An Ultrasound Survey of the Radial and Ulnar Arteries in an American Population: Implications for Transradial Access.

BACKGROUND: Palpation-guided access of the radial artery (RA) has transradial access (TRA) failure rates averaging 6%-7%. This study aimed to measure RA and ulnar artery (UA) diameters by ultrasound in a typical American population, in hopes of elucidating data that may improve TRA success rates. METHODS: Intraprocedural ultrasound measurements of the RA and UA in 565 consecutive patients undergoing TRA were retrospectively analyzed. RESULTS: The RA is usually larger than the UA, with diameters of 3.0 mm and 2.7 mm, respectively. The UA was larger than the RA in 23% of the population studied, being larger than the RA by ≥20% in 6.5%. Men have larger RAs and UAs than women, with RA/UA diameters of 3.2/2.7 mm and 2.8/2.4 mm, respectively. Body mass index did not correlate with RA diameter. An RA to sheath ratio of <1.0 would have occurred in 6% of men and 16% of women with the use of a 6-Fr slender sheath. The distal RA was 0.5 mm (16%) smaller in diameter than the RA. CONCLUSIONS: The RA is usually larger than the UA and will be the artery of choice for access in most patients. The UA was larger than the RA by ≥20% in 6.5% of patients studied, possibly making it the wrist artery of choice for access in many of these patients. No clinical variables predict RA or UA diameters. Ultrasound may improve TRA success rates by allowing accurate sizing of the RA/UA, thereby preventing inadvertent sheath oversizing causing radial artery spasm and TRA failure.

Real-Time Ultrasound-Guided Venous Access of the Arm for Right Heart Catheterization.

OBJECTIVE: Arterial access from the wrist for cardiac catheterization is increasingly being used. Right heart catheterization (RHC) is an integral part of many of these procedures. Reliable venous access from the arm allows avoidance of femoral or jugular venous access for RHC. It is uncertain if ultrasound guidance offers a benefit for venous access of the arm for RHC. This study sought to assess the efficacy of ultrasound-guided venous access of the arm (UGVAA) for RHC. METHODS: A retrospective study was performed on consecutive patients undergoing RHC at a single institution between August 2015 and July 2016. Baseline data, procedural information, and success rates of UGVAA and RHC were assessed. RESULTS: A total of 266 consecutive RHC procedures were identified, of which 253 (95.1%) were performed via arm venous access; of these, a pre-existing intravenous catheter was used in 3 cases, UGVAA was used in 241 cases, and UGVAA was probably used but not documented in 9 cases. There was 100% success of venous cannulation and sheath placement in these 253 patients. RHC via the arm vein was successful in 248 patients (98.0%) and failed in 5 patients (2.0%). Mean procedure time for RHC via arm access was 5.7 minutes. The femoral approach was used in 12 patients (4.5%). A jugular approach was used in 1 patient (0.4%). All patients had concomitant left heart catheterization via transradial access. CONCLUSIONS: UGVAA is a highly efficacious and safe technique, with a success rate of 98% for RHC in our consecutive series of 253 patients. UGVAA may allow for near-universal use of arm veins for RHC.

Comparison of Hemostasis Times with a Chitosan-Based Hemostatic Pad (Clo-SurPlus Radial™) vs Mechanical Compression (TR Band®) Following Transradial Access: A pilot Study.

BACKGROUND: Hemostasis following transradial arterial access (TRA) is usually achieved by mechanical compression. This study investigated if use of a chitosan-based hemostatic pad (Clo-SurPlus Radial™) combined with mechanical compression (TR Band®) could shorten hemostasis time after TRA, compared with a TR Band® alone. METHODS: 40 patients undergoing cardiac catheterization and/or percutaneous coronary intervention were assigned into 4 cohorts post TRA: 10 patients received mechanical compression with a TR Band® alone for 120 min. The other 30 patients received compression with a Clo-SurPlus Radial™ pad combined with a TR Band® for 60 min, 45 min, and 30 min, respectively (n = 10/per cohort). Times to hemostasis and access-site complications were recorded. RESULTS: There were no differences in patient characteristics, mean dose of heparin, or mean activated clotting time value at the end of procedure among the four cohorts. Median time to hemostasis with the TR Band® alone was 120.5 min versus 60 min, 45 min and 30 min for the 60-min, 45-min, and 30-min Clo-SurPlus Radial™ pad combined with the TR Band® cohorts, respectively. No radial artery occlusion, late rebleeding nor hematoma was noted in this series of patients. CONCLUSIONS: In this pilot trial, use of a Clo-SurPlus Radial™ pad in combination with a TR band® significantly shortened hemostasis time, as compared to a TR band® alone, with no increased complications noted.

