Optimal equipment for radial access (sheath selection, sheath length, hydrophilic coating, needle type)
Jacek Legutko, M.D., Ph.D. Professor of the Jagiellonian University, University Hospital in Krakow, Poland
President of the Association of Cardiovascular Interventions
of the Polish Cardiac Society
Speaker’s name: Jacek Legutko
I have the following potential conflicts of interest to report:
Research contracts Consulting: Volcano, St. Jude, Terumo
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
I do not have any potential conflict of interest
Potential conflicts of interest
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Mechanisms and Predictors of Failed Transradial Approach for PCI
Dehghani P, et al. JACC Cardiovasc Interv. 2009;2:1059-1064
Radial artery puncture – Right vs. Left
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Right or left RA ??? Radial artery puncture – Right vs. Left
Right RA… Left RA...
Operator’s comfort Operator has to bend
Lower radiation dose for physician Higher dose of radiation
Look out for RSA tortuosity LSA not so tortuous
1-catheter coronary angio Coronary angio with 2 diagnostic
catheters
Mind the size of the catheters (0.5 F
smaller than for transfemoral
Same size of catheters as for
transfemoral approach
Requires more catheter navigation for
coronary ostia engagement
Easier to engage coronary ostia
Angiography of LIMA might be tricky Easy accessible LIMA
Radial Artery Puncture – Right vs. Left
Left RA become green:
Very obese patient
Tortuous or occluded RSA
SVGs implanted
Difficult RCA intervention
Local anaesthesia Examine the puls
Skin incision RA puncture
Wire insertion Arterial sheath insertion
Puncture technique
Risk factors for …
… RA spasm … RA patency
Younger age Apropriate diagnostic.guiding
catheter size
Female
NTG/ligno/werapamil ia
DM
sedation
Small RA diameter 180-250 cm exchange wire
Multiple punctures Hydrophilic catheters
Lack of operator’s experience Delicate manovers with catheters
Warm saline injection ia/warm
covering on forearm
Workhorse in my cathlab – BALTON portfolio
Transradial Access Portfolio Radial Introducer Sheats
+ Regular J-Tip 0.035” Diagnostic Guidewires
Loops/turtuosity
Difficulties…
How to overcome the problem?…
Coronary guidewire (BMW, BHW, Extra Support wire)
Right Judkins diagnostic 5 or 6F catheter
spasm
Difficulties…
cocktail i. a. (Werapamil/NTG/ligno)
Long hydrophilic sheath
Sheathless catheter
If 0.035” diagnostic guidewire
doesn’t go
Use 0.014’ coronary guidewire to
introduce long hydrophilic sheath or
sheathless catheter into the brachial
or subclavian artery
Liang, et al. Catheter cardiovasc Interv. 2010;75:222-224.
Transradial Guiding Catheter Size Selection
http://www.asahi-intecc.com/medical/international/product/gc_se.php
Transradial Guiding Catheter Size Selection
Distribution of radial artery diameter
Saito S. Catheter Cardiovasc Interv. 1999;46:173-178.
Size of guiding catheters 5F 6.5 F
sheathless 6F 7.5 F
sheathless
External diameter
1.73 mm 2.16 mm 2.69 mm
2.49 mm
Kissing balloons
Not possible ok ok ok
Transradial Guiding Catheter Size Selection
Jolly S, et al. Lancet 2011;377:1409–20.
Perforations / hematomas…
In case of perforation the best prevention of large hematoma is exchange of your
sheath into appropriately sized Sheatheless guiding catheter and to continue the
procedure!!!
Pseudoaneurysms…
Usually they heal spontaneously, but sometimes surgery is needed…
Broad Range of Options
Transradial Kit
Special transradial
tapered introducer kit
M Coat
Hydrophilic M Coating
M CoatTM A-kit
M CoatTM R-kit
Thin-wall technology for 1
Fr reduction in outer
diameter
Hydrophilic M Coating
For more complex procedures, difficult access,
complications: TERUMO dedicated devices
Transradial Access Portfolio Radial Introducer Sheats
Radifocus® Introducer II
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Suture eye Aids in securing the sheath to the skin
Colour-coded sheath support For size determination
Unique Terumo Cross-Cut Valve Avoids bleeding and air aspiration
Snap-on/Click-off dilator Prevents backout during insertion
Kink-resistant design Helps keeping the lumen open throughout the procedure
Radifocus Introducer II – M Coat:
M Coat Hydrophilic Coating Easy insertion and removal
Smooth guidewire-to-dilator and
dilator-to-sheath transitions Reducing penetration resistance
Transradial Access Portfolio Radial Introducer Sheats
For more complex procedures, difficult access,
complications: TERUMO dedicated devices
Radifocus® Introducer II
23
Suture eye Aids in securing the sheath to the skin
Colour-coded sheath support For size determination
Unique Terumo Cross-Cut Valve Avoids bleeding and air aspiration
