Radial artery catheterization

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

The first introduction to the use of radial artery for cardiac catheterization was made by Radner in 1948.^[1] Subsequently, a Canadian Cardiologist, Lucian Campeau, in 1989 re-introduced the practice.^[2] There have been a gradual increase in its preference over the femoral approach internationally;^[3] with United States experiencing a 10-fold increase (1 in every 6 PCIs performed) in the adoption of transradial procedures between 2007 and 2012,^[4] largely as a result of reduced major bleeding, vascular complications, length of hospital stay and cost, and increased patient satisfaction and quality of care. The rationale for the choice of radial access include:

• Decreased risk of limb ischemia – The hand has a dual arterial supply i.e., radial and ulnar arteries, which unites to form the superficial and deep palmer arches. Therefore, the radial artery is not an end artery like the femoral artery, thus decreasing the risk of arterial occlusion post PCI.
• Decreased risk of bleeding – The superficial course of the distal radial artery allows for easy compressibility in order to minimize hemorrhage post PCI.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

In human anatomy, the radial artery is the main blood vessel, with oxygenated blood, of the lateral aspect of the forearm.

The radial artery arises from the bifurcation of the brachial artery in the cubital fossa. It runs distally down the anterior part of the forearm. There, it serves as a landmark for the division between the anterior and posterior compartments of the forearm, with the posterior compartment beginning just lateral to the artery. The artery winds laterally around the wrist, passing through the anatomical snuff box and between the heads of the first dorsal interosseous muscle. It passes anteriorly between the heads of the adductor pollicis, and becomes the deep palmar arch, which joins with the deep branch of the ulnar artery.

Along its course, it is accompanied by a similarly named vein, the radial vein.

The named branches of the radial artery may be divided into three groups, corresponding with the three regions in which the vessel is situated.

• Radial recurrent artery – arises just after the radial artery comes off the brachial artery. It travels superiorly to anastomose with the radial collateral artery.
• Palmar carpal branch of radial artery – a small vessel which arises near the lower border of the pronator quadratus
• Superficial palmar branch of the radial artery – arises from the radial artery, just where this vessel is about to wind around the lateral side of the wrist.

• Dorsal carpal branch of radial artery – a small vessel which arises beneath the extensor tendons of the thumb
• First dorsal metacarpal artery – arises just before the radial artery passes between the two heads of the first dorsal interosseous muscle and divides almost immediately into two branches which supply the adjacent sides of the thumb and index finger; the lateral side of the thumb receives a branch directly from the radial artery.

• Princeps pollicis artery – arises from the radial artery just as it turns medially to the deep part of the hand.
• Radialis indicis – arises close to the princeps pollicis. The two arteries may arise from a common trunk, the first palmar metacarpal artery.
• Deep palmar arch – terminal part of radial artery.

The artery’s pulse is palpable in the anatomical snuff box and on the anterior aspect of the arm over the carpal bones (where it is commonly used to assess the heart rate and cardiac rhythm).

The radial artery is used for coronary artery bypass grafting and is growing in popularity among cardiac surgeons.^[2] Recently, it has been shown to have a superior peri-operative and post-operative course when compared to saphenous vein grafts.^[3]

• Allen test

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  Tendons of forefinger and vincula tendina.
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  Cross-section through the middle of the forearm.
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  Transverse section across distal ends of radius and ulna.
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  Transverse section across the wrist and digits.
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  Diagram of the anastomosis around the elbow-joint.
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  The radial and ulnar arteries.
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  Front of right upper extremity, showing surface markings for bones, arteries, and nerves.

