Femoral access is most common for non-coronary vascular interventions e.g. peripheral vascular

1. Safety and Feasibility of Trans-radial Access for
Non-coronary and Peripheral Vascular
Interventions
Saqib Zia MD, FACS, RPVI
Director of Vascular Quality and Performance Improvement
Assistant Professor of Surgery
Division of Vascular and Endovascular Surgery
Donald and Barbara Zucker School of Medicine at Hofstra Northwell
Staten Island University Hospital Northwell Health
Staten Island, New York, USA
Stat 1

2. Disclosures
• None
2

3. Background
Trans-radial access (TRad) widely used for coronary interventions
with good success
History
•1948: First attempted transradial coronary angiogram using
radial cut-down
•1989: Campeau reported first 100 cases of percutaneous
transradial coronary angiogram
•1993: First transradial coronary angioplasty with stent
implantation
Campeau L. Percutaneous radial artery approach for coronary angioplasty. Cath Cardiovasc Diag 1989:16:3-7
Kiemeneij F, Laarman GJ Percutaneous transradial artery approach for coronary stent implantation. Cath Cardiovasc Diag. 1993
Oct;30(2):173-8.

4. Introduction
Femoral access is most common for non-coronary vascular interventions e.g.
peripheral vascular
Limitations:
• Groin infection, hematomas
• Severe femoral disease (e.g. plaques, calcification, occlusions)
• Difficult ilio-femoral anatomy (e.g. tortuosity)
• Recent groin bypass (e.g. aorto-bifemoral, femoral-popliteal)
• Morbid obesity
• Complications can occur in 1.8% of diagnostic and 4% of therapeutic cardiac
catheterization procedures

5. Introduction
Radial Access might be considered as an alternative option. The utility and
safety of in non-coronary vascular interventions is not as well established
 Radial Access widely used for percutaneous coronary interventions:
• Safer and cost-effective
• Better patient satisfaction
• Early ambulation and discharge
 We present our experience with radial access for non-coronary and
peripheral vascular interventions
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6. Methods: Study Design
 Retrospective, single center study, 3 years data
 Patients undergoing TRad for non coronary vascular diagnostic or
therapeutic procedures
 Four board certified vascular surgeons
 Reviewed:
- Demographic data
- Indication for TRad
- Type of intervention
- Sheath size
- Procedural outcomes and access site complications
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7. Methods: Inclusion and Exclusion Criteria
• Allen's test as well as duplex examination before the procedure
• Inclusion Criteria:
- Palpable radial pulse, minimum radial artery diameter of 2.5 mm with minimum or
no calcifications and a normal Allen's test score were included in the study
• Exclusion Criteria:
- Nonpalpable radial pulse, a positive Allen's test, severe calcifications, small radial
artery, radial artery anomalies such as radial loop, and the need to preserve the
radial artery for anticipated future dialysis access
• Outpatient setting
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8. Methods: Description of Technique
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• Local anesthesia with sedation
• Portable C-arm OEC®9900 Elite (General Electric Medical Systems, Waukesha, WI).
• The arm positioned on an arm board, abducted 45°, and the wrist
hyperextended.
• Ultrasound guided access into radial artery, 1 cm proximal to the styloid
process
• Check-Flo® micropuncture radial artery access set (Cook Medical Inc.,
Bloomington, IN)

9. Description of Technique
A bolus of 80 U/kg of systemic unfractionated heparin intravenously
Intra-arterial spasmolytic cocktail mixture via microsheath:
- 5-mg verapamil
- 200 μg of nitroglycerine
- 5 mL of 1% lidocaine
A 5F short Pinnacle® sheath (Terumo Medical Corp., Somerset, NJ) initially.
Left arm preferred as it gives better angle for the catheterization of descending
aorta and minimizes the manipulation of aortic arch branches.
260-cm-long, 0.035″ Hydrophilic Coated GLIDEWIRE® (Terumo Medical Corp., Somerset,
NJ) advanced into the subclavian artery and a SOS Omni Selective Catheter
(AngioDynamics, Latham, NY) advanced over it
Month Day, Year 9
Kiemeneij F, et al. Evaulation of a spasmolytic cocktail to prevent radial artery spasm during coronary procedures.
Catheter Cardiovasc Interv, 2003 vol. 58(3) pp. 281-4

10. 10
Fig. 1. (A) SOS Omni catheter passed through left subclavian artery into
the arch of aorta. (B) SOS Omni catheter retracted over the wire to guide it
into the descending aorta.

