1. Transradial Best Practices for Radial Access
Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine, University of Illinois at Chicago
Chief, Cardiology, Jesse Brown VA Medical Center
Chicago, Illinois

2. Disclosure Statement of Financial Interest
Within the past 12 months, I have had a financial interest/arrangement or affiliation with the organization(s) listed below.
Grant Support/Research Contract:
Sanofi Aventis
VA Cooperative Study
Consulting Fees/Honoraria/Speakers Bureau:
Merit Medical
St. Jude Medical
Eli Lilly
CSI
Boston Scientific
Equity Interests: None
Royalty Income/Intellectual Property Rights: Merit Medical
Salary/Salary Support/Employee: None

3. Need for Best Practices?
With rapid growth in use of this technique, many practices have developed
Many of these approaches are supported by high-quality evidence, some not so much
Goal is to improve quality and outcomes by promoting those practices with solid base of evidence
Identify area where more work is needed

5. Best Practices Consensus Statement-2014 FOCUS AREAS
Prevention of radial artery occlusion
Reduction of patient and operator radiation exposure
Transitioning to transradial for primary PCI
Catheterization and Cardiovascular Interventions 83:228–236 (2014)

6. Radial Artery Occlusion
Radial artery patency assessed before discharge and at the first post-procedure visit
Catheterization and Cardiovascular Interventions 83:228–236 (2014)

7. Radial Artery Occlusion
Adequate anticoagulation
UFH (at least 50 u/kg or 5,000 units iv/ia)
Bivalirudin for heparin allergic
Catheterization and Cardiovascular Interventions 83:228–236 (2014)

8. Radial Artery Occlusion
Patent hemostasis
Lowest profile equipment
Catheterization and Cardiovascular Interventions 83:228–236 (2014)

9. Radiation Protection Follow routine ALARA practices
Position arm next to torso
Increase TR experience
Use of extension tubing, additional draping
Left radial approach when tortuous anatomy is a consideration (elderly, short stature)
Minimize fluoroscopy for catheter exchanges
Utilization of “low frame” rates or stored fluoroscopic images when feasible
Catheterization and Cardiovascular Interventions 83:228–236 (2014)

10. Radial access for Primary PCI
Demonstrate proficiency with TR-PCI
100 PCI with radial-first approach
Low femoral cross-over rate (<4%)
Consider L radial approach:
LIMA
Risk of tortuous anatomy: >75, <5’5’’ (165cm)
Catheterization and Cardiovascular Interventions 83:228–236 (2014)

11. Systematic use of LRA in Primary PCI Lahey Clinic as a case study
Slide courtesy of Chris Pyne MD
Systematic use of LRA in Primary PCI Lahey Clinic as a case study
Larsen P, et. al. CCI 2010

12. Radial access for Primary PCI
Demonstrate proficiency with TR-PCI
100 PCI with radial-first approach
Low femoral cross-over rate (<4%)
Consider L radial approach:
LIMA
Risk of tortuous anatomy: >75, <5’5’’ (165cm)
Establish time criteria to bailout to contralateral radial or femoral
Catheterization and Cardiovascular Interventions 83:228–236 (2014)

13. Algorithm for transradial primary PCI
Courtesy of SV Rao
Patient presents with STEMI
Administration of dual antiplatelet therapy
Administration of parenteral anti-thrombin therapy
Arrival to cath lab
Radial access
Consider Left Radial Approach if prior CABG,
age ≥ 70 years, height ≤ 5’5”
Diagnostic angiography of non-IRA
Guiding catheter to IRA
PCI of IRA
> 3 min
> 10 min
> 20 min
BAILOUT
Rao SV, et. al. Transradial Best Practices. CCI 2014

14. Radial access for Primary PCI
Demonstrate proficiency with TR-PCI
100 PCI with radial-first approach
Low femoral cross-over rate (<4%)
Consider L radial approach:
LIMA
Risk of tortuous anatomy: >75, <5’5’’ (165cm)
Establish time criteria to bailout to contralateral radial or femoral
Prep femoral access site in case HD support needed
Catheterization and Cardiovascular Interventions 83:228–236 (2014)

15. Future Directions… New topics: Updates: Ultrasound Ulnar access
Routine Allen’s testing
Radiation protections strategies
RAO prevention: Ulnar compression

16. Questions?????
Thank you.