1. ^ Sajja LR, Mannam G, Pantula NR, Sompalli S. Role of radial artery graft in coronary artery bypass grafting. Ann Thorac Surg. 2005 Jun;79(6):2180-8. PMID 15919345
2. ^ Cohen G, Tamariz MG, Sever JY, Liaghati N, Guru V, Christakis GT, Bhatnagar G, Cutrara C, Abouzahr L, Goldman BS, Fremes SE. The radial artery versus the saphenous vein graft in contemporary CABG: a case-matched study. Ann Thorac Surg. 2001 Jan;71(1):180-5; discussion 185-6. PMID 11216742

• Image at umich.edu – pulse
• Radial artery puncture – medicalstudents.com

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de:Arteria radialis no:Arteria radialis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Bleeding is a common complication of the available therapies for the treatment of acute coronary syndromes. There are increasing evidences showing that major bleeding is independently associated with increased risk for mortality and ischemic events among patients with acute coronary syndrome undergoing percutaneous coronary intervention.^[1][2] The development of ischemic events (i.e., myocardial infarction and stroke) may be explained by the activation of coagulation cascade by major bleeding, cessation or inadequate antiplatelet and antithrombotic therapies, and depletion of coagulation factors as a complication of blood transfusion. According to a meta-analysis study, radial access was associated with a 73% reduction in major bleeding compared with femoral access; a similar trend was also observed with the risk of ischemic events.^[3]

Transradial PCI has also been shown to be associated with a reduced time to mobilization (i.e., early mobilization),^[4][5] cost and length of stay among patients with ACS. In a meta-analysis study, there was a reduction in the length of hospital stay by 0.4 days in the radial group when compared with the femoral group.^[3] Consequently, there was reduced expenditure per patient and increased patient turnover at the hospitals.

Among patients who had undergone both radial and femoral access procedures, there was a strong patient preference for transradial catheterization as well as improved quality of life measured by reduced body pain, back pain, and ease of walking.^[6][7]

Other potential advantages of radial over femoral access include:

• Provides an opportunity for same day/outpatient PCI^[8][9]
• Absence of retroperitoneal hematomas, femoral pseudo aneurysms, and arteriovenous fistulas
• Improved access in the obese patient
• Reduced incidence of limb threatening ischemia due to the dual blood supply of the hand (ulnar and radial arteries)
• Advantageous for patients with severe occlusive aortoiliac disease
• Advantageous for patients with back pain, obesity, congestive heart failure who have difficulty laying flat on their back.
• Less likelihood of local nerve injury
• Radial artery is easily compressible due to its superficial course

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hesham Bahaa El-Din, M.B.B.Ch., M.Sc.

The data that had been published up till now entails an incidence of about 2% to 34% of radial artery spasm, which would result in transfemoral approach being used instead. ^[1]. So some precautions should be made beforehand in anticipation of such complications.

1- Radial artery spasm:-

• In order to decrease the incidence of radial artery spasm, some interventionist tend to give light sedation as well as intra-arterial Nitroglycerin and calcium channel blocker (verapamil or diltiazem) in order to relax the smooth muscles of the radial artery.

2- Vessel tortuosity. Some of the tortuous forms are:-

• Alpha shape radial artery.
• S-shaped radial artery.
• Proximal and distal omega shaped radial artery.
• Brachial alpha loop.
• High origin radial artery.

A lot of techniques has been used to overcome tortuosities. when a regular 0.35″ J-wire is unable to cross the tortuous vessel, a PTCA 0.014″ is used to cross this part. Then Balloon-Assisted Tracking (BAT) can be useful. It is a technique in which a small compliant balloon usually 2.0mm X 15.0 or 20.0 mm is inflated at the tip of the Guide-in catheter with half to one third of the balloon is inside the catheter. Balloon is inflated slightly over the nominal pressure, the catheter is then steered across the tortuous vessel over the PTCA wire. This technique can also be used in case of radial artery spasm.^[2]

3- Guide catheter support and selection may be reduced.

4- Loss of radial artery pulse in 4% of cases.

5- Potential increase in the duration of the procedure and fluroscopy time

6- The radial artery has been instrumented should there be a desire to use it as a conduit for CABG

7- It is the second and not the first approach learned by trainees

8- There is a learning curve in treating spasm, navigating anatomy, and manipulating catheters

9- Anatomically there can be a loop in the artery near the brachial in about 10% of cases

10- Smaller sheaths are required (4-8F)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• Absence of palpable radial artery pulse
• Abnormal Allen test (oximetry/ plethysmography), indicating that only one artery supplies the hand
• Presence of upper extremity peripheral vascular disease such as Buerger’s disease and severe Raynaud’s disease
• Presence of arteriovenous shunt for dialysis
• Potential use of the radial artery as a conduit for aortocoronary bypass
• Cellulitis or other infections over the radial artery
• Coagulation defects
• Patients who may require intra-aortic balloon pump counterpulsation (IABP)
• Devices that are not compatible in 7F or smaller sheaths such as TEC, larger Rotoblator burrs, certain stents
• Congenital abnormalities of upper limb vasculature such as extreme tortuosity, anomalous take off of the radial artery, or severe atherosclerosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