11. Radial Access Technique
• The wire exchanged to a 260-cm-long 0.035″ Lunderquist® Extra-Stiff Wire
Guide (Cook Medical Inc., Bloomington, IN).
• The short sheath exchanged over this guidewire to a long (90 cm)
PINNACLE® DESTINATION® Guiding Sheath (Terumo Medical Corp., Somerset, NJ) 5F,
6F, or 7F depending on the intervention planned.
• Diagnostic angiogram via the sheath for angiographic pictures of mesenteric, renal,
iliac or femoral arteries
• If indicated, angioplasty with or without stent performed on the target artery
• The angioplasty balloons and/or stents catheter lengths:
• 135-cm-length for mesenteric and iliac artery interventions
• 150 cm length for common femoral and proximal SFA interventions
Month Day, Year 11

12. Access Closure
• Once the intervention was completed, the wires and catheters removed
• Activated clotting time(ACT) at the end of the intervention.
- ACT:
- <180 sec, removed the sheath and gentle digital pressure
- >180 sec and <250 sec: 25 mg of protamine and remove the sheath
- >250 sec: 50 mg of protamine and removed the sheath
• No closure device was used during the study period
Month Day, Year 12

13. Follow-up
Radial Artery Patency Assessed:
• Hand ischemic symptoms
• Physical examination
• Arterial Duplex
Follow-up
• Immediately post procedure
• 2 weeks follow up

14. Results
 24 Trad for peripheral and non-coronary angiograms were performed on 19 patients
 Patient Cohort
- Mean age: 67.2 years (range: 54–81, ±8 years)
- 12 (63%) female and 7 (37%) male
- 18 (75%) via left radial artery access
- 6 (25%) via right radial artery
- 10 patients were on dual antiplatelet therapy with aspirin and Plavix.
- Symptomatic peripheral or mesenteric arterial disease requiring angiograms
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15. Indications for Radial access
Month Day, Year 15
Absent femoral
pulses
12
50%
Morbid obesity
6
25%
Femoral
bypass
4
17%
Groin wound
infection
2
8%
Indications for TRad
Absent femoral pulses
Morbid obesity
Femoral bypass
Groin wound infection

16. Breakdown of the Procedures Performed
Month Day, Year 16
n = 24
THERAPEUTIC
13 (54%)
Iliac Angioplasty/Stent
7 (29%)
Femoral Anastomosis
Angioplasty
3 (13%)
SFA angioplasty
2 (8%)
Mesenteric angioplasty
1 (4%)
DIAGNOSTIC
11 (46%)

17. Sheath sizes used and related interventions performed
Month Day, Year 17
11 2
10
1
0 2 4 6 8 10 12 14
5F
6F
7F
SHEATH
5F 6F 7F
Diagnostic 11
Therapeutic 2 10 1
SHEATH SIZE AND INTERVENTION
Diagnostic Therapeutic

18. Results
100% success rate for the planned interventions
No access-site hematoma immediately or during the follow-up.
No procedure-related deaths or major cardiovascular adverse events
6 (31%) post-procedural radial artery occlusions:
• 5 patients were completely asymptomatic
• 1 patient self-limiting mild forearm pain lasting for 1 day- No intervention required
• 2 patients were on dual antiplatelet therapy
• 4 occlusions involved the entire length of the radial artery
• 2 occlusions involved the distal radial artery only
Month Day, Year 18

19. Sheath size and radial artery occlusion (RAO)
Month Day, Year 19
Table 2. Sheath size and radial artery occlusion (RAO)

20. Limitations of Radial Access
• Normal Allen’s test
• Learning curve
• Vasospasm
• Radial anomalies e.g radial loop
• LIMA (CABG)
• Longer platform length and relatively short length of available sheaths, balloons and
stents
• Distal lower extremity interventions
• Radial artery occlusion or endothelial injury
o unsuitable conduit for CABG
o unavailable for future access
Month Day, Year 20

21. Lessons Learned
• Minimizing the cannulation time
• Minimizing sheath size
• Anticoagulation during sheath insertion
• Spasmolytics
• Nonocclusive closure and hemostasis
• Preoperative arm evaluation
Month Day, Year 21

22. Conclusions
 Radial access represents a safe and feasible access alternative when standard femoral
access is difficult or not possible for peripheral and non-coronary diagnostic and
therapeutic angiograms in carefully selected patients
 Development of longer and lower-profile devices and better closure devices can
potentially make this technique even more desirable
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23. Radial Access Case
• 65 years old female with significant PAD and CAD
• 2 previous left groin bypasses: Left femoral to peroneal and redo-iliac to profunda
• Right leg severe claudication with SFA occlusion and high grade left iliac artery
stenosis
• Recent cardiac cath from right groin and severe scaring in left groin
Month Day, Year 23

24. Left Radial Access
Month Day, Year 24

25. Month Day, Year 25

26. Month Day, Year 26

27. Month Day, Year 27

28. Left iliac angioplasty
Month Day, Year 28

29. Left iliac post angioplasty
Month Day, Year 29

30. Left leg: Patent bypasses
Month Day, Year 30

31. Month Day, Year 31

32. Right leg
Month Day, Year 32

33. Right SFA occlusion
Month Day, Year 33

34. Month Day, Year 34

35. Month Day, Year 35

36. 36
Thank You