Radial artery access[1]

anatomical description of upperlimb arteries , techniques of radial artery puncture and complications

1. RADIAL ARTERY ACCESS Dr. R.Sayee venkatesh Postgraduate – dept of cardiology Stanley medical college

2. RADIAL ARTERY ANATOMY RADIAL ARTERY ACCESS TECHNIQUES ANATOMICAL SNUFF BOX ACCESS SELECTION OF PATIENTS AND PRIOR TESTS REMOVAL OF CATHETERS AND HEMOSTASIS RADIAL ARTERY ANOMALIES COMPLICATIONS OF RADIAL ARTERY ACCESS ADVANTAGES AND DISADVANTAGES OVER FEMORAL ROUTE SELECTION OF CATHETERS ACCESS OF PREVIOUSLY OCCLUDED ARTERY CATHETER KNOT

3. RADIAL ARTERY Origin: begins at the inferior portion of cubital fossa . COURSE: FOREARM: travels from the medial aspect of the neck of radius to the styloid process of the anterior surface of the radius. Lies deep to the brachio radialis muscle proximally. Distally covered only by fascia and skin. Lies between brachioradialis and flexor carpii radialis muscle. WRIST: Goes around wrist laterally Travels across floor of the anatomical snuff box to the palm of the hand.

4. Branches: MUSCULAR BRANCHES: Supplies small muscles on the radial aspect of forearm mainly extensor compartment . Radial recurrent artery: just after the origin of radial artery. Anastamoses with radial collateral artery from deep brachial artery. Blood supply to elbow joint. PALMAR CARPAL BRANCH: distal border of pronator quadratus Runs along the anterior aspect of the carpal bones. Anastamoses with palmar carpal branch of ulnar artery This forms palmar carpal arch. DORSAL CARPAL BRANCH: At the proximal part of the anatomical snuff box. Anastamoses with dorsal carpal branch from ulnar artery Forms dorsal carpal branch.

5. SUPERFICIAL PALMAR BRANCH: completes the lateral part of the Superficial palmar arch. Predominantly supplied by the direct continuation of the ulnar artery. Lies between palmar aponeurosis and flexor tendons. DEEP PALMAR BRANCH: Direct continuation of radial artery. Forms deep palmar arch of the hand. Medial aspect completed by the deep palmar branch of ulnar artery. Runs between bases of he metacarpal bones and flexor tendons. FIRST DORSAL METACARPAL ARTERY: Supplies the adjacent sides of the thumb and index finger. PRINCEPS POLLICIS ARTERY AND RADIALIS INDICIS ARTERY: When radial artery reaches web space between the thumb and index finger divides into two branches on the dorsal aspect of the hand. Princeps pollicis branch divides into two and supplies the thumb. Radialis indicis runs along the distal end of the index supplying the lateral aspect of the index finger.

6. BRACHIAL ARTERY: Continuation of axillary artery at the inferior border of teres major muscle. Ends at the level of the neck of the radius 1 cm distal to the elbow joint. Divides into radial and ulnar artery at this level. Superficial vessel covered by skin and fascia Ulnar artery largest terminal branch of the brachial artery. Median nerve lies lateral to the artery at its proximal aspect Crosses artery near distal attachment of coraco brachialis anteriorly and lies medially.

7. Branches: Profunda brachii (P)
Nutrient artery of the humerus (N)
Superior ulnar collateral artery (S)
Middle ulnar collateral artery (M)
Inferior ulnar collateral artery (I)
Deltoid artery (D)
Radial artery (R) Ulnar artery (U)

8. AXILLARY ARTERY: Continuation of subclavian artery at the outer border of the first rib. Bordered laterally , posteriorly and inferiorly by lateral , posterior and medial cords of the brachial plexus. Divided by 3 parts by pectoralis minor muscle. Continues as axillary artery at the lower border of teres major muscle.