The hand is normally supplied by blood from the ulnar and radial arteries. The arteries undergo anastomosis in the hand. Thus, if the blood supply from one of the arteries is cut off, the other artery can supply adequate blood to the hand. A minority of people lack this dual blood supply. Allen’s test or oximetry/plethysmography should be performed before the procedure to confirm that there is sufficient blood flow in the ulnar artery should there be loss of patency in the radial artery due to either thrombosis or spasm which can result in gangrenous finger or had loss.

This is the first step towards a successful transradial PCI. Effort should be made to assess the following:

• Age – Patients with ages <70 years are better suitable for r-PCI
• Patients’ hemodynamic status
• History of previous ipsilateral brachial or transradial procedure
• Strong radial arterial pulse and presence of a normal Allen’s test

Although the ulnar artery is rarely used nowadays, it has been successfully attempted in the past with a high success rate comparable to the transradial approach.^[1] Compared with the radial artery, the ulnar artery have been shown to be larger^[2] and more prone to access site failures due to its higher rate of spasms and anatomical variations.^[3] Therefore, the transulnar approach is generally reserved as an alternative option in selected cases, and especially when the radial artery is being preserved in anticipation of its usage as a coronary bypass conduit.^[1]

Radial artery in right upper extremity is usually used in 90% of cases for catheterization due to both operator and patient convenience with typical catheterization.^[4] Other factors to consider in making a choice between left and right radial artery include the presence of a left internal mammary artery (IMA) graft and the possible future need for a bypass graft conduit from the non-dominant hand.

The following factors favor the use of left radial artery for PCI:^[5]

• Short statured patients
• Patients with abdominal obesity who tend to have compressed abdominal aortas
• Evaluation and treatment of infradiaphragmatic pathology
• Left subclavian and left vertebral interventions
• Reduced fluoroscopy time and radiation dose^[6]

This test is named after Edgar Van Nuys Allen.^[7]. The utility of the Allen’s test has been questioned,^[8] and no direct association with ischemic complications of radial artery cannulation has ever been demonstrated. In 1983, Slogoff and colleagues reviewed 1,782 radial artery cannulations and found that 25% of them resulted in complete radial artery occlusion, without apparent adverse effects.^[9] A number of reports have been published in which permanent ischemic sequelae occurred even in the presence of a normal Allen’s test.^[10][11] In addition, the results of Allen’s tests do not appear to correlate with distal blood flow as demonstrated by fluorescein dye injections^[12] or photo plethysmography.^[13]

Modifications to the test have been proposed to improve reliability.^[14]

Despite this lack of association with outcomes, the Allen’s Test is often performed in clinical practice.

This is used to test the patency of the palmer arch.

• The hand is elevated and the patient/person is asked to make a fist for about 30 secs.

• 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 can be observed at the finger nails).

• Ulnar pressure is released and the color should return in 7 secs.

Inference: Ulnar artery supply to the hand is sufficient and it is safe to cannulate the radial artery

If color does not return or returns after 7 seconds, then the ulnar artery supply to the hand is not sufficient and the radial artery therefore cannot be safely cannulated.

Below is a video demonstrating Allen’s test

{{#ev:youtube|jq0ai5uXx68}}

Reverse Allen’s test may be performed in patients who require a second procedure through the same radial site. In reverse Allen’s test, the physician releases pressure over the radial artery rather than the ulnar. This may detect proximal radial artery disease/occlusion that may be asymptomatic. Patients with an abnormal Reverse Allen’s Test should not undergo a repeat transradial procedure from same radial site.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.;Hesham Bahaa El-Din, M.B.B.Ch., M.Sc.

The transradial approach (TRA) for coronary/cardiac catheterization is slightly more challenging than the transfemoral route. It requires more maneuvers and catheter steering along the course of the radial artery to reach the level of the coronary sinus in the ascending aorta. The right transradial approach is usually preferred over the left side due to the ease of accessibility for the operating physician.

