`
`Grossman & Baim’s
`Cardiac Catheterization,
`Angiography,
`and Intervention
`
`EIGHTH EDITION
`
`EDITOR
`
`MAURO MOSCUCCI, MD, MBA
`Professor of Medicine
`
`Chairman, Department of Medicine (Acting)
`Chief, Cardiovaecular Division
`
`University of Miami Miller School of Medicine
`Miami. Florida
`
`a. Wolters Kluwer Lippincott Williams & Wilkins
`Health
`Philadelphia - Baltimore - New York - London
`Buenos Aires - Hong Kong - Sydney ‘ Tokyo
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`filh edition © 2000 by LiPPINCOTT WILLIAMS iSt: WILKINE
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`
`Library of Congress Cataloging-in-Publicatiun Data
`Cardiac eatheterization. angiography, and intervention
`Gross-man Sr Bairnls cardiac catheterization. angiography. and intervention] editor. Mauro Moscueet. MD, MBA,
`omit-55m of medicine. chairman. Department of Medicine. University of Miami Miller School of Medicine. Miami.
`Florida. -—- Elghth edition.
`P53” cm
`includes bibliographical references. and index.
`iSEN 973—1-451142740—9 (hardback)
`
`i. Moscucci. Mauro. editor or compilation. it. Title. ili. Title: Grossrnan
`1. Cardiac catheteriza lion. 2‘ Angtography.
`and Eaim's cardiac catheterization. angiography. and intervention.
`RCEB35iC25C3Ei 2013
`616.]‘20734—dc23
`
`2013025399
`—-—————_.—_______—__________
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`Care has been taken to confirm the accuracy of the information presented and to dacrihe generally accepted
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`quences from application oi the information in this hook and make no warranty. expressed or implied. with respect
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`particular situation remains the professional responsibility of the practitioner.
`The authors. editors. and publisher have exerted every effort to ensure that drugsciection and dosage set forth in
`this text are in accordance with current recommendations and practice at the time oipublication, However. in view of
`ongoing research. changes in government regulations. and the constant flow of information relating to drug therapy
`and drug TCECUDHS. Iht I‘tadfir is Uffieii to Check the package insert [or each tirug for any change in indications and
`dosage and for added warnings and pretautions, This is particularly important when the recommended agent is a
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`
`Contributors
`
`vii
`
`Preface to the Eighth Edition
`
`xi
`
`Preface to the Website to the Eighth Edition
`Acknowledgments xv
`
`xiii
`
`1. Cardiac Catheterization History and Current Practice Standards
`Mauro Moscucci
`
`1
`
`1
`
`2. Cineangiographic imaging, Radiation Safety, and Contrast Agents
`Stephen Halter and li/lauro Moscucci
`Integrated Imaging Modalities in the Cardiac Catheterization Laboratory 44
`Robert/fl. Ouaife and John D. Carroll
`
`17
`
`3.
`
` SECTION I GENERAL PRINCIPLES
`
`SECTION III HEMODYNAMIC PRINCIPLES
`10. Pressure Measurement 223
`Mauro Moscucci and William Grossman
`11. Blood Flow Measurement: Cardiac Output and Vascular Resistance
`Mauro Moscuccl and William Grossman
`12. Shunt Detection and Quantification 261
`William Grossman and Mauro Moscucci
`13. Calculation of Stenotic Valve Orifice Area
`BlaseA. Carabello and William Grossman
`
`4. Complications
`Mauro Moscucci
`
`77
`
`5. Adjunctive Pharmacology for Cardiac Catheterization
`Kevin Croce and Daniel l. Simon
`
`106
`
`SECTION II BASIC TECHNIQUES
`
`139
`
`.