9. Superior (highest) thoracic A – Acromiothoracic ( thoracoacromial ) L – Lateral thoracic S – Subscapular A – Anterior circumflex humeral P – Posterior circumflex humeral H – Highest (superior) thoracic T – Thoracoacromial L – Lateral thoracic S – Subscapular P – Posterior circumflex humeral A – anterior circumflex humeral

10. SUBCLAVIAN ARTERY: RIGHT SIDE – ARISES FROM BRACHIO CEPHALIC TRUNK LEFT SIDE – FROM ARCH OF AORTA EXTENDS UPTO OUTER BORDER OF FIRST RIB – AXILLARY ARTERY TOTALLY 8 BRANCHES 1 ST – VERTEBRAL ARTERY 2 ND – INTERNAL MAMMARY ARTERY 3 RD – THYRO CERVICAL TRUNK INFERIOR THYROID ARTERY ASCENDING CERVICAL ARTERY TRANSVERSE CERVICAL ARTERY SUPERFICIAL BRANCH 4 TH – COSTOCERVICAL TRUNK - SUPREME INTERCOSTAL ARTERY - DEEP CERVICAL ARTERY

11. ABERRANT SUBCLAVIAN ARTERY MOST COMMON CONGENITAL VASCULAR ANOMALY OF AORTIC ARCH 1% RIGHT SUBCLAVIAN ARTERY – ABERRANT – ARISES DISTAL TO THE ORIGIN OF THE LEFT SUBCLAVIAN ARTERY. CROSSES BEHIND ESOPHAGUS – VASCULAR RING AROUND ESOPHAGUS CAUSES DYSPHAGIA – DYSPHAGIA LUSORIA

12. Radial artery access: 2 to 3 cms proximal to flexor crease of the wrist. If too distal – hemostasia is difficult since minor movement may change the compression pressure over the RA pressure site. Leads to the perforation of reticular ligament of wrist. If too proximal – difficult to palpate radial artery beneatg forearm muscles. Higher risk of forearm hematoma. 1cc of 2% lignocaine used. 21 gauge access needle. Technique: THROUGH AND THROUGH TECHNIQUEOR COUNTER PUNCTURE Angle – 30 to 45 degrees 5F or 6F sheath used. Should have highly tapered tip and smooth transition between introducer and sheath. Hydrophilic sheaths are mostly used.

13. Equipment Two types of needles are commonly used for arterial puncture, as follows:
A micropuncture needle, which is placed by using a Seldinger technique with a guide wire
A cannula -over-needle, which is then used to upsize to a sheath over a guide wire
The equipment list for radial artery sheath insertion includes the following:
Local anesthetic agent of choice
Topical anesthetic (optional)
Needle ( ie , a micropuncture needle or a cannula -over-needle assembly; see the first image below)
Guide wire – A 0.021- to 0.025-in. Uncoated or hydrophilic wire is used to exchange the needle for the sheath
Radial artery sheath – This may range from 4 to 7 French in size (the authors recommend a sheath length of 10 cm) and should come with a dilator assembly . Skin scalpel
Antispasmodic agent of choice ( eg , verapamil 2-5 mg)
Medical towel or hyperextension splint for positioning
Alcohol-based sterilizing solution ( eg , chlorhexidine )
Angiography drapes
Sterile gloves and gown

14. Anesthesia A combination of local anesthesia and light sedation . A popular choice of local anesthetic is 1-2 mL of 1% lidocaine . Topical anesthetic cream can be applied . Midazolam 1-5 mg for sedation is helpful to reduce vascular tone and the frequency of arterial spasm.

15. POSITIONING: All obstructing jewelry and clothing should be removed from the wrist. Intravenous access should always be obtained, preferably on the contralateral side; The wrist should be shaved to remove excess hair if necessary. A medical towel can be placed underneath the wrist to keep it in hyperextension , or a hyperextension splint can be applied. The groin should also be prepared for access in the event of a failed radial artery insertion. The angiography drape is applied so as to expose the wrist in an area where the radial artery pulse will be palpable.

16. Sheath insertion with cannula-over-needle:
After the wrist has been appropriately prepared, palpate for the radial artery. Infiltrate local anesthetic subcutaneously at least 2 cm proximal to the radial styloid process (in the region where the radial artery pulse is best appreciated) to form a small wheal.

17. Insert the cannula -over-needle through the skin at an angle of approximately 45° directing it proximally toward the radial artery at its expected course. Advance the device slowly until pulsatile bright (arterial) backflow of blood is achieved and is visible in the needle. Gently feed the cannula through, and remove the needle. Backflow of blood through the cannula should still exist.

