A Technical Guide Describing the Use of Transradial Access Technique for Endovascular Interventions

doi:10.1053/j.tvir.2015.04.002

Techniques in Vascular and Interventional Radiology

Volume 18, Issue 2, June 2015, Pages 58-65

https://doi.org/10.1053/j.tvir.2015.04.002 Get rights and content

Transradial arterial access (TRA) has been employed for transcatheter coronary procedures for more than 25 years, with numerous studies demonstrating improved patient safety as compared with transfemoral arterial access. However, TRA remains underused by the interventional radiology and vascular surgery communities. Advantages of TRA over transfemoral arterial access include easier accomplishment of postprocedure hemostasis, decreased risk of hemorrhagic complications, shorter patient recovery leading to immediate ambulation and decreased procedure-related costs, and increased patient satisfaction. In particular, TRA may be advantageous in the population of patients with obesity. The primary patient selection factor to consider before attempting TRA is whether the patient has adequate collateral perfusion to the hand; this is assessed using the Barbeau test. Limitations of TRA may include operator unfamiliarity or learning curve and unavailability of adequate length catheters. The most common complication, although still rare, is localized access site hematoma, which is often asymptomatic. Radial artery occlusion is rare and rarely symptomatic owing to collateral perfusion to the hand. Theoretical increased risk of cerebral embolism during TRA may be minimized by preferentially accessing the left wrist during below-diaphragm procedures, which limits transcatheter manipulation of the aortic arch. Transulnar artery access is under investigation for use in patients who cannot undergo TRA. Providing patients the option of TRA can lead to improved outcomes, potentially increasing safety and patient satisfaction while decreasing procedure costs.

Section snippets

Background

Use of the radial artery as the primary access vessel into the arterial system for transcatheter diagnosis and intervention is not a new concept. The first series describing diagnostic angiography of the coronary circulation using transradial arterial access (TRA) was published in 1989 by Lucien Campeau at the Montreal Heart Institute.¹ Campeau suggested percutaneous radial access as a safer alternative to percutaneous and “cutdown” brachial or axillary access. His series of 100 patients

Advantages of the Transradial Approach

There are several obvious advantages of TRA over transfemoral arterial access (TFA). First, the radial artery is more superficial than the femoral artery, and there are no surrounding critical structures that are susceptible to injury. In addition, inadvertent injury to the artery itself, such as dissection or thrombosis, is significantly less detrimental to the patient because of the dual blood supply to the hand.¹ The radial artery is also readily compressible, which decreases the incidence

Patient Selection

As is the case with every procedure, patient selection is paramount. Although not every patient is ideally suited for TRA, many operators believe that approximately 90% of patients can undergo TRA for PCI using a “radial first” approach. It remains to be seen whether this high percentage translates to the noncoronary space. It has become clear that TRA is associated with a steeper learning curve as compared with TFA. When initially learning this technique, higher rates of femoral crossover are

Setup and Access

For interventional procedures below the diaphragm, such as hepatic embolization, left radial artery access is preferred over right-sided access for several reasons. There is a slightly shorter distance to the target vessel from the left wrist, which can be crucial given the current limitations of catheter lengths (discussed subsequently in detail). In addition, the guiding catheter or sheath is not positioned across the great vessels during the procedure, theoretically limiting the risk of

Radial Artery Hemostasis

Nonocclusive “patent” hemostasis is a key technique in minimizing risk of postprocedural radial artery thrombosis. The prevention of radial artery occlusion-patent hemostasis evaluation trial (PROPHET) study in 2008 demonstrated that this technique is superior to occlusive pressure in maintaining radial artery patency.²⁰ Nonocclusive hemostasis is typically performed using a wrist band device. There are several such devices in the market today, which are listed in Table 2. The most common

Complications

The most common, albeit rare, complication seen in our practice is a localized minor hematoma (grade 1) with mild pain at the access site. This is often self-limited and can be treated with nonsteroidal anti-inflammatory drugs if necessary. Despite proper patent hemostasis technique, radial artery thrombosis will occur in a minority of cases, which are almost always asymptomatic.²¹ Factors associated with a decreased rate of radial artery occlusion include increased heparin dose, smaller sheath

Patient Preference and Cost-Effectiveness

As more interventions move from the hospital setting to outpatient offices, improved patient comfort and faster discharge times are increasingly important. This is currently the trend in busy interventional oncology practices across the United States, Canada, and Europe. In our practice, TARE is performed solely on an outpatient basis, and TACE is performed with a 23-hour observation admission and trending toward a completely outpatient procedure. Procedure cost is also an extremely important

Future Directions

Inability to successfully access the radial artery does not preclude a patient from distal arm access. Many operators have used the ulnar artery as an alternative to the radial artery, especially if radial artery spasm or severe tortuosity is encountered or if the ulnar artery is dominant. De Andrade et al²⁹ described their experience with transulnar access in a prospective registry of 410 patients, with a low access site complication rate of 3.9%.

