It is necessary for the radial artery to be easily visualized for the access puncture. An arm support or cradle can be used.
When a lab is transitioning from transfemoral to transradial cardiac catheterizations, the process can be either encouraging or discouraging to all staff involved. To ease the transition, it might be useful to employ previously implemented ideas, techniques and equipment selections that have had positive outcomes. This article will discuss patient preparation, equipment selection and address common inventory concerns that occur when developing a transradial catheterization program. The ideas and initiatives discussed in this article are those that we undertook at the Jesse Brown VA Medical Center in Chicago and may not reflect other cath labs’ setup. However, most of the concepts are applicable to all catheterization labs.
Many cardiology equipment vendors support using the transradial approach as an alternative catheterization method. Some of the typical equipment used when performing an angiogram and/or angioplasty using the femoral approach can also be used when during the transradial approach. (Table 1) Many vendors also have made additions by creating “dedicated” transradial supplies that can aid in performing successful transradial catheterizations. There is a learning curve when performing transradial catheterizations, thus selecting the right equipment and appropriate pre-procedure patient preparation are essential in reducing the overall procedure time.
It is necessary for the radial artery to be easily visualized for the access puncture. Position the arm so the patient’s wrist-hand angle is approximately 60 degress. An arm support or cradle can be used, and tape should be placed across the palm to secure the position. The arm may be hyper-extended in the supine position and slightly elevated with a foam arm support, (Alimed, Dedham, Mass.) which will allow comfortable patient positioning up to the elbow during the procedure.
The wrist splint keeps the patient’s arm and wrist in the supine position both during and post procedure. After the procedure, it is important that the patient does not flex the wrist to prevent bleeding from the access site. (Figure 3) There are many devices and methods to achieve this goal. Placing a rolled towel underneath the arm so that the wrist could be slightly overextended without constraint is another common technique. Taping the fingers and hand will prevent rotation of the wrist with the needle stick.
Radial Arm Board
During a transradial catheterization procedure, the arm is positioned at the patient’s side to reduce radiation exposure. Positioning of the arm at a 90 degree T-shaped angle makes it difficult to obtain angulated views, exposes the operator to increased radiation and makes interventional procedures more cumbersome. An arm board makes it easier for the arm to be positioned properly. This board is placed halfway under the patient with the extended portion providing a working space during the procedure.
Transradial Access Drape
When setting up to perform a cardiac catheterization through the radial artery, it is advisable to also prep and drape the groin area for the possibility of transfemoral access. Using a combination radial-femoral drape, which allows for access to both the radial artery and the femoral artery, can be used to ensure that there is no break in the sterile field. According to the Association of periOperative Registered Nurses (AORN), a break in the sterile field compromises sterility and is against the recommended practice for maintaining sterile technique during a procedure.
Right Heart Catheterization
An “all-access” specially designed drape is used when patients are undergoing a left and right heart catheterization. The unique design allows for three prepped access sites (radial, femoral and right brachial) at once with one drape when the brachiocephallic vein is used for right heart catheterization access.
Balloon Wedge Swan Catheter
The 4 French balloon wedge Swan-Ganz catheter (Teleflex-Arrow, Miami, Fla.), allows use of a smaller access site by using a 4 French radial sheath. Thermodilution cardiac output measurements cannot be recorded using this catheter, but a 6 French catheter is available that can easily be used through this approach. This would result in avoiding the groin altogether when performing a right and left heart cath.
During the Procedure
Radial artery access is achieved with a short bevel 21-gauge needle, and typically, a 0.018-0.021 guide wire. This smaller needle system allows for better control and pulsatile blood flow can be seen immediately. Difficulty obtaining access can be a major concern when performing a catheterization via the radial artery. These difficulties may prolong the time to gain access; therefore prolonging the overall length of the procedure. It is suggested during a radial artery catheterization to use a smaller needle than one traditionally used during femoral catheterization, which may reduce difficulty when obtaining access.
There are a variety of sheaths available on the market that may be suitable for radial access. There are some characteristics, however, that may be desired in a radial sheath such as a tapered edge and hydrophilic coating. The tapered edge allows for smooth insertion of the sheath, and a hydrophilic coating on the sheath reduces the incidence of radial artery spasm during transradial coronary procedures.
Although a JL 4 and JR 4 catheter can be used for left and right coronary artery cannulation, there are catheters on the market by various vendors designed specifically for radial artery access. Examples of radial-specific catheters are the Jacky Radial Catheter (Terumo), the Tiger Radial TIG Catheter (Terumo), and Sarah Radial (Terumo). The Ultimate 1 and 2 (Merit Medical) can also be used to cannulate either coronary ostia. These catheters have the common characteristic of a primary and secondary curve. A radial-specific catheter enables angiography of both right and left coronaries with a clockwise and counterclockwise rotation of one catheter. Eliminating catheter exchange can result in less total procedure time as well as fluoroscopy time and less incidence of radial artery spasm.
