
compressed
released

29. Larger the Ulnar higher the
VTI increase
3.5
Ulnar Diameter (mm)
3
2.5
2
1.5
1 r=0.60, P < 0.0001)
0.5
0
0 5 10 15 20
DVTI

30. PROPHET-II
610 patients randomized to
Group I: Patent Hemostasis
Group II: Patent Hemostasis
+ Ulnar compression

31. PROPHET-II
• Interruption of ulnar artery flow during
hemostatic compression of radial artery
further reduces the incidence of radial artery
occlusion after TRA

32. Our Protocol
• Monitor radial patency every 15 min
• Adjust hemostatic pressure to maintain radial
patency
• Remove pressure device in 2 hours.
• Apply light dressing (e.g Bandaid)
• Avoid compressive dressing.

33. Have we made a difference?

34. Radial Artery Occlusion Rates
Early Late
12
10.5 Pre-Patent hemostasis Post-Patent hemostasis
10
9.0
8
6.9
%
6 5.3 5.0
4
2 1.8
1.1 0.8
NR NR
0
Sanmartin Rathore Plante Pancholy Cubero Bernat
Anticoagulation UFH 70-100 u/kg UFH 70 u/kg UFH 70 u/kg UFH 50u/kg UFH 70-100 u/kg UFH 5000 u
Or Bivalirudin
Patent hemostasis No No No Yes Yes Yes +
Ulnar compression
Coutesy of SV Rao, MD

35. Radial Artery Occlusion Rates
Early Late
12
10.5 Pre-Patent hemostasis Post-Patent hemostasis
10
9.0
8
6.9
%
6 5.3 5.0
4
2 1.8
1.1 0.8
NR NR
0
Sanmartin Rathore Plante Pancholy Cubero Bernat
Anticoagulation UFH 70-100 u/kg UFH 70 u/kg UFH 70 u/kg UFH 50u/kg UFH 70-100 u/kg UFH 5000 u
Or Bivalirudin
Patent hemostasis No No No Yes Yes Yes +
Ulnar compression

36. Summary
• Radial artery hemostasis is effective, safe
cheap and well-tolerated

37. Summary
• Radial artery hemostasis is effective, safe and
cheap
• RADIAL ARTERY PATENCY NEEDS TO BE
ACTIVELY PURSUED
• AVOID EXCESS DURATION OF COMPRESSION
• TEAM APPROACH

38. Any questions?

39. Any questions?
Second Edition out by 1-2012

40. Thank You