Snap-on/Click-off dilator Prevents backout during insertion
Kink-resistant design Helps keeping the lumen open throughout the procedure
Radifocus Introducer II – M Coat:
M Coat Hydrophilic Coating Easy insertion and removal
Smooth guidewire-to-dilator
and dilator-to-sheath
transitions Reducing penetration resistance
Transradial Access Portfolio Radial Introducer Sheats
For more complex procedures, difficult access,
complications: TERUMO dedicated devices
• Unique thin-wall technology
• 1 Fr size reduction in outer diameter
• Maintaining larger inner-diameter equivalent
• M CoatTM hydrophilic coating
• Ease of insertion and removal
• Less penetration resistance than conventional sheaths1
• TIF Tip Technology
• Total Integrated Fit, optimal tapering design
for smooth penetration
Glidesheath Slender®
1. Kiemeneij F. et al. Hydrophilic Coating Aids Radial Sheath Withdrawal and Reduces Patient Discomfort Following Transradial Coronary Intervention: A Randomized Double-Blind Comparison of Coated
and Uncoated Sheaths. Catheterization and Cardiovascular Interventions 59:161–164 (2003)
Equivalent
Diameter 6 Fr 6 Fr
Sheath 5 Fr
Sheath
Equivalent
Lumen
Transradial Access Portfolio Radial Introducer Sheats
For more complex procedures, difficult access,
complications: TERUMO dedicated devices
7-in-6
6-in-5
5-in-4
Transradial Access Portfolio Radial Introducer Sheats
For more complex procedures, difficult access,
complications: TERUMO dedicated devices
Glidesheath Slender®
6Fr
7Fr
5Fr
7Fr GSS
5Fr GSS
6Fr GSS Down
Sizing
0.20mm 0.12mm
Glidesheath Slender Radifocus Introducer II
Transradial Access Portfolio Radial Introducer Sheats
For more complex procedures, difficult access,
complications: TERUMO dedicated devices
2.06 2.09 2.09
2.13
2.29
2.41 2.48
2.52 2.46
2.62
2.73 2.74
2.88
2.79
2.97 3.02
3.08
1.7
1.9
2.1
2.3
2.5
2.7
2.9
3.1
3.3
Cook FlexorCheck Flo 4F
CordisRadialSource
4F
Merit MedicalPrelude Radial
4F
TerumoGlidesheathSlender 5F
TerumoRadifocus
Introducer II5F
Cook FlexorCheck Flo 5F
CordisRadialSource
5F
Merit MedicalPrelude Radial
5F
TerumoGlidesheathSlender 6F
TerumoRadifocus
Introducer II6F
Cook FlexorCheck Flo 6F
CordisRadialSource
6F
Merit MedicalPrelude Radial
6F
TerumoGlidesheathSlender 7F
TerumoRadifocus
Introducer II7F
CordisRadialSource
7F
Cook FlexorCheck Flo 7F
The smallest 5, 6 and 7Fr sheath on the market
O.D. in mm
Above measurements taken from internal evaluation of competitive devices. Engineering Data on File. 4Fr 5Fr 6Fr 7Fr
Transradial Access Portfolio Radial Introducer Sheats
For more complex procedures, difficult access,
complications: TERUMO dedicated devices
Procedural success rate 99,1%
Low rate of radial artery
occlusion (0,88%)
Low rates of vascular
complications and spasm
Less invasive shorter
compression time
Routine use of
Glidesheath Slender (6F)
for angiography &
intervention is safe &
feasible
Potential to allow complex
PCI while limiting local
trauma to the artery
• 114 patients
• All comer population,
including ACS and
complex PCI
Aminian A. et al. Catheter Cardiovasc Interv. 2014;1;84:436-42.
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Transradial Access Portfolio Radial Introducer Sheats
For more complex procedures, difficult access,
complications: TERUMO dedicated devices
• Atraumatic wire shape
– J-tip minimizes the chance of vascular damage
– J-tip avoids unintentional engagement of vascular
side branches
• Flexible wire morphology
– Tracks tortuous anatomy with ease
• Hydrophilic coating
– Minimizes the chance of vasospasm
Radifocus® Guidewire M J-Tip 0.035” Diagnostic Guidewires
One-piece
construction
Great steerability
Nitinol alloy core
Kink-resistant, for faster
navigation through even
the most tortuous vessels
Transradial Access Portfolio Guidewire
1.5 mm J-Tip guidewire,
tracking through the radial
artery with an average
diameter of 2.3mm1
Transradial Guiding Catheter Size Selection
Transradial Guiding Catheter Size Selection
Transradial Guiding Catheter Size Selection
Pulsoxymetry monitoring during the
procedure
How to reduce the risk of RA occlusion?
European Heart Journal (2012) 33, 2521–2528
Proved May decrease the risk Not really reducing
the risk
Anticoagulation
(UFH, 5000 U, even for
coronary angio)
Hydrophilic sheath Long vs short sheath
Patent hemostasis RA spasm prophylaxis Sheathless technique
5F > 6F > 6F > 7F Shorter compression
after procedure
Avoid puncturing the
same RA again
Conclusions
Routine
procedure
RA Spasm
HC
RA perforation
Need for large
lumen GC
Thank you for your attention!
2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College
2nd Department of Cardiology and Cardiovascular Interventions, University Hospital in Krakow Poland