Optimizing Transradial Interventions, Recognizing and Managing Complications

1. Optimizing Transradial Interventions, Recognizing
and Managing Complications
Ramon Quesada, M.D., FACP, FACC, FSCAI
Medical Director, Interventional Cardiology, Cardiac Research & Outcomes
Baptist Cardiac & Vascular Institute
Clinical Associate Professor of Medicine Herbert Wertheim College of Medicine at
Florida International University

2. Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship Company
Grant/Research Support None
Consulting Fees/Honoraria Abbott, Cordis, St. Jude, W.L.
Gore, NMT Medical, Terumo & Boston
Scientific Corporation
Major Stock Shareholder/Equity None
Royalty Income None
Ownership/Founder None
Intellectual Property Rights None
Other Financial Benefit None

3. How to Optimize TRA
 Be aware of anatomical considerations
in patient selection
 Implement proper techniques to avoid
failure
 Anticipate the possibility of common
problems as well as rare complications

4. Stages of TRA: Possible Problems and Complications
Subclavian &
Coronary
Cannulation
Traversing Subclavian Tortuosity
Anatomical Variations
Rare but possible Complications
Anatomical Variations
Radial Artery Spasm
Perforation ACCESS
Removal of
Sheath/
Catheter
Radial Artery Occlusion
Hematoma / Pseudoaneurysm
Bleeding/Compartment syndrome

5. How to Optimize TRA ~Access
 Be aware of anatomical considerations
in patient selection
 Implement Proper Techniques to Avoid
Techniques to
Failure
Avoid Failure
 Anticipate the possibility of common
problems as well as rare complications

6. Forearm Normal Vascular Anatomy
Fujii et al. J Invasive Cardiol 2010;22:536-40

7. Modified Allen Test Essentials
y To avoid ischemic hand complications, the
percutaneous transradial approach is only performed
in patients with patent hand collateral arteries, which
is usually evaluated with the modified Allen’s test
(MAT).
y This qualitative test measures the time needed for
maximal palmar blush after release of the ulnar artery
compression with occlusive pressure of the radial
artery

8. Combined
plethysmography (PL) and
pulse oximetry (OX) tests
Safe to proceed with TRA
Avoid TRA
Barbeau GR, Arsenault F, Dugas L, et al. Evaluation of the ulnopalmar
arterial arches with pulse oximetry and plethysmography: comparison
with the Allen’s test in 1,010 patients. Am Heart J. 2004;147:489-493.

9. Incidence and Implications of Arterial Anomalies
y Analysis and incidence of
arterial anomalies completed
by Fujii et al on 163
consecutive patients.
y Classification of all
anomalies and then
stratification of the
“difficulty” of transradial
access for that anomaly was
completed.
y Overall it was concluded
that 98.8% of patients were
acceptable for TRA. Fujii et al. J Invasive Cardiol 2010;22:536-40

10. Anatomical Variations
Fujii et al. J Invasive Cardiol 2010;22:536-40

11. Anatomical Variations
Fujii et al. J Invasive Cardiol 2010;22:536-40

12. How to Optimize TRA ~ Access
y Be aware of anatomical considerations in
patient selection
y Implement proper techniques to avoid failure
y Anticipate the possibility of common
problems as well as rare complications

13. Causes of Transradial Approach Percutaneous
Coronary Intervention Failure
Radial Artery Loop Guidewire-induced Severe Spasm not relieved Severe Subclavian Tortuosity
Dissection by inter-arterial nitro &
verapamil
Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064

14. Radial Anomalies and Procedural Failure
120
7%
N=1540
100
80
60
2.3% 2.0% 2.5%
40
20
0
High
Radial Loop Tortuosity Others
Bifurcation
Success 103 22 23 34
Failure 5 13 7 5
Failure Success
Lo TS, et. Al. Heart, 2009:95: 410-15