`
`B. Percutaneous Approach, includingTransseptal and Apical Puncture
`Claudia A. Martinez and Mauro Moscucci
`
`139‘
`
`170
`7. Radial Artery Approach
`Mauricio G. Cohen and Sunll M Rao
`8. CutdOWn Approach: Brachial, Femoral, Axillary, Aortic andTransapical
`Ronald F.’ Caputo, G. Randall Green, and William Grossman
`9. Diagnostic Catheterization in Childhood and Adult Congenital Heart Disease 208
`Gabriele EgidyAssanza, James E. Lock, and Michael J. Landzbarg
`
`191
`
`223
`
`245
`
`272
`
`xvii
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`14. Pitfalls in the Evaluation of Hemodynamic Data
`Zoltan G. Turf
`
`234
`
`SECTION IV ANGIOGRAPHIC TECHNIQUES 295
`
`15. CoronaryAngiography 295
`Mauro Moscucci
`
`335
`16. Coronary Artery Anomalies
`Paolo Angelini and Jorge Mange
`
`17. CardiacVentriculography 354
`Mauro Moscuccl and Robert C. Handel
`
`18. Pulmonary Angiography 370
`Kyung Cho and Nils Kucher
`
`399
`19. Angiography of the Aorta and Peripheral Arteries
`Michael H. Jafl} John Rundbaclr, and Kenneth Rosenfielcl
`
`SECTION V EVALUATION OF CARDIAC FUNCTION 431
`
`20. StressTesting During Cardiac Catheterization: Exercise, Pacing,
`and Dobutamine Challenge
`431
`William Grossman and Mauro Moscucci
`
`21. Measurement ofVentricularVolurnes, Ejection Fraction,
`Mass,Wall Stress, and RegionalWail Motion 456
`MichaalA. Fifar and William Grossman
`
`22. Evaluation of Systolic and Diastolic Function of the Ventricles
`and Myocardium 467
`William Grossman and Mauro Moscucci
`
`23. Evaluation ofTamponade, Constrictive, and Restrictive Physiology 489
`Mauro Moscucci and Barry A. Borlaug
`
`
`SECTION VI SPECIAL CATHETER TECHNIQUES 505
`
`24. Evaluation of Myocardial and Coronary Blood Flow
`and Metabolism 505
`Morton J. Kern and Michael J. Lim
`
`25.
`
`545
`lntravascular ImagingTechniques
`Yasuhiro Honda, Peter J. Fitzgerald, and Paul G. Yook
`
`576
`26. Endomvocardial BiOpsy
`Sandra Ir! Chaparro and Mauro Moscucci
`
`27. Percutaneous Circulatory Support: Intra-aortic Balloon Counterpulsation,
`impella,TandemHeart, and Extracorporeal Bypass
`601
`Daniel Burkhoff, Mauro Moscucci, and Jose RS. Henriques
`
`SECTION VII
`
`INTERVENTIONAL TECHNIQUES 627
`
`28. Percutaneous Balloon Angioplasty and General Coronary Intervention 627
`Abhiram Prasad and David R. Holmes
`
`29. Atherectomy,Thrombectomy, and Distal Protection Devices
`Hobart N. Flame and Jeffrey J. Popma
`
`665
`
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`xix
`
`so.
`
`Intervention forAcute Myocardial Infarction
`William O'Neill
`
`697
`
`31. Coronary Stenting 710
`Ajay J. Kirfane and Gregg W. Stone
`32. General Overview of Interventions for Structural Heart Disease
`Mauro Moscucci, John D. Carroll, and John G. Webb
`
`760
`
`33. PercutaneousTherapies forVaIvular Heart Disease 772
`Ted Feldman and Mauro Moscucci
`
`805
`34. Peripheral intervention
`Mahdi H. Shishehbor and Sarnir Fl. Kapadia
`
`35.
`
`Intervention for Pediatric and Adult Congenital Heart Disease
`Robert J. Sommer
`
`839
`
`36. Cardiac Cell-BasedTherapy: Methods of Application
`and Delivery Systems
`871
`Joshua M. Hare, Arnon Bium, and Alan W. Heldman
`
`31. Aortic Endovascular Grafting 891
`Arash Bornak, Gilbert Fl. Upchurch. and Omaida C. Velazquez
`
`38. Pericardial Interventions: Pericardiocentesis, Balloon Pericardiotomy,
`and Epicardial Approach to Cardiac Procedures
`904
`Mauro Mosouoci and Juan E [files-Gonzalez
`
`39.