Catheter selection is an important key in the success of the procedure. Standard catheters (e.g Judkin’s Left and Judkin’s right) can be used for the TRA. However due to the common anomalies that could be seen along the course of the radial, subclavien, and axillary arteries, special “dedicated Radial Catheters” had been developed (e.g. Tiger, Jacky, and Kimmy). The most commonly used guidewires are those with hydrophilic coating, due to the expected tortuosity of the arterial course.

1. Before the start of the procedure a “time out” should be taken to revise the indication, important labs, and the patency of the wrist circulation as discussed previously. Allen’s test or Barbeau test.
2. Make sure that all of the equipment is ready and recheck the sizes .
3. The wrist should be shaved (if necessary) and cleansed in the usual sterile fashion. In addition, the groin should be prepped in case of access failure or the need for urgent IABP or a temporary venous pacemaker.
4. Intravenous (IV) line should be started on the contralateral extremity. If an IV should be placed in the intervention extremity, it must be placed proximal to the wrist preferably at the level of the elbow.
5. Sterilization of the whole arm should be done using the standard sterile techniques and covered in sterile drapes except for the region of the radial artery – distal part of the palmar surface of the forearm – which is left exposed for easier access.
6. Most operators prefer to give anxiolytics e.g Midazolam (1-2 mg) before the start of the procedure to decrease patient anxiety and hence decrease radial spasm.
7. The arm should be fully extended; slightly elevated with full supination, and the wrist hyperextended.
8. Palpation of the radial artery against the styloid process of the radius with the middle three fingers to find the point of maximal impulse “PMI” is performed.
9. An amount of 0.5cc to 1.0 cc of local anesthetic is injected superficially over the PMI.
10. Two techniques are used to puncture the radial artery to obtain access:-
    • Direct/single wall puncture : same technique used in the femoral approach.
    • Transfixation/ double wall puncture: in which a special kind of puncture needle 18-21 guage is used to puncture the vessel. An indicator at the needle cap would show successful penetration of the artery. Penetrate the other wall of the vessel then withdraw the needle leaving the canula inside the double puncture. Slowly withdraw the canula until a pulsatile flow of blood is noticed.
11. An exchange length 0.035-0.038 inch J-tip guidewire is inserted.
12. A small incision is made to the skin at the entry of the wire to facilitate the sheath insertion.
13. Radial sheath of 23 cm long and 4-6 Fr size should then be introduced.
14. Through sidearm of the sheath, 5000 IU of heparin should be administered.
15. To reduce spasm, 500 mcg of diltiazem can also be administered via the sidearm.
16. Coronary catheters are then advanced along the guidewire into aorta.
17. Left and right coronary arteries are then catheterized using a Judkins, Amplatz or multipurpose catheter.
18. Hemostasis is achieved by direct pressure at the puncture site at the end of the procedure after removal of radial sheath.
19. Radial pulse, and hand circulation should be monitored after the procedure for every 2 hours until discharge.

Radial sheath kits are now available which contain hydrophilic coated sheaths in sizes 4-6 Fr equipped with graduated introducers, various micropuncture needles and guidewires.

Radial Compression Devices are used for hemostasis after the removal of the radial sheath. In the picture below is one example of the devices used.

5. Continuously monitor radial artery pulsation distal to the wrist band, and check pulse oximeter for intact hand circulation.

6. Remove wrist band after 1-2 hours according to patient status.

Below is a video demonstrating radial artery approach in cardiac catheterization followed by application of TR band {{#ev:youtube|XhZroo-_oUA}}

