Best practices for transradial angiography and intervention
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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]
Overview
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]
Recommendations
Monitoring for and Reducing the Risk of Radial Artery Occlusion
| “ | 1. Patients undergoing transradial procedures should have radial artery patency assessed before discharge and at the first postprocedure visit.
2. Adequate anticoagulation should be administered to patients undergoing diagnostic transradial procedures. The recommended regimen is intra-arterial or intravenous unfractionated heparin at a dose of at least 50 u/kg or 5,000 units in patients without contraindications to unfractionated heparin. Patients with heparin-induced thrombocytopenia with or without thrombosis should receive intravenous bivalirudin 0.75 mg/kg bolus for diagnostic cases; for PCI, this bolus dose of bivalirudin should be followed by an infusion of 1.75 mg/kg/hr. 3. Transradial procedures should be performed using the lowest profile system available to successfully complete the procedure and obtain optimal angiography. 4. Patent hemostasis technique should be used in all patients who undergo transradial procedures. |
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Reducing Patient and Operator Radiation Exposure
| “ | 1. In addition to following SCAI recommendations for minimizing radiation exposure, operators performing transradial procedures should position the patient’s accessed arm next to the patient’s torso.
2. There is a relationship between radial proficiency and a decrease in patient and operator radiation exposure such that exposure between radial and femoral is comparable among experienced radial operators. Thus, operators should make an effort to maintain a high proportion of transradial procedures in their practice. 3. The use of extension tubing to increase the distance from the radiation source should be considered for transradial procedures. 4. Left radial approach has been associated with shorter fluoroscopy times and should be considered in patients where tortuous vascular anatomy is expected (e.g., age>75 years, short stature). 5. Operators should avoid fluoroscopically tracking the guidewire and/or catheters while traversing the arm unless resistance is felt. 6. Catheter exchanges should be performed without fluoroscopy whenever possible. 7. Documentation of angioplasty balloon and stent positioning should be done using “fluoro save” if available. |
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Transitioning to Transradial Primary PCI
| “ | 1. Operators and sites should not start performing transradial primary PCI until they have performed at least 100 elective PCI cases with a “radial first” approach and their femoral crossover rate is >4%.
2. An a priori left radial approach should be strongly considered in patients undergoing transradial primary PCI who are post-CABG with a pedicle LIMA graft. 3. An a priori left radial approach should be considered in patients undergoing transradial primary PCI who are older than age 75 years or who are 5'5" (165 cm) or shorter. 4. Bailout to either contralateral radial or femoral access is recommended if the time to obtain radial access is >3 min, or the time from introducer sheath placement in the radial artery to engaging the infarct-related artery with the guide catheter is >10 min (including the time to inject the non-infarct artery), or the total time from radial artery introducer sheath placement to dilating the infarct lesion is >20 min. 5. Door-to-balloon times should be monitored closely when starting a transradial primary PCI program and cases with times that extend beyond recommended benchmarks should be reviewed to identify whether the radial approach was responsible for the delay. 6. Femoral access sites should be prepared routinely in patients with STEMI when the operator is early in their experience with transradial primary PCI or when the need for adjunctive devices like intra-aortic balloon counterpulsation is anticipated. |
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References
- ↑ Rao, SV.; Tremmel, JA.; Gilchrist, IC.; Shah, PB.; Gulati, R.; Shroff, AR.; Crisco, V.; Woody, W.; Zoghbi, G. (2013). "Best practices for transradial angiography and intervention: A consensus statement from the society for cardiovascular angiography and intervention's transradial working group". Catheter Cardiovasc Interv. doi:10.1002/ccd.25209. PMID 24123781. Unknown parameter
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