Schussler JM and Rao SV 2014

Radial Artery Angiography
and Complications
Jeffrey M. Schussler, MD, FACC, FSCAI
Sunil V. Rao, MD, FACC, FSCAI

Disclosures
• Schussler – no financial disclosures
• Rao –
– Consultant
• The Medicines Company
• Astra Zeneca
– Speaker
• The Medicines Company
• Medtronic
– Research Funding
• Ikaria
All faculty disclosures are available on the CRF
Events App and online at www.crf.org/tct

Question 1
You wish to perform left heart catheterization
through the radial approach. In evaluating a
patient prior to the procedure, you occlude the
ulnar and radial arteries, allow the hand to
blanch and then release the ulnar artery:
Within 5 seconds the hand is normal in color.
A) This is a “positive” Allen’s test (normal)
B) This is a “negative Allen’s test
C) You should have used plethysmography

Question 1
Allen’s Test
Allen’s Test: Positive when
reperfusion occurs <10
seconds (<5 seconds is
best) after occlusion of
radial and ulnar artery, then
releasing the ulnar.
Barbeau: Plethysmography
after radial occlusion only.

Question 2
A patient’s Allen’s test is negative (good
radial pulse, but weak collateral
circulation). A radial approach is really ideal
(severe PVD). You elect to perform radial
artery angiography anyway. This is:
A) Not a good idea – find a lawyer
B) Reasonable – risk of radial artery
occlusion is low anyway
C) Why are you doing Allen’s tests
anyway?

Question 2
In 1,000 patients scheduled for cath, the relative
percentages of a clearly positive (< 5 sec), moderately
positive (between 5-9 sec), or negative
modified Allen's test (10 sec and more) is 49%,
24%, and 27%
Cathet Cardiovasc Diagn. 1996 Aug;38(4):352-4.
The reliability of the Allen’s test has been called into
question. Some studies suggest that abnormal Allen’s
test precludes the use of transradial access in patients
with abnormal Allen’s test
J Am Coll Cardiol. 2005;46:2013-2017.

Question 3
A 56 year old woman is sent to see you for left heart
catheterization. Her BMI is 40, and she has concerns
about the bleeding risks of heart catheterization.
Asking about the radial approach, you tell her that:
A) Radial artery access success is significantly
lower compared with the femoral approach
B) Bleeding rates are lower when compared to
femoral access
C) PCI success rates are significantly less than the
femoral approach.

Question 3
Ten thousand six hundred seventy-six procedures
were performed using radial approach:
Major VCs occurred in 16 patients only (0.2%) and
were radial related in 10 (62.5%) and nonradial
related in 6 (37.5%) patients.
Access crossover rate was 4.9%, differed according
to the operator radial experience and significantly
decreased over time.
Burzotta F, Trani C, Mazzari MA, Tommasino A, Niccoli G, Porto I, et al.
Vascular complications and access crossover in 10,676 transradial
percutaneous coronary procedures. Am Heart J. 2012;163:230-238.

Question 3
Association between vascular access site for PCI and complications
Rao et a. JACC Vol. 55, No. 20, 2010
May 18, 2010:2187–95

Question 4
The types of sheaths which may reduce radial
artery spasm include:
A) Long sheaths
B) Hydrophilic sheaths
C) Non-hydrophilic sheaths
D) Sheaths with a ratio of 1:1 with the radial
artery

Question 4
The types of sheaths which may reduce radial
artery spasm include:
A) Long sheaths
B) Hydrophilic sheaths
C) Non-hydrophilic sheaths
D) Sheaths with a ratio of 1:1 with the radial
artery
JACC Cardiovasc Interv 2010;3(5):475–483.
Int J Cardiol. 2004;96:255-258.

Question 4
Circulation: Cardiovascular Interventions February 2012 vol. 5 no. 1 127-133
Circulation: Cardiovascular Interventions
February 2012 vol. 5 no. 1 127-133

Question 5
Medication which is typically used at
the time of sheath insertion to prevent
spasm includes
A) verapamil
B) nitroglycerine
C) nicardipine
D) All of the above

Question 5
A) Verapamil – 5 mg – watch out
for negative inotropic effects
(also burns)
B) Nitroglycerine – 100 mcg – can
cause hypotension
C) Nicardipine – 100-500 mcg –
expensive

Question 6
Predictors of radial artery spasm include:
A) Age < 60
B) Recent use of nitrates
C) Female
D) History of smoking