Other potential applications for TRA in the

Conclusion

Transradial intervention has broad applications for interventional radiology. In particular, hepatic embolization procedures are well suited for this approach. Learning and implementing transradial access technique enables operators to offer comprehensive, cost-efficient, and safe care to their patients.

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Cited by (62)

Safety of Prostatic Artery Embolization via Transradial Access versus Transfemoral Access
2024, Journal of Vascular and Interventional Radiology
To compare prostatic artery embolization (PAE) via transradial access (TRA-PAE) versus transfemoral access (TFA-PAE) to assist access selection.
Procedural outcomes and adverse events were evaluated in 998 patients who underwent PAE at a single center from April 2014 to August 2022; 821 (82%) underwent TRA-PAE (Group R) and 177 (18%) underwent TFA-PAE (Group F). Mean age and prostate size of Groups R and F were 69.2 years (SD ± 8.4) and 117.4 g (SD ± 63.1) and 75.2 years (SD ± 12.1) and 127.2 g (SD ± 83.6), respectively (P < .01 and P = .16; postpropensity matching: P = .38 and P = .35, respectively). Indications for PAE included lower urinary tract symptoms, acute or chronic urinary retention, and hematuria. Procedural and patient-specific metrics were reviewed. Technical success was defined as bilateral PAE. Adverse events were recorded according to the Society of Interventional Radiology (SIR) adverse events classification. Statistical significance was defined as P < .05.
Technical success was achieved in 798 (97.2%) patients in Group R and 165 (93.2%) patients in Group F. Mean procedural time, single- and continuous-rotation fluoroscopy time, dose area product, and air kerma were significantly lower in Group R than in Group F (P < .001). Moreover, 6 (0.7%) patients in Group R and 9 (5.5%) patients in Group F had access site ecchymoses, whereas 5 (0.6%) patients in Group R and 6 (3.6%) in Group F had access site hematomas. Two patients experienced transient ischemic attacks (TIAs) after TRA-PAE and recovered without intervention. Two occult radial artery occlusions were noted, but no patient experienced hand ischemia.
In a large single interventional radiologist cohort, TRA-PAE demonstrated similar technical success to that of TFA-PAE with lower access site hemorrhagic complications and radiation requirements; however, TIA and occult radial artery occlusions remain a concern.
Transradial Endovascular Intervention: Results From the Radial accEss for nAvigation to Your CHosen Lesion for Peripheral Vascular Intervention (REACH PVI) Study
2022, Cardiovascular Revascularization Medicine
The transradial approach has been proposed as an alternative to traditional transfemoral access for diagnostic and therapeutic purposes in several catheterization procedures. Historically, extended length devices for lower limb endovascular interventions have been limited. The aim of this study was to investigate the acute clinical outcomes of orbital atherectomy (OA) via transradial access (TRA) for the treatment of lower extremity peripheral artery disease (PAD).
REACH PVI was a multicenter, prospective, observational study (NCT03943160) including subjects with PAD and target lesion morphology appropriate for OA. All patients were followed post-procedure through the first standard of care follow-up visit.
A total of 50 patients were enrolled. In most cases the indication for intervention was disabling claudication (74.0%). Overall, 50 target lesions were treated, 92.0% of lesions were femoropopliteal and 8.0% were infrapopliteal. The average lesion length was 98.3 ± 87.5 mm and 78.0% of the lesions were severely calcified. Balloon angioplasty was performed in 98.0% of target lesions, while a stent was deployed in 16.0%. Treatment success was 98.0%; in only one case the result was sub-optimal (>30% stenosis with stent placement) and a significant dissection was reported. No serious distal embolization, serious thrombus formation or serious acute vessel closure were observed intra- or post-procedurally.
Transradial OA followed by percutaneous transluminal angioplasty for lower extremity PAD is feasible and demonstrates a favorable safety profile. Extended length devices such as the Extended Length Orbital Atherectomy System could further facilitate transradial endovascular procedures by increasing its spectrum of application.
Wrist Extension Does Not Change the Position of the Radial Artery: Cadaveric Study With Application to Arterial Line Placement, and Transradial Neurointerventional Procedures
2021, World Neurosurgery
Citation Excerpt :
It has benefits over the transfemoral approach including lower morbidity and mortality, lower risk of bleeding, earlier discharge, and collateral circulation to the hand from other arteries. Nevertheless, it has downsides including the difficulty of the procedure owing to the smaller size of the artery, the time spent performing the procedure, and the lack of relevant training and experience among medical specialists.1-7 Overall comparisons between the transfemoral and transradial approaches have led many centers and clinicians to opt for the latter because there are fewer side effects overall, leading to lower hospital costs and greater patient satisfaction stemming from earlier ambulation and fewer postoperative complications.14,15