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

1. Radial arterial sheath removal after cardiac catheterization or PCI, or peripheral angiography with or without intervention will be performed by trained personnel
2. Radial sheaths placed by cardiologists must be removed by a trained or supervised Cardiology Fellow or attending. Radial sheaths placed by a vascular surgeon must be removed by a Vascular surgery attending, fellow, PA, NP or trained surgical resident as designated by vascular MD’s.
3. Radial artery sheaths will be removed in the Cardiac Catheterization Laboratory prior to transfer to a medical surgical inpatient unit. A radial artery sheath may be removed in the ICU or VICU setting.
4. This device is placed on the hyper extended wrist and tightened via a Velcro band.
5. A small green box indicates where the band should be placed proximal to the radial percutaneous site. Single wall stick; place the green dot on the TR Band about 3-4 mm proximal to the skin insertion site. Double wall stick; place the green dot just 1 mm or two proximal to the skin insertion site
6. The TR Band inflator syringe is filled with 18 cc of air and slowly injected into the one-way side port which inflates the balloon overlying the radial artery.
7. Concomitantly, the radial sheath is slowly pulled out completely, as the balloon is inflated to the maximum of 18 cc of air.
8. Then slowly, withdraw air back out via the syringe, 1cc at a time, until the operator observes for blood leaking out from the puncture site, at which time, 1 cc of air is re-injected into the balloon and the syringe is disconnected.
9. Keep the plunger in place with your thumb when inflating/deflating the TR band. Releasing the plunger will cause air to expel out of the band to quickly
10. Remember to keep the syringe for later deflation

Application tips to remember:

1. Make sure the radial artery insertion site is 3 or more cm proximal to the wrist crease. If the site and thus the band are too close to the wrist, it may slip if the wrist bends
2. Make sure the site is cleaned with sterile saline and dried completely before the band is placed on the wrist
3. Place the green box proximal to the sheath insertion site(Terumo logo closest to the patients little finger)
4. Pulling the sheath slowly as you are simultaneously inflating the TR Band to 18 cc’s. You should be completely removing the sheath at about the same time you hit 18cc’s.
5. Once all 18cc’s are in the band and the sheath is removed, you slowly about 1cc per second begin reducing the amount of air in the band while visualizing the access site for a blood flash
6. Once you visualize a blood flash you immediately put 1 to 2cc’s back into the band and disconnect the syringe confirming that the blood has ceased.
7. If the air is released slowly out of the band, there is no need for gauze to be positioned under the TR Band. If you are removing the air slowly and at first sight of a blood flash 1 to 2 cc’s is put back into the band you will have a dry field. You want to have complete visualization of the access site, you do not want a gauze pad to block your visualization of the arteriotomy.
8. Also, there is no need to make a skin nick when introducing the sheath (unless completely necessary). The Glidesheath is hydrophilic coated and has a near seamless transition and will not require a nick for insertion. The TR Band is designed to provide the least amount of pressure to gain hemostasis while maintaining flow through both the radial and ulnar arteries. The TR Band is not designed to provide hemostasis for both the arteriotomy of the access site as well as a large skin nick. That is why with the design of both these products a skin nick is not needed and you should never experience a situation in which you would need more than 18cc’s of air, which is occlusive pressure.

TR-Band used to achieve radial artery hemostasis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Ayokunle Olubaniyi, M.B,B.S [2]

Like any other arterial puncture in any part of the body, complications are not uncommon, including radial artery spasms and occlusion, bleeding, radiation exposure, e.t.c. However, these complications can be minimized by the use of appropriate medications, radiation protective devices, and most importantly, by implementing efficient, high-quality, and personalized transradial training programs that educate the entire catheterization laboratory team.^[1]

Radial artery spasm (RAS) remains one of the major limitations of transradial approach for PCI.^[2] The radial artery was demonstrated to have stronger contractions to common vasoactive substances, thus, increasing its propensity to spasm especially in situations of trauma.^[3] The incidence of RAS varies from 12% among high risk patients in whom transfemoral approach was contraindicated^[4] to 22% among patients without prior administration of intra-arterial vasodilators.^[5] The increased incidence in RAS may be due to the small size of radial artery, female gender, long and difficult procedures with multiple catheter exchanges, sheath size, and operator inexperience.^[6]

Some of the measures that have been shown to reduce the incidence and severity of RAS include:

• Generous patient sedation
• Use of spasmolytic cocktails such as verapamil, nitroprusside or combination of both^[7][8][9]
• Use of a hydrophilic sheath of the smallest possible diameter
• Wiping and flushing catheters with solutions containing calcium channel blocker or nitrates
• Using a smaller catheter size
• Use of intra-arterial Papaverine for the treatment of severe arterial spasm^[10]
• Adequate time should be given for the artery to relax before removing catheters or sheaths to prevent arterial evulsion

