How to set up a trans-radial approach programme? Patient selection, learning curve, anatomic variations... Dr. med. Helmut Heinze Vivantes Klinikum Neukölln Rudower Str. 48, 12351 Berlin Email: [email protected] If you are an Interventional Cardiologist - we want you to join the TRI- Team! Coronary procedures 2010: USA: less than 10 % radial China: more than 60 % radial Our hospital: 65 % radial Patient selection • Get experience with femoral 5F Interventions • Start with Age 50-75 y Patient selection Avoid : • time critical patients (STEMI) • repeat access to the same vessel • patients with renal insufficiency • Vasculitis, Raynaud syndrome, Carpal tunnel syndrome • Thoracic abnormalities Prefer : • Obese patients ! • LIMA- grafts: easy with left radial access Be careful: • patients with peripheral / aortic disease often have tortuous subclavian arteries Preparations and Considerations Allen Test forearm angio < 5 % necessary Easier access radial! Reasons for Failure of Transradial Approach • • • • • • Radial artery puncture failure Arterial loops or atypical vessels Radial artery spasm Tortuous Subclavian Arteries (prevalence ~ 10%) Atypical coronary ostiums Not enough backup for intervention with 6F • Radial access will make your interventions easier, but sometimes femoral access can easily overcome inadequate radial problems. Peripheral and aortic disease Easy radial access Difficult femoral access Access is usually very easy and fast! 2ml Lidocain 2% not too close to the wrist ! Usually no scalpel needed Use short (8cm) specially designed transradial sheath Radial Spasm after Nitro 200 µg ia More common in younger women and less sick patients, typical for „ruleouts“ Often sedation is helpful Difficult artery Difficult access to Aorta ascendens Access to Aorta ascendens LAO ~ 45 ° JR Deep breath Sometimes hydrophilic wire helpful Use 180 cm 0.035 J- wire for easier catheter exchange Keep the tip of the wire in the aortic root for catheter exchange Theory True in ~90% of cases Access to LCA usually very easy with JL 3,5 (right) or JL 4.0 (left) RAO 30° or LAO 45° Access to RCA usually more challenging Try ccw rotation LAO 40- 50° Real Life Stop Check for alternatives Only for very experienced toughies Reasons for Failure of Transradial Approach • Radial artery puncture failure (more often in repeat • • • • • access) Arterial loops or atypical vessels (don‘t try again, other side often same problem, ulnar possible?) Radial artery spasm Tortuous Subclavian Arteries (prevalence ~ 10%) • Right or Left • often possible with more experience, don‘t wait to long to change access site Atypical coronary ostiums (have different catheters available) Not enough backup for intervention with 6F • Mother and Child catheters, 5 in 6 Fr, deep engagement, use EBU- catheters Guide Catheter Selection Size: 3.0 3.5 3.75 4.0 Size: 5 Catheter selection (>95% of cases) RCA LCA SVG • Diagnostic catheters: • Guiding catheters: • • • • • • • • • • • • • • • • • • • JR4, JR5, AL 0.75, AL 1, AL 2 AR mod, AR2 3DRC TIG II JL3.5 JL4 JR5 AL1 MP JR5 XBRCA ~ RBU AL 0.75, AL1 Extra Backup 3.5 Extra Backup 3.75 Extra Backup 4.0 JR5 AL1 MP • Guideliner Left or Right? Left Radialist Right Radialist Left or Right? Both! Cardiogenic Shock in Anterior MI Severe peripheral arteriopathy Anterior MI, right radial approach Cardiogenic Shock in Anterior MI No problems after IABP Result Hemostasis Radistop TR Band Similar Procedure Times. Higher Access Failures With TRA Hetherington et al. Heart Online, July 2009 Interventional Cardiologists handshake Don’t call yourseIf Interventional Cardiologist if you are not in the TRI- Team!