The radial artery is gaining popularity as a vascular access site for neurointerventional procedures. However, recent analyses of wrist position and radial artery anatomy has suggested that the extended position of the wrist is not always necessary. Therefore, the following cadaveric study was performed to verify these findings.
Twenty adult cadaveric upper limbs underwent dissection of the radial artery. The radial artery was exposed but left in its anatomical position. With the hand supinated, the wrist was extended to 45 degrees and 90 degrees. Observations were then made of any movement of the artery during these ranges of motion. Next, a tension gauge was attached to the radial artery and any tension on the artery measured during the above noted ranges of motion.
During extension of the wrist, none of the radial artery specimens was found to move in any direction. Moreover, an average of only 0.28 N of tension on the artery was found with wrist extension up to 90 degrees. Our cadaveric study found that, contrary to popular belief, extension of the wrist during cannulation of the radial artery does not change the position of the artery nor does it significantly alter the tension on the artery.
These data support several recent clinical studies.
Collateral Circulation Testing of the Hand– Is it Relevant Now? A Narrative Review
2021, American Journal of the Medical Sciences
Testing for collateral circulation of the hand before any radial artery procedure has been a subject of many controversies. Neither the Allen's test (AT) nor the plethysmography based Barbeau test, adequately and reliably test for collateral circulation. With growing interest in radial approaches for vascular procedures, its common use for arterial monitoring and blood gas sampling, there has been a growing interest in the relevance of assessing collateral hand circulation. Multiple studies now refute the utility of collateral testing, yet it continues to be propagated as an essential triaging assessment tool by educators. Allen's, or modified Allen tests (MAT) are operator dependent and often subjected to observational bias. Barbeau test is more objective, however, it fails to show added benefit in assessing pre-procedural patency. Despite studies questioning the validity of collateral circulation assessment, these tests continue to preclude radial approach. There is no standardization for being considered an abnormal test across literature and the significance of an abnormal test translating into a clinical outcome has not been investigated in prior studies. This may be attributed to the robust vascular supply of the hand, connections at the digital circulation level and vessel recruitment in an event of occlusion. We reviewed this topic extensively and make an argument that non-invasive collateral testing should be abandoned as a triage tool for radial artery procedures such as arterial punctures, arterial monitoring, and transradial vascular procedures.
Society of Interventional Radiology Quality Improvement Standards on Radial Artery Access
2021, Journal of Vascular and Interventional Radiology
Uterine Artery Embolization for Secondary Postpartum Hemorrhage
2021, Techniques in Vascular and Interventional Radiology
Postpartum hemorrhage (PPH) affects approximately 14 million women yearly, accounts for 25% of delivery-related deaths in the world and is the main cause of emergency peripartum hysterectomy. Traditionally, PPH is defined as at least 500 mL of blood loss after vaginal delivery or 1000 mL of blood loss after cesarean-section. However, several authors have suggested a simpler definition to include women who experience hemodynamic instability after birth regardless of amount of blood loss. Secondary PPH is defined as bleeding that occurs after 24 hours to 12 weeks from delivery, and can fail medical management. It is imperative that the clinical team recognize the signs and symptoms of secondary PPH and, if necessary, consult the interventional radiology service for a minimally invasive option of uterine artery embolization, which has shown up to 95% success rate.

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A Technical Guide Describing the Use of Transradial Access Technique for Endovascular Interventions

Section snippets

Background

Advantages of the Transradial Approach

Patient Selection

Setup and Access

Radial Artery Hemostasis

Complications

Patient Preference and Cost-Effectiveness

Future Directions

Conclusion

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

JACC Cardiovasc Interv

Am Heart J

Int J Cardiol

Int J Cardiol

JACC Cardiovasc Interv

J Vasc Interv Radiol

Am Heart J

Cardiovasc Revasc Med

Percutaneous radial artery approach for coronary angiography

Cathet Cardiovasc Diagn

Percutaneous transradial artery approach for coronary stent implantation

Cathet Cardiovasc Diagn

How to transform you into a radialist: Literature review

Cardiovasc Med

Adoption of radial access and comparison of outcomes to femoral access in percutaneous coronary intervention

Circulation

Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison

Am Heart J

A multicentre comparison of transradial and transfemoral approaches for coronary angiography and PTCA in obese patients: The TROP registry

EuroIntervention

Comparison of access-related bleeding complications in women versus men undergoing percutaneous coronary catheterization using the radial versus femoral artery

Am J Cardiol