18. After the artery has been successfully punctured, introduce the guide wire through the cannula. Once the guide wire has been smoothly advanced through the device, remove the cannula while leaving the guide wire in place; the guide wire will be used to guide the sheath into the radial artery. To avoid accidental embolization of the guide wire, the length of wire left exposed outside the patient must always be greater than the length of the sheath. Always hold onto the wire with a hand.

19. Introduce the sheath (with the dilator inserted) over the guide wire into the radial artery A small superficial skin incision may be made where the guide wire enters through the skin to facilitate smooth passage of the sheath. If resistance occurs, the tip of the wire may be watched via fluoroscopy. If resistance is met and the sheath is definitely in the artery, the guide wire may be removed, and verapamil 2.5-5 mg, nitroglycerin 200 µg, or both may be injected through the sheath dilator.
After the insertion of the sheath, if passing a 0.035-in. Guide wire is difficult, angiography may be performed to check the arterial anatomy. Once the sheath is fully advanced, the guide wire and the dilator assembly may be removed (see the image below). After the removal of the dilator, the sidearm may be used for administration of compatible medications ( eg , heparin, verapamil , and nitroglycerin ; diazepam must not be administered intra-arterially).

20. ANATOMICAL SNUFF BOX ACCESS: The anatomical snuffbox is a hollow space on the radial side of the wrist when the thumb is extended; Bounded by the tendon of the extensor pollicis longus posteriorly. tendons of the extensor pollicis brevis and abductor pollicis longus anteriorly. The RA crosses the floor that is formed by the scaphoid and the trapezium bones. Site: PROXIMAL TO THE ORIGIN OF POLLICIS BREVIS ARTERY AND DISTAL TO THE ORIGIN OF A BRANCH TO SUPERFICIAL PALMAR BRANCH. Facilitates blood flow to palm through supl palmar artery. Prevents retrograde thrombus formation happening in normal puncture.

21. Position: semiprone position. Patient asked to grip his thumb under four fingers and slightly to abduct the wrist. 4F, 5F, 6F can be used.

22. Advantages: Patients requiring multiple RA procedures coronary bypass surgery with use of a free RA graft. short hemostasis time, because of the superficial position of this small vessel. Compression is exerted on the palmar side of the hand. hemostasis will not result in congestion of the hand since no major veins are obstructed. hemostasis is relatively mild and very well tolerated by the patients. Considered for cases with radial spasm at the wrist level.

23. Spasmolytic therapy: Dilltiazem 2.5 to 5 mg Verapamil 2.5 to 5 mg Nitroglycerine 500 -1000 microgram CCB‘s carefully used in patients more prone for hypotension like severe aortic stenosis. Lack of pre treatment – 30% chance of radial spasm. Heparin dosage 2500 to 5000 units.

24. Selection for radial access Age <70 yrs. Hemodynamic stability Palpable large radial artery With strong pulse Normal Allen’s test. RELATIVE CONTRAINDICATIONS: Feeble radial pulse Raynaud‘s disease Presence of av shunt. Potential use of RA as conduit for aortocoronary bypass

25. ALLEN’S TEST: Confirms dual circulation to the hand. Simultaneous occlusion of both the radial and ulnar arteries at the level of wrist until hand blanches. Release of pressure over ulnar artery Observe the hand for reperfusion. Positive Allen’s: - reperfusion within 7 secs. Negative – longer than 15 secs. Borderline – 8 to 15 secs. Named for Edgar Van Nuys Allen.

26. Original test
The original test proposed by Allen is performed as follows:
The patient is asked to clench both fists tightly for 1 minute at the same time.
Pressure is applied over both radial arteries simultaneously so as to occlude them.
The patient then opens the fingers of both hands rapidly, and the examiner compares the colour of both. The initial pallor should be replaced quickly by rubor.
The test may be repeated, this time occluding the ulnar arteries.

27. Modified test In the modified Allen test, one hand is examined at a time.
The hand is elevated and the patient is asked to clench their fist for about 30 seconds.
Pressure is applied over the ulnar and the radial arteries so as to occlude both of them.
Still elevated, the hand is then opened. It should appear blanched (pallor may be observed at the finger nails). Ulnar pressure is released while radial pressure is maintained, and the colour should return within 5 to 15 seconds. REVERSE ALLEN’S: RADIAL ARTERY IS FIRST RELEASED BEFORE ULNAR ARTERY. FAILURE OF BLUSHING – RA OCCLUSION.