15. TRA Failure in Low (8%) to Intermediate (42%) Volume Operators
N = 2,100
Overall Failure rate: 4.7%
No Hydrophilic sheaths & no specialty
design radial guide catheters
Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1

16. Multivariate Predictors of TR-PCI Failure
TR-PCI Failure
Stratified by Patient
Height
Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064

17. Transradial Procedure
July 1, 1998 - April 30, 2001
Diagnostic 722
Converted to femoral 67 (9.3%)
Intervention 403
Ad Hoc 232 (57.6%)
Converted to femoral 31 (7.7%)
Right Radial Approach 94%

18. Transradial: Aborted or Converted Cases
due to Access Problems
Tortuousity Radial artery 36
Brachial artery 9
Subclavian artery 12
Ascending aorta 2
Unable to Cannulate LCA 8
RCA 3
SVG 4
IMA 5
Other Lack of back up 8

19. Are the Right and Left Radial Arteries
Equal in Ease of Access?

21. TALENT TRIAL: Fluoroscopy Time and DAP per
Operator’s Experience
Subgroup analysis of fluoroscopy time and DAP for fluoroscopy according to the operator's skill
(seniors compared with fellows). Results are expressed as median (squares) and IQR (bars).
Sciahbasi, A, Am Heart J 2011;161:172-9.

22. Transradial Access: Basic Tools
Transradial wire in kit
Cope Mandril Wire Guide 0.025 mm
Transradial needle 3.5 cm/21g
Thinwall needle 2.5 cm/21g

23. Microcatheter

24. Radial Artery Access
Needle in
Cross Section Radial Artery Injection
Wire Placement
Radial A. –
Slow Flow

25. Wire Fracture

26. How to Optimize TRA ~ Access
y Be aware of anatomical considerations in
patient selection
y Implement proper techniques to avoid failure
y Anticipate the possibility of common
problems as well as rare complications
26

27. Technical Tips for Successful Transradial Cannulation
y Use a 21 G x 2.5 cm thin wall needle to cannulate the
radial artery
y Advance a 0.025 inch guidewire through the needle
y After the introducer is inserted, give “cocktail” of
Verapamil 2 mg, lidocaine 2% (1 cc) diluted in saline,
followed by 50 units/kg heparin bolus and 100-200
mcg of nitroglycerine.
Quesada et al, “Transradial Coronary Interventions”,
Interventional Cardiology Secrets, 2003, pp. 203-210

28. Sedation and Verapamil Virtually
Eliminate the Spasm Problem
Before After

29. Severe vasospasm can lead to avulsion of
the radial artery- rare but preventable
Severe spasm can lead to
eversion of the radial artery.
The best therapy is prevention:
•Hydration
•Sedation
•Vasodilator Cocktail
•Hydrophilic Sheath
Radial artery seen protruding from the radial
artery access site.
Dieters, RS, Catheterization and Cardiovascular Interventions 58:478–480 (2003)

30. The radial artery is a thick-walled vessel composed mainly
of smooth-muscle cells arranged in concentric layers. This
marked muscular component of the artery, together with the
high density of alpha1-receptors, make this vessel
especially susceptible to spasm
Journal of Cardiothoracic and Vascular Anesthesia, Vol 22, No 3 (June), 2008: pp 428-430

31. The branching point of the axillary artery where
Catheter Entrapment papaverine was injected.
(A) The transradial catheter,
(B) Tip of the transfemoral catheter,
The transfemoral catheter deviating away (C) The abnormal high origin of the profunda brachii
from the transradial catheter in the axillary artery,
artery. (D) The anterior circumflex humeral artery, and
(E) The posterior circumflex humeral artery.