A novel technique for simultaneous hemostasis of ipsilateral radial and ulnar artery access sites.

With the increased use of transradial artery access (TRA) for diagnostic and coronary interventional procedures, crossover to the ipsilateral ulnar artery after TRA failure is being reported more frequently. A major challenge with ipsilateral transradial and ulnar artery access is achieving efficient patent hemostasis of both the radial and ulnar arteries at the completion of the procedure. In this report, we describe two cases of failed TRA with subsequent ipsilateral ulnar artery access. A novel and practical technique of simultaneous patent hemostasis of both the ipsilateral radial and ulnar artery access sites is described, using a QuikClot® Radial® hemostasis pad and a TR Band® .

Comparison of Hemostasis Times With a Kaolin-Based Hemostatic Pad (QuikClot Radial) vs Mechanical Compression (TR Band) Following Transradial Access: A Pilot Prospective Study.

BACKGROUND: Hemostasis following transradial access (TRA) is usually achieved by mechanical compression. We investigated use of the QuikClot Radial hemostasis pad (Z-Medica) compared with the TR Band (Terumo Medical) to shorten hemostasis after TRA. METHODS: Thirty patients undergoing TRA coronary angiography and/or percutaneous coronary intervention were randomized into three cohorts post TRA: 10 patients received mechanical compression with the TR Band, 10 patients received 30 min of compression with the QuikClot Radial pad, and 10 patients received 60 min of compression with the QuikClot Radial pad. Times to hemostasis and access-site complications were recorded. Radial artery patency was evaluated 1 hour after hemostasis by the reverse Barbeau's test. RESULTS: There were no differences in patient characteristics, mean dose of heparin (7117 ± 1054 IU), or mean activated clotting time value (210 ± 50 sec) at the end of procedure among the three groups. Successful hemostasis was achieved in 100% of patients with both the 30-min and 60-min compression groups using the QuikClot pad. Hemostasis failure occurred in 50% of patients when the TR Band was initially weaned at the protocol-driven time (40 min after sheath removal). Mean compression time for hemostasis with the TR Band was 149.4 min compared with 30.7 min and 60.9 min for the 30-min and 60-min QuikClot groups, respectively. No radial artery occlusion occurred in any subject at the end of the study. CONCLUSIONS: Use of the QuikClot Radial pad following TRA in this pilot trial significantly shortened hemostasis times when compared with the TR Band, with no increased complications noted.

Real Time Intraprocedural Ultrasound Measurements of the Radial and Ulnar Arteries in 565 Consecutive Patients Undergoing Cardiac Catheterization and/or Percutaneous Coronary Intervention via the Wrist: Understanding Anatomy and Anomalies May Improve Access Success.

OBJECTIVES: Ultrasound evaluation of both the radial artery (RA) and ulnar artery (UA) in patients undergoing cardiac catheterization/percutaneous coronary intervention. BACKGROUND: Arterial access from the wrist is almost exclusively obtained from the RA. Crossover to secondary femoral arterial access was observed in up to 7.6% in randomized multicenter trials utilizing palpation guided RA access. METHODS: Intraprocedural ultrasound evaluation of the RA and UA was performed in a consecutive series of patients. A difference of ≥20% in diameter was defined as significant. In the case of a dual artery, measurements of the dual arteries and the proximal confluens were obtained. RESULTS: A total of 566 RA/UA measurements were analysed (patients: n = 565, female: n = 201 [35.5%], mean age: 66.5 years). Overall, the RA measured 3.03 ± 0.57 mm and the UA 2.70 ± 0.57 mm (P < 0.01). The RA was larger in 210 (37.1%) and the UA in 37 (6.5%) measurements. A dual RA was present in 25 (4.4%) measurements. The mean diameters of the smaller and larger of the dual RAs were 1.82 ± 0.37 and 2.59 ± 0.36 mm (P < 0.01). The corresponding proximal confluens measured 3.10 ± 0.40 mm. No dual UA was observed. CONCLUSION: In 10.9 % of patients, a larger UA or a dual RA with a more accessible confluens was observed. This information can only be obtained using ultrasound and may improve arterial access from the wrist if the larger UA or RA confluens is accessed instead of blind palpation guided RA access.

Evolving Techniques to Improve Radial/Ulnar Artery Access: Crossover Rate of 0.3% in 1,000 Consecutive Patients Undergoing Cardiac Catheterization and/or Percutaneous Coronary Intervention via the Wrist.