Question 6
Several factors are associated as an
independent predictor of radial artery
spasm including age > 65,
hypertension, female sex (strongest
association), but surprisingly history of
smoking was not independently
associated with radial artery spasm.
J Interv Cardiol 2013 Apr;26(2):208-13

Question 7
In meta-analyses of transradial compared
with transfemoral access for coronary PCI,
there is a consistent and statistically
significant reduction of:
A) MI
B) Cardiovascular mortality
C) All cause mortality
D) Bleeding

Question 7
76 studies involving a total of 761,919 patients
comparing TRA with TFA
TRA was associated with a 78% reduction in
bleeding (OR 0.22) and 80% in transfusions
(OR 0.20)
These findings were consistent in both
randomized and observational studies.
Bertrand OF, Belisle P, Joyal D, Costerousse O, Rao SV, Jolly SS, et al. Comparison of
transradial and femoral approaches for percutaneous coronary interventions: a systematic
review and hierarchical Bayesian meta-analysis. Am Heart J. 2012;163:632-648

Question 8
As a routine part of transradial coronary,
the following is given to prevent radial
artery thrombosis:
A) Heparin
B) Warfarin
C) Aspirin
D) Clopidogrel

Question 8
• Anticoagulation
• Historically, heparin as high as 7000 units have been
given, with reduction of thrombosis with higher doses.
• Early evidence (non-randomized) was found in studies
in which the rate of RAO was as high as 71% of
patients receiving no heparin, 24% of patients
receiving 2000–3000 U of heparin, and 4.3% of
patients receiving 5000 U of heparin (P<0.05)
• Typically transradial operators administer between
2000–5000 U of heparin.
• Heparin can be given intravenously or through the
arterial sheath, and does not have an impact on RAO.
Caputo et al - CCI Core Curriculum 2011

Question 9
You plan to perform transradial angiography, and after
achieving access, you want to give anti-coagulation with
heparin. Which of the following statements is true?
A) A dose of 2,000 u is enough to prevent thrombosis of
the radial artery for transradial procedures
B) A dose of 5,000 u is enough to prevent thrombosis of
the radial artery for transradial procedures
C) Heparin is not necessary for transradial procedures as
long as you’re quick

Question 9
• Transradial operators administer between 2000 –5000U of
heparin, although practice patterns vary and approxi-
mately 5% of operators give no heparin at all.
• Whether the heparin is given intravenously or through the
arterial sheath does not have an impact on RAO
• Schiano et al randomly assigned 162 patients to 5000 U
of heparin versus 50 U/kg with an upper limit of 5000 U.
• No RAO was ob-served in either group, but compression
time was shorter in the weight-adjusted group (204.5 minutes
versus 235.5 minutes,P0.00001).
• Another study randomly assigned patients to 2000 U versus
5000 U of heparin and found that there was a trend toward
increased RAO in the very-low-dose group, although it
was not statistically significant (5.9% versus 2.9%,P0.17).
JACC Vol. 55, No. 20, 2010
May 18, 2010:2187–95

Question 10
The concept of patent hemostasis, with regards to post-
transradial sheath removal and management refers to the
concept of :
A) Permitting antegrade flow through the radial artery after
sheath removal
B) Allowing a small amount of bleeding to occur after
sheath removal
C) Manual compression
D) Use of pressure bands (e.g. TR band, Vasc band, etc)

Question 10
The Prevention of Radial Artery Occlusion-Patent Hemostasis
Evaluation Trial (PROPHET) patients were randomly assigned to
conventional pressure application versus compression guided by pulse
oximetry .
The intervention group had significantly less RAO than the control
group, both at 24 hours (5% versus 12%, P<0.05) and at 1 month
(1.8% versus 7.0%, P<0.05).
-------------------------------
The Radial Compression Guided by Mean Artery Pressure Versus
Standard Compression with a Pneumatic Device Trial (RACOMAP)
tested the concept using the TR band: Patients were randomly
assigned to compression guided by mean arterial pressure versus a
control group that received a standard 15 cc of air in the bladder.
This intervention led to a 10-fold reduction in the rate of RAO
(1.2% versus 12.0%,P=0.0001).