32. Impact of Length and Hydrophilic Coating of the
Introducer Sheath in Radial Artery Spasm during TRA
y There was significantly less radial artery spasm and
less discomfort in patients with hydrophilic coated
sheaths compared to non-hydrophilic coated .
Hydrophilic Non-hydrophilic P
RAS (Spasm) 19% 39.9% <0.001
Discomfort 15.1% 28.5% <0.001
Sterile Abscess 5% 0.3% 0.001
RAO(Occlusion) 8.9% 10.0 0.624
• J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S , V O L . 3 , N O . 5 , 2 0 1 0 MAY 2 0
1 0 : 4 7 5 – 8 3 Rathore et al. Impact of Sheath on Radial Artery Spasm

33. Impact of Length and Hydrophilic Coating of the
Introducer Sheath in Radial Artery Spasm during TRA
 There was no significant difference in the incidence of
spasm (RAS), discomfort, or RAO (Occlusion) based
on length of introducer.
Long Short P
RAS (Spasm) 27.9% 30.8% 0.389
Discomfort 21.5% 22.2% 0.414
RAO 8.3% 5.3% 0.42
(Occlusion)
y No patients received vasodilators
• J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S , V O L . 3 , N O . 5 , 2 0 1 0 MAY 2 0
1 0 : 4 7 5 – 8 3 Rathore et al. Impact of Sheath on Radial Artery Spasm

34. Sterile Abscess After Hydrophilic-Coated
Radial Artery Sheath
Gilchrist, I. C. et al. J Am Coll Cardiol Intv 2010;3:484-485

35. Adjunctive Tools for TRA
y For tortuosity at the radial brachial level,
and anatomical variations, 0.014
coronary floppy wires are sufficient.

36. Radial Perforation - Repaired
Glue
R. Quesada, 2006

37. Perforation
y Early recognition is the most important factor
y If a perforation occurs, although I treated with
vascular glue,other approaches would include :
– Limited angio if the wire is across the main vessel you
can attempt balloon sealing (perforations usually occur
because you have entered a small side-branch or
because of extreme tortuosity)
– If you feel resistance -- Never Push!
– Application of an elastic bandage
– Arm elevation to prevent compartment syndrome

38. Compartment Syndrome Presentation
There are classically 5 “Ps” associated with
Compartment Syndrome
1. PAIN (out of proportion to expected)
2. Paresthesia
3. Pallor
4. Paralysis
5. Pulselessness
6. Poikilothermia (failure to thermoregulate)
Of these, only the first two are reliable in the diagnosis
of compartment syndrome

39. J Neurol Neurosurg Psychiatr2005;76: 1465
Compartment Syndrome post Transradial Access
Leeches were effective in treating a massive
hematoma causing right forearm compartment
syndrome. The patient had been treated with
anticoagulants before cardiac catheterization via the
radial artery. Hardening and discoloration of the
forearm was followed by motor and sensory deficits of
the hand. Thirteen leeches removed about 145 ml of
blood, with resolution of symptoms and signs.
J Neurol Neurosurg Psychiatr2005;76: 1465
Example of a forearm wrapped with an
elastic bandage at the site of a suspected
micropuncture in the midportion of the
forearm. The standard hemostasis device is
seen in place in the foreground. There was
no visible or measurable
hematoma after removal of the elastic wrap
that had been placed during the initial
access procedure
Gilchrist, I. CARDIAC INTERVENTIONS TODAY
JANUARY/FEBRUARY 2008 pp 39-42

40. How to Optimize TRA ~
Subclavian & Coronary
y Be aware of anatomical considerations in
patient selection
y Implement Proper Techniques to Avoid
Failure
y Anticipate the possibility of common
problems as well as rare complications
40

41. How to Optimize TRA ~
Subclavian & Coronary
y Be aware of anatomical considerations in
patient selection
y Implement Proper Techniques to Avoid
Failure
y Anticipate the possibility of common
problems as well as rare complications
41

