Ultrasound can help with planning and obtaining radial artery access for cardiovascular procedures. Planning ultrasound examines artery size and anatomy to select the optimal access site and sheath size, reducing fluoroscopy time. Ultrasound guided access improves first stick success rates and reduces average access time compared to palpation or blind access techniques. Meta-analyses show ultrasound guidance significantly increases the chance of successful first attempt radial artery access. While radial angiography provides information if access fails, ultrasound is preferable for access planning and guidance due to reduced pain, contrast, and radiation compared to angiography.

1. Predicting Radial Access
Success: Role of Ultrasound and
Routine Radial Arteriography
Ian C Gilchrist, MD, FSCAI
Professor of Medicine
Pennsylvania State University
Heart & Vascular Institute
Hershey, PA

3. Question: Do you use Ultrasound
Routinely to Plan or Obtain Radial
Access?
} A – Never
} B – Rarely (<1 out of 10 cases)
} C – Sometimes (up to 50%)
} D – Always (>50% of cases)

4. SCAI 2013
Why Image at All?
Loops
(2.3%)
Tortuosity
(2.0%)
Anatomic Variation(*)
(7.0%)
1540 patients, 96.8% success, high-volume radial operators, United Kingdom
Anatomic issues associated with >3/4 of procedural failures
Lo, Nolan et al, Heart 2009;95:410-415. * J Invasive Cardiol 2010;22:536–540

5. SCAI 2013
Angiography
Best for when the wire won’t go,
“What to I do now?”
Quickly gives the big picture
Can’t be used prior to access
Contrast potentially toxic & painful

6. SCAI 2013
Ultrasound
Planning Access
Obtaining Access

7. SCAI 2013
Planning Ultrasound
Sheath Sizing
Identify
Optimal Arm
for Access
//pie.med.utoronto.ca/OBAnesthesia/OBAnesthesia
Define lumen size
Identify potential anatomic variants and loops
Ultrasonic Assessment
Radial, Ulnar & Antecubital region

8. SCAI 2013
Outcomes ± Planning Ultrasound
No Ultrasound
(n=643 PCI)
Ultrasound
(n=570 PCI)
Fluroscopy Time:
Ultrasound = 12.5 ± 5.3 minutes
No Ultrasound = 24.1 ± 7.5 minutes (P<.001)
0%
2%
4%
6%
8%
10%
12%
14%
Spasm
Crossover
Failure
2% 2%
2%
12%
8%
10%
Percent
Chugh et al. PRIMAFACIE-TRI. Catheterization and Cardiovascular Interventions. online: 26 FEB 2013.
Spasm, Crossover and Procedural Failure
P<.001
P<.01
P<.001

9. SCAI 2013
Access Ultrasound
//pie.med.utoronto.ca/OBAnesthesia/OBAnesthesia
Real-time observation of artery
& access needle entry
Set up
Identification
Needle Entry

10. SCAI 2013
Ultrasound Guided Radial Access
0%
20%
40%
60%
80%
100%
Ultrasound
Double-Wall
Single Wall
35 [31-55] secs
78 ± 38 secs
134 ± 88 secs
Roberts et al, TCT2012 Abstract 395, also Cardiac Interventions Today 2013;7(2)39-44.
Pancholy et al. Catheter Cardiovasc Interv. 2012;80(2):288-91.
Ultrasound (Roberts) vs Double/Single Wall Access (Pancholy)
Success
1st Stick
Average Time to Access

11. SCAI 2013
Ultrasound Guided Radial Access
Study
Levin (n=69) 2003
Shiver (n=60) 2006
Shwemmer (n=30) 2006
Ganesh (n=152) 2009
Total (95% CI)
Risk Ratio
M-H, Random, 95% CI
0.01 0.1 1 10 100
Favors Palpation Favors Ultrasound
Meta-analysis: Association of Ultrasound-Guided
Access with 1st Attempt Access Success
Shilok, et al. Chest 2011;139:524–529.
Levin et al. Crit Care Med 2003;31:481-484.
Schwemmer et al. Eur J Anaesthesiol 2006;23:476-480.
Shiver et al. Acad Emerg Med 2006;13:1275-1279.
Ganesh et al. Pediatr Crit Care Med 2009;10:45-48.

12. SCAI 2013
Routine Ultrasound & Radial
Angiography?
“That it will ever come into general use, not
withstanding its value, is extremely doubtful; because
its beneficial application requires much time and gives
a good bit of trouble both to the patient and the
practitioner; because its hue and character are
foreign and opposed to all our habits and
associations.”
John Forbes
The London Medical and Physical Journal, 1822;47(275): p142.

13. SCAI 2013
The End
Thank you