28. BARBEAU TEST: A pulse oximeter is placed on the ipsilateral thumb and the morphology of the plethysmography tracing is noted. The examiner then occludes the radial artery, and any change in the tracing is noted. 4 types are seen Type c and d are exclude from radial catheterization.

29. Type A: normal waveform after immediate and 2 minutes of compression
Type B: dampened waveform after immediate compression, but normal at 2 minutes
Type C: absent waveform after immediate compression, and dampened by 2 minutes
Type D: absent waveform after immediate compression out to 2 minutes

30. The most accurate way of assessing dual hand circulation is with duplex ultrasonography. Ultrasound imaging allows for a detailed assessment of the patient’s anatomy, including the size of the radial and ulnar arteries. Doppler is used to characterize blood flow in the artery, in collaterals, and can also be used to guide compression of the artery at the end of procedure.

31. Catheter removal: No role for the measurement of clotting profile prior to sheath removal. Vascular sheaths should be removed at the completion of procedure without delay. Amount of compression is adjusted to maintain arterial flow and compression. Compression is applied for 1-2 hrs with gradual release of pressure. If gp iib/iiia inhibitors used for 4 hrs. Prolonged sheath placement – radial artery occlusion and reflex sympathetic dystrophy.

32. Patent hemostasis: If compression of the artery is too aggressive a no-flow state will develop, and this may lead to thrombosis. Using the reverse Barbeau test to assess radial artery flow in patients who received conventional compressive dressings, Sanmartin et al found that 60% of patients had absent radial flow during compression. The rate of RAO was 10% at 7-day follow-up. The only independent predictor of RAO was absence of anterograde flow during hemostasis . led to the concept of patent hemostasis , whereby just enough pressure is applied to the puncture site to stop bleeding while maintaining anterograde flow in the radial artery. The Prevention of Radial Artery Occlusion-Patent Hemostasis Evaluation Trial (PROPHET) confirmed this finding.

33. RADIAL ARTERY ANOMALIES HIGH BIFURCATION RADIAL ARTERY: The reference anatomical line for origin derived anomalies was the intercondylar line of the humerus, because it is a fixed line representing the proximal border of the antecubital fossa. Bifurcation of the brachial artery into radial and ulnar arteries proximal to this line is considered a variant pattern. 3 types Lower third of humerus, middle third of humerus, upper third of humerus The most common radial anomaly Incidence of 48.8%. majority of these vessels (44%) they were small caliber with over 85% being <3 mm in diameterwas at the level of mid-humerus.

34. A Typical course of the RA. B Rudimentary RA with three roots (anastomoting branches): the superior root from the axillary artery (not illustrated), the middle root from the median artery and the inferior root from the anterior interosseous artery. In this case the RA was present on its entire course. Described by Gruber (1870a). C RA replaced by an atypical branch of the anterior interosseous artery. Original Gruber (1870b) classification was maintained in the labelling of this drawing. D Low division and trifurcation of the brachial artery. Described by Vollala et al. (2008). E Low origin of the RA co-occurring with a double recurrent radial artery.

35. RA loop an anomaly in which the proximal part of RA turns a full 360° loop distal to the bifurcation of the brachial artery. The presence of a radial loop was associated with a high procedural failure rate with 7 out of the 8 procedures (87.5%) Extreme radial tortuosity was defined as angulation more than 45–90° along the vessel.

36. Management of RADIAL ARTERY LOOP

37. Comparison between right and left radial techniques: Left radial more preferred when Cannulation of LIMA graft needed Diagnostic and interventional procedures of infra diaphragmatic pathology in tall patients Entering descending aorta is easier and straighter with left approach. For addressing stenosis of leftsubclavian, left vertebral and LIMA.

