Segev A

What s Available for Trans-
Radial Access
Amit Segev, MD, FESC
Interventional Cardiology
Chaim Sheba Medical Center
Sheba Medical Center
Tel Hashomer The Leviev Heart Center

Anatomy
Radial
Artery Ulnar
Artery

Palmar
Arch


Allen s test


Interpretation of Allen s


Assessment of ulnar arch by
oxymetry
n Allen’s test is subjective and difficult to
interpret
n Barbeau score

2
min

Sheba Medical Center Barbeau.
G
et
al;
Am
Heart
J
2004;147:489–93


Barbeau score

NO

Barbeau.
G
et
al;
Am
Heart
J
2004;147:489–93


Room Setup


Immobilizing wrist


Access
Anatomic Limitations


RADIAL ACCESS
Micro Puncture kit
Hydrophilic Sheath


Radial Spasm
n  Prevention
n Sedation / Nitro / Verapamil
n Hydrophilic-coated sheath and catheter
n  Treatment
n Nitro / sedation / verapamil / Time…

8 minutes
later


Terumo Wire


Anatomic variations
n  23 % of 2 211 radial procedures
n  Tortuosity:
n  3.8 %
n  98.8 % of success rate of the procedure
n  Stenotic radial artery
n  1.7 %
n  91.9 % of success rate of the procedure
n  Hypoplastic radial artery
n  7.7 %
n  93.9 % success rate
n  Radio-ulnar loop/radial reccurent artery
n  0.8 %
n  83.3 % success rate
Catheterization and Cardiovascular Interventions 67:870–878 (2006)

Radial/Brachial loop
n Terumo GW
n Coronary 0.014 wire
n Straightened the brachial loop with 4-5-6 F
catheter
n Long exchange wires

Catheterization and Cardiovascular Interventions 68:260–262 (2006)

Tortuous Subclavian / Innominate artery

n  Deep breath to lower the heart
n  Terumo wire
n  Coronary wire
n  Straighten Subclavian by placing stiff wire
n  Long sheath


Understanding the Catheter s Course

Right Radial Left Radial Femoral

2 points of 1 point of 1 point of
resistance resistance resistance


TRA: Mechanisms of Failure
Total number of Failures 98/2100 (4.6%)

Failure of arterial access
Inadequate arterial puncture 13%
Failure to advance catheter to ascending aorta
Radial artery spasm 34%
HYDROPHYLIC SHEATHS NOT USED
Radial artery dissection 10%
Radial artery loop/tortuosity 6%
Radial artery stenosis 1%
Failure to complete PCI due to lack of guide support
Subclavian tortuosity 18%
Inadequate guide backup support 17%

n=2,100 Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064


Catheter selection – why
Standard femoral Dx catheters may be used as
well as several other universal curves

•  Learning curve
•  Single vs. Double catheter technique
–  Judkins: JL3.5 and JR4 or 5 (XB??)
–  Single catheters:
•  Jacky, Tiger, Sarah, Kimny, Fajadet
•  TRA PCI
–  Right: JR4 or 5 – Left: EBU 3.5 / XB3.0
–  Single Catheter Technique: Ikari L


Catheter Selection: Femoral vs Radial
Radial access requires the use of finger-based torque movements instead of  
the wrist-based used in femoral access

•  Catheter Manipulation Technique
–  Transradial approach can involve more tortuosity than the femoral
approach
–  TRA necessitating small (finger-based) clockwise and
counterclockwise torquing movements and active catheter holding
as there may be multiple friction points in the subclavian and the
aorta

JL 3.5 Radial JL 4.0 Femoral
Different curve mechanics,  
Sheba Medical Center sizing and backup support

Transradial Curves for Left Coronary –
Judkins Left

Standard curve for the left coronary artery
(may be particularly useful for short left
coronary arteries)
Sizing suggestions:
Downsize the curve by 0.5 from what is used   Judkins engagement technique, similar to
for a femoral approach femoral approach. Very fine torquing
movements may be required to direct the
catheter toward the left coronary artery


Transradial Curves for Left Coronary – Extra Backup

Workhorse curve for left coronary
artery
Sizing suggestions:
JL3.5 = EBU3.5 / XB3
JL4.0 = EBU3.75
Comparable to:
Cordis: XB, XBLAD
BSC: Muta Left, Radial Curve,
Brachial Curve


Transradial Curves for Left Coronary – EBU/XB


Single Catheter Solutions
for Diagnostic Catheterization

Terumo s Optitorque
Diagnostic Catheter
Available in 5F and 6F

Amplatz
shape tip

Tiger Jacky

Rarely coaxial, good for Amplatz type tip (to address
RCA, the tip tends to engagement issues), better
point superior suited for LV


Jacky Catheter: Selective Engagement of
RCA and LM


IKARI Left Catheter


IKARI Catheter vs. Standard Catheters

Ikari Y, et. al. Journal of Invasive Cardiology 2005

IKARI Left Catheter: Multivessel Intervention


Transradial Curves for Right Coronary –
Judkins Right

Standard curve for right coronary artery
(may be particularly useful for
inferior takeoffs)
Sizing suggestions:
Same as femoral approach
Comparable to: Judkins engagement technique, similar to
femoral approach. Apply a clockwise
Cordis: Judkins Right rotation to engage right coronary artery
BSC: Judkins Right

Transradial Curves for Right Coronary –
Judkins Right

Deep intubation of RCA with JR4


Considerations for Using 5F Guide Catheters

•  Miniaturization of products allow 5F use
•  Small radial arteries may not be suited for
6F guides
•  Less spasm, less patient discomfort
•  Lower incidence of radial vessel occlusion
•  Less contrast/ injection = less nephrotoxicity


My Way…
Works in >95% of cases
•  Lidocaine 2% 0.5cc
•  Dedicated radial sheath: Terumo,
Cordis 6FR
•  IA verapamil 2.5 mg
•  IV heparin 3000-5000U
•  Diagnostic catheters 5FR– JL3.5 + JR4
•  Guiding catheters 6FR – XB3.0 or JR4


Conclusions
•  Room setup is crucial
•  Radial puncture – follow rules
–  Use only dedicated radial kits
•  NEVER push against even minor resistance
•  Find the catheter that works best for you – Practice
makes perfect
•  Catheter engagement and support represent
significant barriers to transradial procedural success
–  Keep the guidewire in the catheter until you cannulate
•  Knowledge of catheter selection and technique enable
successful PCI
•  Complex PCI is achievable with existing equipment
–  CTO, bifurcations….
•  TR specific guiding catheters may offer advantages


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