Although most cases of radial artery occlusion are asymptomatic, cases of hand ischemia have been reported.^[11] As a result of this, coupled with the fact that a persistent RAO could make future access of the ipsilateral radial artery for angioplasty, intra-arterial pressure monitoring, coronary artery bypass surgery, or hemodialysis impossible or difficult, more aggressive measures should be implemented to prevent RAO, especially nowadays where greater than 50% of physicians performing transradial PCI do not routinely evaluate radial arterial patency before discharging their patients.^[12]

According to the Best Practices for Transradial Angiography and Intervention (2013), the evidence-base practices associated with a reduced risk of RAO include:

^aUnfractionated heparin 70 units/Kg up to 5000 units and bivalirudin 0.75 mg/kg bolus followed by 1.75 mg/kg/hr infusion during procedure. ^bThis is the most effective strategy to reduce the risk of RAO^[1][13]

Below are the steps involved in the patent hemostasis process:

Varying degrees and severities of hematomas have been reported. The most common location occurs at the puncture site, but rare cases involving the mediastinum,^[14] mediastinum and neck,^[15] or even the forearm muscle^[12][16] have been reported in association with the transradial approach. A grading system similar to the femoral approach have also been used: Grade 1 (<5cm), grade 2 (<10cm), grade 3 (distal to the elbow) and grade 4 (proximal to the elbow). The independent predictors of bleeding were identified as: creatinine clearance <60 mL/min, procedure duration, and sheath size.^[17]

Bleeding is a common complication of r-PCI which can result into devastating consequences. Compartment syndrome is a limb-threatening surgical emergency which requires a high index of suspicion and timely application of appropriate protocols once local bleeding is suspected such as discontinuation of anticoagulant therapy, pain and blood pressure control, external compression with a blood pressure cuff, close monitoring of distal perfusion of the hand (plethysmography) and consultation to a vascular surgeon is also recommended in cases of limb ischemia.^[18]

Some observational studies have shown that the transradial approach to PCI is associated with an increased radiation exposure in the patient, and especially, the operator.^[19] According to a large study, radial artery catheterization was associated with a 23% increase in radiation exposure when compared with the transfemoral access.^[20] This is largely dependent on operator proficiency. Two studies demonstrated that increasing operator experience with the transradial approach is associated with a lower patient and operator radiation exposure.^[21][22] Some measures which have been shown to reduce exposure to radiation include the use of transradial protection board,^[23] lead-free radiation shield over the right sheath insertion site,^[24] and the use of left radial artery, which is associated with a lower fluoroscopy time and radiation dose compared with the right radial angiography.^[25]

Other complications associated with the transradial approach are listed below:

• Local pain and swelling
• Thrombosis^[26]

• Embolization^[27]
• Infection^[28]
• Pseudoaneurysm^[29]
• Blood loss^[30]
• Limb ischemia
• Arteriovenous fistula
• Cerebral embolization^[31]
• Peripheral neuropathy
• Accelerated atherosclerosis
• Transient vocal cord paralysis
• Delayed reflex sympathetic dystrophy
• Subcutaneous granulomatous reaction (hydrophilic coating) or sheath-associated sterile abscesses

Optical coherence tomography (OCT) has been used by Yonetsu et al to define the damage to the radial artery in 73 arteries of 69 patients ^[32]. 32% of patients developed intimal tears and 16% of patients developed medial dissections. Repeat catheterization was associated with increased fibro-intimal hyperplasia. Cardiac catheterization via the radial approach may render the radial artery unsuitable for coronary artery bypass grafting. There can be a loss of pulse in about 4% of cases. Use of smaller guide catheters and sheathless guides may potentially reduce the risk of these complications.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

The best practices on transradial angiography and intervention is a set of evidence-based recommendations regarding the practice of coronary angiography via access through the radial artery. The Society for Cardiovascular Angiography and Intervention (SCAI), through the radial committee, has come up with recommendation made by consensus with the aim of maximizing the benefits and standardizing certain methods to reduce potential complications in transradial procedures.^[1]

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