OBJECTIVES: To evaluate several techniques to reduce crossover rates in wrist artery access in patients undergoing cardiac catheterization (CC)/percutaneous coronary intervention (PCI). BACKGROUND: Palpation-guided radial artery (RA) access for CC/PCI is associated with a crossover rate to femoral artery (FA) access in up to 7.6%. METHODS: A retrospective analysis of a single-center consecutive series of patients undergoing CC/PCI was performed. After one 0.4 mg sublingual NTG tablet, the RA and UA were assessed by intraprocedural ultrasound imaging to select the more suitable artery for ultrasound-guided access. A tight "knuckle wire" technique using a 0.014 inch Prowater® coronary wire was used to negotiate RA, UA, and brachial loops when a standard wire would not easily cross. Crossover was defined as any reason requiring secondary arterial access from the contralateral arm or FA. RESULTS: A total of 1,162 consecutive patients treated from January 2012 to April 2014 were evaluated. Primary arterial access from the wrist (RA/UA) was performed in 1,000 (86.1%, RA: 977, UA 23) and planned FA access in 162 patients (13.9%). The overall crossover rate from the wrist was 0.3% as a result of 3/1,000 patients requiring crossover to the contralateral arm (radial loop: n = 1, brachial loop: n = 1, vessel injury: n = 1). No crossover to the FA was necessary. All primary FA access sites were successful. CONCLUSIONS: Crossover rates of primary wrist artery access to alternative arterial access for CC/PCI can be reduced to less than 1% applying the aforementioned techniques.

Radioprotective lightweight caps in the interventional cardiology setting: a randomised controlled trial (PROTECT).

AIMS: The aim of this study was to test the radioprotection efficacy and comfort of newer bilayer barium sulphate-bismuth oxide composite (XPF) caps in an interventional cardiology setting. METHODS AND RESULTS: Operators were randomly assigned to wear standard fabric (n=59), 0.3 mm (n=74), or 0.5 mm (n=64) lead-equivalent XPF caps. Radiation doses were measured by using dosimeters placed outside and underneath the caps. Wearing comfort was assessed at the end of each measurement on a visual analogue scale (VAS) (0-100, with 100 indicating optimal comfort). Procedural data did not differ between the XPF and standard groups. Mean standard, XPF 0.3 mm, and XPF 0.5 mm cap weights were 12.5 g, 118.4 g, and 123.7 g, respectively. VAS comfort ratings of the standard and XPF caps did not differ significantly (p=0.272). The mean radiation protection was 12.0%, 95% CI: 4.9-19.1% (standard caps, n=35), 91.5%, 95% CI: 87.4-95.6% (XPF 0.3 mm caps, n=45) and 97.1%, 95% CI: 92.5-100% (XPF 0.5 mm caps, n=44) (p≤0.001 for all group comparisons). Using the XPF caps, a cumulative total radiation dose reduction by almost factor 10 was evident (272 procedures, 22,310 µSv outside the XPF caps, 2,770 µSv inside the caps). CONCLUSIONS: Lightweight XPF caps show comparable comfort to standard fabric caps, but provide substantial radiation protection during fluoroscopy-guided cardiac interventions.

Real-time ultrasound guidance facilitates transradial access: RAUST (Radial Artery access with Ultrasound Trial).

OBJECTIVES: This study sought to assess the utility of ultrasound (US) guidance for transradial arterial access. BACKGROUND: US guidance has been demonstrated to facilitate vascular access, but has not been tested in a multicenter randomized fashion for transradial cardiac catheterization. METHODS: We conducted a prospective multicenter randomized controlled trial of 698 patients undergoing transradial cardiac catheterization. Patients were randomized to needle insertion with either palpation or real-time US guidance (351 palpation, 347 US). Primary endpoints were the number of forward attempts required for access, first-pass success rate, and time to access. RESULTS: The number of attempts was reduced with US guidance [mean: 1.65 ± 1.2 vs. 3.05 ± 3.4, p < 0.0001; median: 1 (interquartile range [IQR]: 1 to 2) vs. 2 (1 to 3), p < 0.0001] and the first-pass success rate improved (64.8% vs. 43.9%, p < 0.0001). The time to access was reduced (88 ± 78 s vs. 108 ± 112 s, p = 0.006; median: 64 [IQR: 45 to 94] s vs. 74 [IQR: 49 to 120] s, p = 0.01). Ten patients in the control group required crossover to US guidance after 5 min of failed palpation attempts with 8 of 10 (80%) having successful sheath insertion with US. The number of difficult access procedures was decreased with US guidance (2.4% vs. 18.6% for ≥5 attempts, p < 0.001; 3.7% vs. 6.8% for ≥5min, p = 0.07). No significant differences were observed in the rate of operator-reported spasm, patient pain scores following the procedure, or bleeding complications. CONCLUSIONS: Ultrasound guidance improves the success and efficiency of radial artery cannulation in patients presenting for transradial catheterization. (Radial Artery Access With Ultrasound Trial [RAUST]; NCT01605292).