Post-Procedure Compression Bands
Achieving hemostasis after a radial catheterization may be less difficult when compared to femoral catheterization. The radial artery is a much smaller artery than the femoral artery and because of its superficial location, it is easier to apply direct pressure to the access site to achieve hemostasis. Although applying direct pressure is easier with the radial artery, occlusion of the radial artery is an important concern of transradial catheterization. The clinician applying the hemostasis band should not apply flow-limiting compression, but patent hemostasis. Absence of radial artery flow during compression represents a strong predictor of radial artery occlusion. There are several radial bands on the market that can apply direct pressure to the site post procedure. The bands can be removed before the patient is discharged home. Some facilities may apply an ace wrap bandage before discharge to help remind the patient not to overuse the wrist.
Inventory Cost and Management
When comparing the overall procedure costs of a transfemoral catheterization versus a transradial catheterization, the costs are less for the latter. The transradial approach may appear to cost more due to the need for specialized sheaths, wires and catheters, but the post-procedure process when performing femoral cardiac catheterization can outweigh those costs. Catheter cost can be lower because specialized radial catheters are able to engage both the left and the right coronary arteries, helping to reduce the number of catheters used. Also, consider the cost of using a vascular closure device with a transfemoral approach, bed rest recovery time, the higher incidence of bleeding or vascular complications and patient satisfaction. Most hemostasis bands cost significantly less than a femoral artery vascular closure device and patients are ambulatory post-procedure. This can lead to less of a burden on nursing staff and possible earlier discharge, which all can result in lower recovery costs.
Inventory management may become a concern as the transition is made from transfemoral to transradial catheterization. Some vendors will allow a consignment while transradial equipment is trialed for a specific length of time. This is important so that there does not become an overstock of purchased items that does not fit the needs of your transradial program. Moving toward performing more transradial procedures than transfemoral may also call for fewer inventories of 7 French and 8 French catheters, as well as femoral closure devices.
Trial and error when selecting equipment for transradial catheterization is common, but now the industry is providing various tools needed to successfully perform a cardiac catheterization using the transradial approach. Once there is a final selection of transradial equipment for your facility, it would be more efficient for the staff to know what inventory is needed to help facilitate access, as well as become comfortable with arm position and preparation for the procedure.
Other Radial Access Information Sources on DAIC
1. Salgado Fernandez J, Calvino Santos R, Vazquez Rodriguez JM, Vazquez Gonzalez N, Vazquez Rey E, Perez Fernandez R, Bouzas Zubeldía B, Castro Beiras A. “Transradial approach to coronary angiography and angioplasty: initial experience and learning curve.” Rev Esp Cardiol. Feb. 2003, 56(2):152-9. Spanish. PubMed PMID: 12605760.
2. Quesada, R.(2010). “Adopting Radial Access: A review of preparation, technique, and post-procedure considerations when using transradial access.” Endovascular Today. Retrieved from: http://bmctoday.net/evtoday/2010/05/article.asp?f=adopting-radial-access
3. Komocsi, A., Konyi, A., Kovacs, E., & Ungi, I. (2010). “Radiation exposure during cardiac catheterization: Implications for the transradial approach.” Interventional Medicine & Applied Science, Vol. 2 (3), pp. 105–109. Retrieved from: www.akademiai.com/content/h3t003646677371g/fulltext.pdf
4. “AORN’s Recommended Practices for Maintaining a Sterile Field.” Infection Control Magazine. Retrieved March 10, 2011 from www.infectioncontroltoday.com/news/2005/03/aorn-s-recommended-practices-for-maintaining-a-st.aspx.
5. Rathore S, Stables RH, Pauriah M, Hakeem A, Mills JD, Palmer ND, Perry RA, Morris JL. “Impact of length and hydrophilic coating of the introducer sheath on radial artery spasm during transradial coronary intervention: a randomized study.” JACC Cardiovasc Interv. May 2010, 3(5):475-83. PubMed PMID: 20488402.
6. Kim SM, Kim DK, Kim DI, Kim DS, Joo SJ, Lee JW. “Novel diagnostic catheter specifically designed for both coronary arteries via the right transradial approach. A prospective, randomized trial of Tiger II vs. Judkins catheters.” Int J Cardiovasc Imaging, June-Aug. 2006, 22(3-4):295-303. Epub Nov. 22, 2005. PubMed PMID: 16328852.
7. Sanmartin, M., Gomez, M., Rumoroso, J. R., Sadaba, M., Martinez, M., Baz, J. A. and Iniguez, A. “Interruption of blood flow during compression and radial artery occlusion after transradial catheterization.” Catheterization and Cardiovascular Interventions, 2007, 70:185–189. doi: 10.1002/ccd.21058
8. Louvard Y, Lefèvre T, Allain A, Morice M. “Coronary angiography through the radial or the femoral approach: The CARAFE study.” Catheter Cardiovasc Interventions. Feb. 2001, 52(2):181-7. PubMed PMID: 11170325.