42. How do you deal with tortuousity?
y Use a Benson or Wholey wire into the
ascending aorta. If there is significant
tortuousity in the subclavian artery, switch to
a stiff exchange 0.035 or 0.038 Cook or
Amplatz wire.
y Pull the wire into the shaft of the catheter in
order to facilitate torquing for coronary
cannulation.
Quesada et al, “Transradial Coronary Interventions”,
Interventional Cardiology Secrets, 2003, pp. 203-210

43. Commonly Used Guiding Catheter Shapes
Left Arm Approach Right Arm Approach
For Lesions in LCA For Lesions in LCA
- XB 3.5 - XB 3.0
- JL 4 - JL 3.5
- Kimny - Kimny
For Lesions in RCA For Lesions in RCA
- JR 4 - JR 4
- AL I or AL II - AL I
- Castillo 1 & 2 - Barbeau
- Kimny - Kimny

44. New Diagnostic Radial Catheters
TIG-MOD 4.0
Ikari Right
Ikari Left

45. Special Featured Catheters
TIGER and JACKY

46. Possible Rare Complications of Transradial Access ~
Subclavian & Coronary
y Aberrant Anatomy leading to
Perforation: Dissection of Arteria
Lusoria
y Cardiovocal Syndrome
y Mediastinal hematoma

47. Arteria
Lusoria

48. Arch Aortogram and MRA of the Major Arteries of the Upper Body
Abnormal origin of right (RT) subclavian artery arising directing from the descending
aorta instead of the right innominate artery
Yiu, K.-H. et al. J Am Coll Cardiol Intv 2010;3:880-881

49. Dissection as a result of
arteria lusoria
Forms an acute angle (70°) with the proximal aortic arch
aberrant right subclavian artery
the false lumen with
retained contrast
medium
Huang, I, J Chin Med Assoc • July 2009 • Vol 72 • No 7

50. During the diagnostic procedure, because of evident tortuosity of the right
subclavian and innominate arteries, a supportive angiographic guide and an
accurate manipulation were needed to advance and rotate catheters.
Several minutes after the procedure, the patient developed a cardiovocal
syndrome with dysphonia, perceived as hoarseness and breathiness.
Subsequently an important dysphagia affecting her feeding pattern
occurred.

51. An ear nose and throat physical examination with fiberoptic laryngoscopy revealed
right hemi laryngeal palsy without intra laryngeal edema, likely due to right recurrent
laryngeal nerve (RLN) stupor.
Fig. 1. The figure shows the right vocal fold fixed in abduction during respiration (A) and
phonation (B) (images obtained during the videoendoscopic exam with
Digital Video Stroboscopy System, by Kay Elemetrics Corporation).
Intravenous steroid therapy was started and the nerve dysfunction complete
recovered as shown by a second laryngoscopy. At discharge, despite the
complete symptom resolution, a vocal rehabilitation period was recommended.

52. Scheme showing the course of the
recurrent laryngeal nerves. The RLN
on the right side hooks around
behind the subclavian artery, while
on the left side this nerve passes
around behind the aortic arch before
ascending in the neck

53. Basal extreme tortuosity of
right subclavian and
innominate arteries
preventing any catheter
manipulation.

54. Subclavian and innominate
arteries straightening after
diagnostic catheter
introduction; a supportive
angiographic guide was
required to rotate and
advance the catheter in the
coronary ostium.
The straightening determined by the catheter
introduction in the tortuous right subclavian and
innominate arteries likely caused an unfavorable
anatomical change leading to a temporary
compression/stretch of right RLN

55. Vascular injury resulting in a small leak in the branches
of the innominate artery is a possible complication of the
transradial approach.

56. A 61 year-old male patient with diabetes mellitus.
Diagnostic coronary angiography via the radial
approach showed eccentric intermediate stenosis
of the LAD ostium and a focal 99% tight stenosis
in the distal LCx followed by segmental 70%
stenosis.
Approximately 30 min after the diagnostic
procedure, the patient complained of severe
anterior chest pain—no EKG change-
unrelieved by Nitro- returned to cath lab for
urgent PCI –
2 stents placed in left circumflex
post procedure patient still complaining of
painECHO done – negative-
Chest X-ray showed widening of
mediastinum

57. A chest CT scan
showing a large
hematoma in the
anterior mediastinum
around the aortic arch.
Follow up chest CT scan
after recurred chest pain
showing increased hematoma
in the anterior mediastinum.

