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In 1989, cardiologist Lucien Campeau described the first transradial diagnostic coronary angiography. In 1993, Dutch cardiologist Kiemeneij performed the first transradial cardiac stent placement, which significantly boosted the adoption of radial access techniques. Posham et al. demonstrated that for most abdominal interventional radiology procedures, utilizing the transradial approach is both feasible and safe.
Presentation
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Anatomy
Vascular anatomy hand
- Digital Arteries
- Superficial Arch
- Deep Arch
- Ulnar Artery
- Radial Artery
In approximately 1% of cases, the radial artery runs very superficially through the anatomical snuffbox, which can lead to it being mistaken for the cephalic vein, resulting in unwanted arterial injections. In about 7% of cases, the radial artery branches off proximally from the brachial artery, which does not necessarily impede radial access or the procedure itself. In 2.3% of cases, a radial loop is present, where the artery makes a complete loop. At the top of this loop, a perforating branch generally arises. Unintentional deep catheterization of this branch can lead to perforation. This is a real risk, as many practitioners do not perform catheterization in the arm under fluoroscopy due to geometric limitations of the angiostatic device. Additionally, in approximately 2.0% of cases, while a complete loop is not present, the artery may still exhibit significant tortuosity. Furthermore, 2.5% of cases have various other structural abnormalities, such as extensive atherosclerosis, radial artery occlusion, abnormal branching patterns, and hypoplasia with a very small diameter of the artery.
Indications
- Bland embolizations of visceral organs
- Chemo-embolizations of visceral organs
- Radio-embolizations of visceral organs
- Embolization of the liver
- Embolization of the spleen
- Embolization of the kidneys
- Embolization of the stomach
- Embolization of the intestines
- Uterine embolization
- Prostate embolization
- Elective procedures and acute settings (e.g., in cases of bleeding)
- Stent placement up to the abdominal aortic bifurcation (AFC)
- Stenting of the celiac trunk
- Stenting of the superior mesenteric artery
- Percutaneous transluminal angioplasty (PTA) of the iliac arteries
- Treatment of intracerebral occlusions in stroke cases
Contra Indications
Barbeau Test
Barbeau Test
- Insufficient collateral flow from the ulnar artery for hand vascularization (Allen or Barbeau test)
- Thrombosis in the radial artery
- Severe peripheral vascular disease affecting arterial flow
- Anatomical abnormalities
- Coagulation disorders
- Previous trauma or surgery in the access area
- Patient preference
- Adequate sizing of the artery, see table
| Diameter needed | |
|---|---|
| 4 Fr-sheath | >2,0 mm |
| 5 Fr-sheath | >2,2 mm |
| 6 Fr-sheath | >2,4 mm |
Workup
See contra-indications
Material
Essentials
- Ultrasound
- Micro puncture set
- Antispasmodic cocktail of 200 µg of nitroglycerin, 2.5 mg of verapamil, and 5000 IU of heparin
- Long enough catheters/balloons/stents, depending on the planned procedure
Non Essentials
Positioning
- Head first
- Supine
- Arm in arm rest
- Hand in suppination
Steps
- Time-out procedure
- Sterile wash and draping
- Ultrasound guided local anaesthetic (see Tips & Tricks)
- After sheath placement slowly administer an antispasmodic cocktail: a mixture of 200 µg of nitroglycerin, 2.5 mg of verapamil, and 5000 IU of heparin
Tips & Tricks
Distal Radial Artery Puncture
Distal Radial Artery Puncture
- A distal puncture results in fewer radial occlusions because, in the event of localized thrombosis, blood flow through the radial artery is maintained via the palmar arch.
- For puncturing any artery, it is customary to anesthetize the puncture site using 1% or 2% lidocaine. By adding nitroglycerin, a vasodilator, the artery can be dilated by 10%, thereby reducing the likelihood of vasospasm due to the puncture. To prepare this solution, dissolve 100-300 µg of nitroglycerin in 9 ml of lidocaine and infiltrate along the artery as far as the anesthetic needle can reach, typically 4 to 5 cm
- If the sheath becomes stuck during the procedure, follow these steps
- Administer the Antispasmodic Cocktail: Reintroduce the antispasmodic mixture (nitroglycerin, verapamil, and heparin) to alleviate vasospasm
- Reinfiltrate: If necessary, infiltrate with a mixture of nitroglycerin and lidocaine along the artery
- IV Mild Sedation: If the sheath remains stuck, provide intravenous mild sedation (e.g., a combination of fentanyl and midazolam)
- Tumescent Technique: If sedation does not resolve the issue, apply tumescent anesthesia around the median nerve
- Apply a Blood Pressure Cuff: If the sheath is still resistant to removal, inflate a blood pressure cuff around the brachial artery to 20 mmHg above systolic to induce reactive hyperemia and create space around the sheath
- Patience: Allow time for the spasms to subside; do not forcibly remove the sheath
- Consult Anesthetist: If all options fail, consult with an anesthetist to consider deepening sedation or, if necessary, moving to general anesthesia
| Conversion to femoral access | 1.2% |
| Major complications | 0.1% |
| Pseudoaneurysm | |
| Minor complications | 2.4% |
| Radial artery occlusions | |
| Hematoma/local bleeding | |
| Radial artery spasm | |
| Pain complaints | |
| Risk of stroke after transradial vs. transfemoral access | <0.5% in both groups |
| Stuck sheath becoming stuck due to vasospasms | Rare |
Radial Band Protocol, TR Band Placement:
Duration
The radial band must remain on the wrist for at least 2 hours
1 Hour Post-Placement
- Remove 2 ml of air from the radial band using the special blue syringe
1.5 Hours Post-Placement
- If there is no bleeding from the site, remove another 2 ml of air from the radial band with the blue syringe
2 Hours Post-Placement
- Allow the radial band to deflate slowly over 1 minute using the special blue syringe
In Case of Bleeding
- Inject a minimum of 2 ml of air into the radial band until the bleeding stops
- Wait for 30 minutes
- Then, remove 2 ml of air from the radial band
For Third Episode of Bleeding
- Consult with the physician regarding further management
After the Radial Band is Completely Deflated
- Keep it on for an additional 30 minutes. If re-bleeding occurs, the balloon can be easily reinflated. If there is no bleeding after 30 minutes, the radial band can be removed. Remove the band slowly
Do NOT discard the radial band!
Post-Removal Care
- The patient must remain in the department for an additional hour after the radial band is removed
Following 24 hours: avoid excessive wrist bending, refrain from driving, and do not lift heavy objects (maximum weight of 3 kg)