38. common reasons to cross over artery access: RADIAL OCCLUSION UNDERDEVELOPED RADIAL ARTERY (RA) EXTREME TORTUOSITY SCLEROSIS OR CALCIFICATIONS ARTERIA LUSORIA PREVIOUS RIGHT RADIAL FAILURE PRESENCE OF AN ARTERIOVENOUS SHUNT IN THE ARMS PAST OR FUTURE USE OF THE RA AS FREE ARTERIAL GRAFT AND PATIENT PREFERENCE.

39. RA SPASM: Has abundance of alpha adrenergic receptors in adventitia. More prone for spasm. Overall incidence – 5.6% Severe spasm – 0.5% Symptoms: pain during passage of guidewire/ cathter along the course of radial artery. Multiple radial artery puncture Confirmed by RA angiogram One or additional doses of cocktail. Analgesic or sedation helpful. Catheter may be strongly gripped.

40. Classification of radial artery spasm: Grade I: minimal pain along the course of radial A during or immediately after the procedure. Grade ii: significant pain along the course of radial artery during or immediately after the procedure. Catheter movement is possible.. Grade iii: severe pain along the course of radial artery. Catheter movement not possible despite two or more cocktail administration. Grace iv: severe pain along with entrapment of catheter.

41. Forearm Hematoma: Cause: radial artery perforation Manual pressure at the local site for 30 mins. Local BP cuff inflation above systolic BP for 5-10 mins followed by release of the cuff. very rapidly expanding hematoma – heparin effect should be reversed. Perforation big & nonocclusive – long balloon dilatation at 3 to 6 atms for 5 to 10 mins. Failure of sealing despite Several balloon inflation – use of covered Stent

42. RADIAL ARTERY OCCLUSION: Factors involved: Catheter – artery mismatch Female sex Lack of pretreatment with clopidogrel Diabetes Very tight compression Weight adjusted heparin before procedure reduces the risk of occlusion. The mean internal diameter of the radial artery (measured 10 mm proximal to the styloid process) was 3.100.60 mm in men and 2.800.60 mm in women Postintervention RAO rates ranging from less than 1% to 33%.

43. Management: If asymptomatic – observation SYMPYOMATIC – Early – 2 options Compression of ipsilateral ulnar artery for 1 hr increases peak flow velocity in radial artery – opens occluded radial artery. Anticoagulation with enoxaparin or fondaparinaux for 4 weeks. Arterial patency rate at 1 month – 87%. Percutaneous techniques: Antegrade approach – brachial artery Retrograde approach – radial artery distal to occlusion. Important to aspirate the thrombus while passing wire – prevents

44. RADIAL ARTERY PERFORATION: Most common cause of forearm hematoma. Incidence 0.1% Resistance to the passage of guidewire/ catheter simultaneously associated with pain in radial / brachial region with or without development of forearm/ arm hematoma. Immediate removal of catheter f/b Injection of diluted contrast through the sideport confirms the site and size of perforation.

45. Classification: Grade I: <1 mm arterial rent ; minimal extravasation of contrast ; no significant hematoma ; self limiting. Grade II: 1 to 2 mm rent ; significant extravasation of contrast ; muscular infiltration & expanding hematoma. Grade III: >2 mm rent ; rapid and significant extravasation of contrast; rapidly expanding hematoma. Grade IV: free radial artery rupture.

46. Other complications: Compartment syndrome Pseudo aneurysm Arterio venous fistula Subcutaneous granulomatous reaction Depigmented scar Delayed reflex sympathetic dystrophy

47. BALLOON ASSISTED TRACKING INDICATIONS: VERY SMALL CALIBER RADIAL ARTERY <1.5 MM TORTUOUS RADIAL OR BRACHIAL ARTERY SEVERE/RESISTANT SPASM RADIAL ARTERY ATHEROSCLEROSIS COMPLEX RADIAL ARTERY LOOPS

48. Inflated ptca balloon partially protruded through the distal end of the guide catheter. Deployed at 3-6 arms. For 5F catheters - 1.5 mm balloon For 6 F catheters – 2mm balloon. Balloon length – 15 to 20 mm Balloon advanced over soft tipped 0.014 guide wire .