58. Second case is
similar to the first
A. Coronary angiogram (AP
caudal projection) showing
tight stenosis in the left
circumflex coronary artery.
B. Chest X-ray (AP view)
C. Chest CT scan showing a
huge mediastinal hematoma
located left of the aortic arch.
D. Follow up chest CT
showing almost complete
resorption of the previous
hematoma.

59. Mediastinal Hematoma
– From the two cases presented here, vascular
injury resulting in a small leak in the branches of
the innominate artery is a possible complication of
the transradial approach.
– Therefore, extra caution and careful maneuvering
of the guidewire is warranted during the transradial
approach. In addition, the use of anticoagulation
seems to be important in continuous extravasation
after the initial break in vascular integrity.

60. How to Optimize TRA ~ Removal of
Sheath & Catheter
y Be aware of anatomical considerations in
patient selection
y Implement proper techniques to avoid failure
y Anticipate the possibility of common
problems as well as rare complications
60

61. Transradial Access Site Complications
y Radial artery occlusion
y Midforearm hematoma
y RA Pseudoaneurysm
y Bleeding with resultant Compartment
Syndrome

62. Radial Artery Occlusion

63. Radial Artery Occlusion Factors
y Artery size: higher incidence with smaller
artery
y Heparin dose: minimum 5000 units, even for
cath
y Artery spasm: pretreatment with verapamil
y Hemostasis device: minimize compression

64. Radial Artery Occlusion Factors
Radial Occlusion vs Heparin Dose Radial Occlusion vs Sheath Size
100% 10%
90% 9%
80% 8%
70% 7%
60% 6%
50% 5%
40% 4%
30% 3%
20% 2%
10% 1%
0% 0%
0 2-3,000 5,000 7F 6F 5F 4F
Dose of Heparin Sheath Size
Spaulding C, et al. Cathet Cardiovasc Diag 1996;39:365-370.

65. Radial Artery Occlusion
y 1372 Procedures
Asymptomatic Radial Thrombus 4.7%
Symptomatic Radial Thrombus 0.2%
Significant Hematoma 0.2%
Significant Pseudoaneurysm 0.2%
y Worst Complication
Compartment Syndrome 1 Case
G. Barbeau, et.al.

66. Prevention of Radial Artery Occlusion—Patent Hemostasis Evaluation Trial
(PROPHET Study): Randomized Comparison of Traditional Versus
Patency Documented Hemostasis After Transradial Catheterization
‘‘Patent Hemostasis’’ Procedure
• The sheath was pulled out 4–5 cm and a plastic band
‘‘Hemoband’’ was placed around the forearm at the
site of entry.
• The needle cap and gauze composite was placed over
the site of entry.
• A pulse oximeter sensor was placed over the index
finger, the hemoband was tightened, and the sheath
was removed.
• Ipsilateral ulnar artery was occluded and the
hemoband was loosened till plethysmographic signal
returned (confirming radial artery patency) or bleeding
occurred.
Samir Pancholy, et al Catheterization and Cardiovascular Interventions 72:335–340 (2008)
*

67. Devices used for radial compression
Hemoband
TR Band

68. Samir Pancholy, et al Catheterization and Cardiovascular Interventions 72:335–340 (2008)

69. Samir Pancholy, Journal of Invasive Cardiology 21: 101-104 (2009)

70. Other Rare Complications

71. How to Optimize TRA
y Be aware of anatomical considerations in
patient selection
y Implement proper techniques to avoid failure
y Anticipate the possibility of common
problems as well as rare complications
71

72. Thank You!
72