Question 11
You did all the right things (heparin, verapamil, patent
hemostasis). The angioplasty went fine. At the 30 day follow
up, you feel for the patient’s right radial pulse, and it’s
absent.
The next step is:
A) Call vascular surgery for a consult
B) Bring them to the cath lab to try retrograde recanalization
C) Do nothing

Question 11
• 5% occlusion
rate (old data)
• About 2/3
recanalize
spontaneously
• Rare to even
be
symptomatic

Question 12
You plan on stenting the lesion in the patient
shown. They had been loaded with clopidogrel
prior to the cath. You gave 2500 u of heparin as
part of the diagnostic angiogram. In order to safely
proceed with the intervention, you now:
A) Add integrillin
B) Give weight based bivalirudin
C) No further medication needed
D) Defer procedure until tomorrow

Question 12
There are several strategies for the timing of anti-coagulation
for diagnostic / interventional procedures through the radial
approach:
• Higher doses of heparin (~5,000 u) tend to reduce RAO
• This can be given through the arterial sheath, or
peripherally
• Heparin can be given at the beginning of the procedure or
prior to sheath removal, without a difference in the risk of
RAO
• Bivalirudin seems to work as well as heparin. It can be
given instead of heparin if PCI is definitely planned, but
also ad-hoc seems to be a reasonable strategy and is safe.
Use of Low-Dose Heparin with Bivalirudin for Ad-hoc
Transradial Coronary Interventions: Experience from a
Single Center JIC Volume 23 - Issue 3 - March, 2011

Question 13
You have no difficulty inserting the radial sheath in a patient for
angiography, but then the J-wire will not pass. You perform a sheath
angiogram and find the following:

Question 13
This finding:
A) Is not uncommon, can reduce successful
completion of radial procedures
B) Is dangerous to cross, and alternate
access sites should be tried
C) Needs surgical evaluation and treatment
D) None of the above

Question 13
Anomalous radial artery anatomy is relatively common and is a cause
of procedural failure.
In one study, 1540 consecutive patients were studied. The overall
incidence of radial artery anomalies was 13.8% (n = 212). 108 (7.0%)
patients had a high-bifurcating radial origin, 35 (2.3%) had a full radial
loop, 30 (2.0%) had extreme radial artery tortuosity and 39 (2.5%) had
miscellaneous anomalies such as radial atherosclerosis and accessory
branches.
Overall transradial procedural success was 96.8%. Procedural failure
was more common in patients with anomalous anatomy than in patients
with normal anatomy (14.2% vs 0.9%, p<0.001).
Procedural failure in patients with high radial bifurcation, radial loop,
severe radial tortuosity and other anomalies was 4.6%, 37.1%, 23.3%
and 12.9%, respectively.
Heart. 2009 Mar;95(5):410-5.

Question 14
You have some difficulty
manipulating your diagnostic
catheters, and perform upper
extremity angiography.
The finding in this picture is:
A)Accessory radial artery
B)Anomalous radial artery origin
C)Bifurcating brachial artery
D)AV fistula

Question 15
You’ve accessed
the right radial
artery for coronary
angiography, and
every time you try to
move into the
ascending aorta,
this happens:

Question 15
The appropriate next step is
A) Proceed with cath through the
current access
B) Switch to femoral
C) Call vascular for a consultation

Question 16
You are planning on performing LHC
through a transradial approach in an 85
year old woman. After inserting the
sheath, you have difficulty passing the
J wire past the elbow.
You perform radial artery sheath
angiography.

Question 16
Your next appropriate step is:
A) Access from the femoral approach
B) External compression
C) Insert a 3.0 x 20 mm coronary
balloon and inflate for 2 minutes
D) Vascular surgery consultation

Question 16
Perforations of the radial artery can occur due to tortuosity, spasm, upon
introducing the j-wire, or changing for guiding catheters.
If heparin has been given, reversal agents can be given, but typically external
compression at the level of the perforation can prevent continued
extravasation.
In our case, a vascular surgeon was consulted, and felt that conservative
management (i.e. no surgery) was fine. His quote to me was that “The forearm
is very forgiving.”
You do need to monitor to make sure that there is no compartment syndrome,
but generally compression and expectant management will work.
Other cases in the literature support this type of treatment .
Türk Kardiyol Dern Arş – Arch Turk
Soc Cardiol 2013; 41:332-335

Question 17
You have a patient with previous CAB x 3
including LIMA to the LAD. In order to more
easily perform complete graft angiography
through a radial approach, you need to:
A) Use femoral approach
B) Right radial approach, using LIMA
cathether to engage L subclavian
C) Left radial approach

Question 17
In patients who had previously undergone CABG surgery,
transradial diagnostic coronary angiography was
associated with greater contrast use, longer procedure
time, and greater access crossover and operator radiation
exposure compared with transfemoral angiography.

Final Thoughts
• Spasm
• Thrombosis
• Damage / Dissection /
Perforation (rare)
• Tortuosity / Anomalies

Schussler JM and Rao SV 2014

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