DEFINITIONS

Transradial access:

• Entry into the arterial vasculature via the radial artery and proximal to the radial styloid process, typically using ultrasound guidance and the Seldinger technique with sheath placement to maintain intraprocedural access.

Transfemoral access:

• Entry into the arterial vasculature via the common femoral artery is typically achieved with ultrasound guidance and the Seldinger technique, using a sheath to maintain intraprocedural access.

Radial artery access technical success:

• Successful radial artery access and completion of the procedure without crossover to a secondary access site or failure to cannulate the target vessel for diagnosis/intervention.

• Barbeau Test:

• A preprocedural diagnostic evaluation of the patency of the radiopalmar arch in which a pulse oximeter sensor is applied to the thumb, and plethysmography waveforms are recorded before and after 2 minutes of radial artery compressions. Plethysmography waveforms are classified as Barbeau A through D. 

• • A = No change in the pulse tracing with radial artery compression

  • B = Damping of the pulse tracing

  • C = Obliteration of the pulse tracing with recovery in <2 minutes

  • D = Pulse tracing loss without recovery in 2 minutes. 

• Oximetry readings are considered “positive” when the pulse wave is present and constant or “negative” when there is no pulse oximetry reading (50).

Radial artery occlusion:

• Absence of radial artery patency. Defined in the Prevention of Radial Artery Occlusion-Patent Hemostasis Evaluation Trial study by the Barbeau Test performed at 1 day and at 1 month, without the return of an index finger pulse oximetry plethysmographic signal upon release of a radial artery following compression of the radial and ulnar arteries, with loss of plethysmographic signal.

Radial artery pseudoaneurysm:

• Iatrogenic disruption of the integrity of the radial arterial wall. Pressurized arterial blood dissects into the surrounding tissues through the breach in the arterial wall, forming a sac that is perfused by and communicates with the radial arterial lumen.

Radial artery perforation:

• Iatrogenic penetration of the radial artery wall at a site other than the intended access site, and identified by extravasation during radial arteriography.

Radial artery spasm:

• Clinically defined by operator difficulty in maneuvering, inserting, or removing a catheter or sheath, as a result of arterial vasoconstriction, and patient reporting mild to severe pain during the placement of the sheath and/or manipulation of a catheter.

Digital ischemia:

• Insufficient flow of oxygenated blood to the digits with the risk of necrosis and subsequent iatrogenic or autoamputation.

Transradial compression device:

• An inflatable transparent plastic device placed over the access site, designed specifically for achieving post-procedural patent radial artery hemostasis (TR band).

Patent hemostasis:

• Compression of the radial artery for hemostasis with the simultaneous documentation of artery patency.

TECHNICAL CONSIDERATIONS

Pulse Oximeter:

• Always on the ipsilateral thumb or index finger

• Maintain throughout the procedure and during recovery time to monitor for adequate perfusion of the hand

• The wrist should be extended. 

Patient Position:

• In patients who cannot lie supine, prone positioning can be utilized.

Access Side:

• Left-sided access is recommended, except for the right chest, neck, and upper extremity interventions. 

Radiation Protection:

• To reduce operator radiation dose, operator shielding and 45–90 abduction of the access site arm is recommended.

Radial Sheath:

• The diameter of the radial sheath used should be less than the anteroposterior, inner-to-inner wall diameter of the radial artery, and the lowest profile sheath required to successfully perform the procedure should be utilized. 

• Hydrophilic sheaths are preferred, as these have been proven to reduce the incidence of radial artery spasm and pain. 

• If the radial artery diameter is small for the necessary sheath, it is important to check the ulnar artery diameter. If the ulnar artery is dominant at the level of the wrist, the ulnar artery can also be utilized. 

• After sheath placement, medication is administered to prevent vasospasm and clot formation. A combination of nitrates, calcium channel blockers, and heparin is typically used for vasospasm prevention. 

Anticoagulation:

• Peripheral Arterial Disease Procedure: 50–100 units/kg intravenous of unfractionated heparin or comparable enoxaparin or bivalirudin

• Visceral Arterial Procedures: 2000–3000 IU intravenous of unfractionated heparin with an additional 1000 IU at 1 hour for procedures longer than 1 hour 

• A higher initial bolus dose of anticoagulation (bolus of 5000 units or a dose of 100 IU/kg) has been shown to reduce the rate of early radial artery occlusion and should be considered for long or complex procedures and for procedures that typically require exchange or manipulation of the diagnostic catheter, such as in uterine fibroid and prostatic artery embolization.