The author Richard Casazza wearing the radial access drape he helped develop at his hospital to reduce setup time.
Radial Access Sleeve with normal arm adduction.
RAS with sheath biased medially (DRI method).
Rotational Atherectomy with RAS and DRI method (stable operating platform).
RAS dual fenestration technology for precise radial artery draping.
RAS with left radial "Drag-over."
The transradial revolution is one of the fastest growing trends in cardiology. Compared to the femoral access technique, transradial access is associated with reductions in access-site complications, bleeding complications and overall morbidity.[1-3] Furthermore, the radial approach in ST-elevated myocardial infarction (STEMI) patients has been associated with significant reduction in major adverse events during follow up. Technology and techniques are constantly evolving and expanding in the field of transradial procedures, including the drapes we employ.
This has led to some centers modifying existing drapes in their inventory, or in some cases developing their own. One example of a homegrown drape that is now commercially produced is the Radial Access Sleeve (RAS). It is a circumferential sterile field that envelops the arm and provides a fast, effective prep of the radial access site. It is equally effective on either right or left radial access. It uses a unique dual fenestration system that allows for precise radial access site prep while preserving sterility. The drape was the brainchild of three cath lab friends — cath lab techs Christos Pitoulis, Richard Casazza and Grace Mullings, RN, at Maimonides Medical Center, Brooklyn, N.Y.
Left Radial Access
The RAS serves as a solution for left radial “drag-over” procedures. Its circumferential coverage allows for the arm to be manipulated across the chest without compromising sterility. Recent studies have suggested that left radial access is associated with lower fluoroscopy times, contrast volume, procedure time, operator exposure [5-8], and even needle-to-balloon time during STEMIs. Cardiac catheterization laboratories traditionally have used the right radial artery because of familiarity of catheter manipulation from the right side of the table by both operators and staff.
Right Radial Access
The RAS can be used in conjunction with standard arm boards with the arm resting while the wrist is slightly hyper-extended. The RAS can be advanced over the arm and the arm board. Once the prep is completed the arm is adducted to the body drape and clamped off, creating a seamless sterile field.
Benefits of a Dedicated Drape
The RAS improves arm-draping times and increases efficiency. The prep times with traditional drapes (where a sterile field must be constructed) is approximately 3.5-4.5 minutes with RRA prep. The LRA prep is significantly more, taking approximately 6-8 minutes to construct a LRA drag over. The RAS takes approximately 1.25 minutes to prep for right or left access sites. This improved prep time helps turnover and could be invaluable for door-to-balloon times during STEMI cases or other urgent revascularizations. Radial access has been shown to cut costs related to lower bed occupancy, a reduction in nursing workload, and decreased pharmacy expenses. This is pertinent to nursing and ancillary staff, cutting 3.5-7.5 minutes of prep time. Over the course of 10 patients, up to 75 minutes could be saved. The RAS is also designed to double as a pedal access drape (AT or PT access) for critical limb ischemia.
The RAS also facilitates a new right radial artery (RRA) access technique called the DRI method (drag-right-in). This technique creates a more ergonomic working platform for operators. Due to the lateral orientation of the radial artery, catheters and wires are also biased laterally, forcing the operator to manipulate the equipment medially to facilitate a stable working platform. As opposed to a transfemoral procedure, the operator works between the patient’s legs and uses the procedural table as the working platform. Even with dedicated radial boards, operators are still forced to manipulate equipment medially.
The RAS with the DRI method overcomes these shortcomings. Following cannulation of the RRA, the operator will hyper-adduct the arm and pronate the wrist 20-30 degrees. This is accomplished by applying clamps at the hand end of the RAS and by the elbow, essentially slinging the arm and creating a seamless transition between the body drape and the RAS. The case then proceeds very similar to a transfemoral case, eliminating the need to manipulate catheters medially. This method pays its dividends when numerous exchanges are needed and the use of bulky equipment is employed.
The new drape may be able to increase efficiency and decrease turnover times for optimization of time and resources.
Watch the video “Update on U.S. Transradial Access Adoption With Sunil Rao at TCT 2015,” a discussion with Sunil Rao, M.D., associate professor of medicine and a member in the Duke University Clinical Research Institute, and a leading proponent of radial access.
1. Kiemeneij F, Laarman GJ, Odekerken D, et al. “A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study.” J Am Coll Cardiol. 1997 May;29(6)1269-75.
2. Hildick-Smith DJR, Lowe MD, Walsh JT, et al. “Coronary angiography from the radial artery-experience, complications and limitations.” Int J Cardiol. 1998 May 15;64(3):231-9.
3. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. “Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systemic overview and meta-analysis of randomized trials.” J Am Coll Cardiol. 2004 Jul 21;44(2):349-56.
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7. Dominici M, Diletti R, Milici C, et al. “Operator exposure to X-ray in left and right radial access during percutaneous coronary procedures: OPERA randomised study.” Heart. 2013 Apr;99(7):480-4. doi: 10.1136/heartjnl-2012-302895. Epub 2013 Jan 23.
8. Salvatore De Rosa, Daniele Torella, Gianluca Caiazzo, et al. “Left radial access for percutaneous coronary procedures: From neglected to performer? A meta-analysis of 14 studies including 7603 procedures.” International Journal of Cardiology 171 (2014) 66-72.
9. Hu HY, Fu Q, Chen W, et al. “Randomized comparative study of left versus right radial approach in the setting of primary percutaneous coronary intervention for ST-elevation myocardial infarction.” Clinical Interventions in Aging 2015:10 1003-1008.
10. Rao SV, Cohen MG, Kandzari DE, et al. “The transradial approach to percutaneous coronary intervention: historical perspective, current concepts, and future directions.” J Am Coll Cardiol. 2010;55:2187-2195.
11. Rinfret S, Kennedy WA, Lachaine J, et al. “Economic impact of same-day home discharge after uncomplicated transradial percutaneous coronary intervention and bolus-only abciximab regimen.” JACC Cardiovasc Interv. 2010 Oct;3(10):1011-9. doi: 10.1016/j.jcin.2010.07.011.