49. UNIVERSAL CATHETERS Same catheter used for engaging right and left coronary sinus. Jacky Tiger Kimny Barbeau MAC 30/30 PAPA

50. ADVANTAGES Less instrumentation Less spasm Shorter procedural time Lower material cost Shorter fluoroscopy time Success rate- 96- 98%. Drawback: non coaxial engagement more common leading to higherchance of coronary ostial trauma. Can be overcome by side hole near end thereby reducing forceful injection of dye into ostium through a non coaxially alinged cathter.

51. Consideration of cAtheters: Diagnostic purpose – 5F Intervention – 6F Most commonly used – tiger catheter. Lack of backup support – can’t be used for intervention purpose. For anomalous origin – amplatz or multipurpose Left coronary intervention: EBU, XB, VODA Right coronary intervention – JR or patel pancholy catheters. Medium orlong sized LM– EBU Short left main – JL RCA – JR RCA with Downard takeoff - MP1 Sheperd crooks deformity – IMA catheter

52. Tortuosity or loops in subclavian artery / arteria lusoria – normal torque is not preserved. Hand eye coordination is more important Wrist movements used for torquing in femoral approach Fine finger movements for torquing in radial Pci through small RA – 5F catheter used. Leftmain Bifurcation stenosis & SVG graft intervention – 7F sheath used. 7F cathter through a small RA-- BAT technique is used.

53. CATHETERS FOR GRAFT CANNULATION: SVG / RA grafts to left and right coronary artery – 5F Tiger / JR, AR PCI of SVG to RCA: MP PCI of SVG to LCA: AL LIMA graft: left TRA preffered. LIMA graft via right TRA: 2 techniques

54. ADVANTAGES OVER FEMORAL ROUTE: Bleeding easy to control. Early ambulation. Shorter hospital stay Economical

55. Disadvantages: Difficult to access More probe for spasm Longer exposure to radiation

56. J- WIRE Length – 150 to 180 cms. Size 0.025 or 0.03 inch J shaped 0.035 avoids entering side branch in forearm and arm. Causes for resistance of passage: Anatomical variations like radial artery loops or tortuous artery. Arterial spasm. How to overcome? Use fluoroscopy while passing wire. If resistance met – use steerable 0.035 inch glide wire or Wholey wire. Advancing the guidewire with torquing. M External compression of radial artery at the culprit site to be performed with the finger of second operator. Attempt made to get the wire into The correct way. If unsuccessful angled hydrophilic Wire should be tried. If unsuccessful change the site.

57. Access through occluded radial artery: 2 techniques: Distal & proximal techniques Distal: 20g teflon cannula placed using through and through technique in the very distal portion of the radial artery. At that site low volume collateral flow pulse felt from backflow from palmar arch. 0.018 inch micropuncture wire introduced Advanced by slow torquing motion. Based on tactile feel and fluoroscopic guidance If no pain – slow torquing and forward pushing. Remove the aguide wire pulsatile flow should now present. 0.021 inch guide wire re inserted and radiofocus glide sheath advanced.

58. If pain presents – wire should be withdrawn & readvanced. If advanced with pain – would have entered false lumen. ADVANTAGES: RECANALISATION OF THROMBOSED RA SEGMENT. INCREASES THE PATENCY OF RADIAL A FOR FUTURE PROCEDURE. DISADVANTAGES: THROMBUS DISLIDGEMENT, MIGRATION & EMBOLISM. PERFORATION AND DISSECTION.

59. PROXIMAL: 20 G needle used to puncture radial artery proximal to the previous entry. Through and through technique. ADVANTAGES: DOES NOT DISTURB THE THROMBUS. LIMITATIONS: Inability to recanalize the occluded portion of radial artery. Hemostasis difficult since RA passes through muscle bellies.

60. CATHETER KNOT: Excessive clockwise rotation while trying to engage RCA ostium . Significant subclavian tortuosity . 1 st technique: Advance 0.035 inch guidewire across the knot. If very tight knot- unsuccessful. 2 nd technique: Fix the catheter distal to knot. Counterclocksise rotation of proximal segment from outside. 3 rd technique: Apply manual pressure over brachial artery in cubital segment for fixing the segment distal to knot Counter clockwise rotation from outside. 4 th technique: Apply BP cuff in brachial region, increase BP to more than 200 mm hg

61. Fixes the artery distal to knot. High success rate than others. Pseudo aneurysm: Usually small size Treated by external compression.

62. THANK YOU