Radial Access for Peripheral Arterial Intervention

ALI AMIN MD, FACS,FACC, RVT

CHIEF OF ENDOVASCULAR INTERVENTIONS READING HOSPITAL AND MEDICAL CENTER

READING, PA USA

Congreso Ventana a las Americas 2014

First Description of Radial Approach 1989

Transradial (TR) Percutaneous Coronary Intervention (PCI)

n  In Europe and Asia is the First access site for coronary intervention

n  Utilizing this access site has been increasing in the US

n  In Canada about 50% use TR access n  In the US is less than 15%

Benefits of TR

n  Decrease in Access site complications n  No closure device n  More rapid ambulation

n  Easier patient mobility n  Same day discharge n  Increase patient comfort (sitting, straining, back

pain, poor pulmonary function, sit up immediately, male to stand up and urinate)

Why Radial? Look at the Anatomy

Anatomic Features Clinical Consequences Flat bony prominence of the radius Ease of compression

Collateralization of the radial artery Absence of Ischemia

Puncture not over joint Motion does not increase risk

No major adjacent nerve No neurologic sequellae

Cooper CJ. A Physician’s Guide: Radial Approach

Femoral : Vascular Access

Meta-Analysis Radial vs. Femoral

Overall risk of entry site complications

Agostoni P et al. JACC 2004;44:349-56

TR Access for Peripheral Intervention

n  Better access than Axillary, Brachial

n  Anatomic reason for various vascular bed

When Femoral Approach is Not Possible or Should be Avoided

n  Aorto-iliac Occlusion or severe tortuosity or Dz n  Recent Aorto-Bifemoral Bypass

n  Pt on Anticoagulation, Lytic Therapy n  Hostile Groin

Carotid- Difficult Arch: Angiography, CAS

n  Type III Arch n  Bovine Arch

Arch Branches

n  Innominate n  Subclavian n  Vertebral

Approach innominate lesion from above due to unfavorable wire bias when coming from a femoral approach.

Use trans-femoral catheter to visualize lesion and direct stent positioning.

Mesenteric Arteries: SMA

Renal

Diagnostic Arteriogram

Iliac Intervention

n  Use Radial when femoral access not possible from retrograde or contralateral approach

B/L Iliac Kissing Stents…. L SFA stenosis

Left SFA PTA

Not Suitable for TR Access

n  Abnormal Allen’s Test

n  Equipment length (past mid SFA): Sheath support 90 cm; Shaft length for Balloon is 150 cm and for Stent 135 cm

n  Tortuosity, Anomaly of Radial, Brachial Artery

Allen’s Test: with Pulse Oximetry

Access for TR

n  Dedicated TR kit

n  Entry needle, wire, short sheath

n  TR band for homeostasis

US Guidance

Micro-puncture Kit (.014 or .018)

Once the Sheath is in…. Give the Cocktail

TR Cocktail into the Sheath

n  NTG 200 mcg n  Heparin 2500 units n  Verapamil 2.5 mg

Summary: TR Approach

n  An accepted alternative to femoral and brachial access

n  Early ambulation, no closure device and patient

comfort is compelling reasons to use TR

n  Endovascular Procedures are limited to shaft length of the balloons and stents; 90 cm sheath support

n  mesenteric, renal, carotid, iliac, proximal and may be mid SFA