`
`921
`Interventions for Cardiac Arrhythmias
`Haris M. Ha qqani and Francis E. Marohiinski
`
`
`SECTION VIII CLINICAL PROFILES
`
`943
`
`40. Profiles in Valvular Heart Disease
`
`943
`
`Ted Feidman, William Grossman, and Mauro Moscucci
`
`41. Profiles in Coronary Artery Disease
`Robert N. Piana and Aaron Kugelmass
`
`970
`
`42. Profiles in Pulmonary Hypertension and Pulmonary Embolism 991
`Scott H. Visovatti and Valierie V. Mciaughiina
`
`43. Profiles in Cardiomyopathy and Heart Failure
`James C. Fang and BarryA. Boriaug
`44. Profiles in Pericardial Disease
`1045
`
`1011
`
`John E Robb, Finger J. Laham, and Mauro Moscucci
`
`1060
`45. Profiles in Congenital Heart Disease
`Gabriele EgidyAssenza, Robert J. Summer, and Michael J. Landzberg
`
`1078
`46. Profiles in Peripheral Alterial Disease
`Christopher J. White and Stephen H. Flames
`
`Index
`
`1113
`
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`Radial Artery Approach
`
`MAURICIO G. COHEN and SUNIL V. RAO
`
`INTRODUCTION
`
`in 1989, Lucien Campeau published his successful series of
`100 coronary angiographies performed via the left radial artery
`with minimal occurrence of complications.1 Subsequently in
`1993, Kiemeneij performed percutaneous coronary interven—
`tiotts (PCI) using 6F guiding catheters in a time when most
`interventional procedures were performed with larger EIF
`catheters.z Since then, transradial access ('l'RA) has continued
`to gain popularity in some regions of Europe, Canada, South
`America. Japan. and other sites outside of the United States
`where ”IRA is used in more than 60% of the cases.3 The most
`
`compelling reason for adopting TRA is the increased patient
`safety that results from the virtual elimination of access
`site bleeding and vascular complications. In addition, TRA
`is associated with early sheath removal,
`improved patient
`comfort, faster recovery, and lower costs in CompariSOn with
`transfernoral access"6 However, a relatively steep learning
`curve, increased radiation exposure, incompatibility of the
`radial artery with sheaths larger than 6F required for large
`rorablator burrs and complex bifurcation stenting, and higher
`access failure rates have been cited as reasons for not system—
`atically adopting "IRA.” An early analysis of the American
`College of Cardiology National Cardiovascular Data Reg—
`istry (ACCINCDR) of procedures performed between 2004
`and 2007 demonstrated a minimal use of Tim in the United
`States, with almost 90% of centers performing less than 2% of
`cases using the radial artery approach,” However. interven-
`tional cardiologists have been more. open to change and TRA
`has gained renewed momentum in the United States with the
`recognition of access site bleeding as a predictor of adverse
`outcomes post-PCI,” wider access to training opportuni—
`ties, and the inception of dedicated micropuncture needles.
`hydrophilicvcoatcd sheaths, and radial hemostasis devices.
`A more recent analysis including 1.776.625 patients treated
`at more than 1,200 U.5. hospitals demonstrated a significant
`uptake in IRA use from 1.3% in 2007 to 12.7% in 2011_“
`
`The ACCIAHA/SCAI guidelines now include TRA as a class
`[IA recommendation with a level of evidence A to decrease;
`
`access site complications." A class llA recommendation for
`TRA is also included in the most recent European guidelines
`for the management of acute ST segment elevation myocar—
`dial infarction in the setting of primary PC], if performed by
`an experienced radial operator.“5
`
`ANATOMICAL CONSIDERATIONS
`
`The radial artery arises together with the ulnar artery from
`the bifurcation of the brachial artery just below the bend
`of the elbow. The radial artery passes along the lateral side
`of the forearm from the neck of the radius to the forepart ol
`the styloid process in the wrist and is smaller in caliber that
`the ulnar artery. it then winds backward, around the lateral
`side of the carpus. The distal portion of the artery in the fore-
`arm is superficial. being covered by the integument and tht
`superficial and deep fascia, lying between the tendons of tht
`brachioradialis and flexor carpi radialis over the prominencr
`of the radius. With an average diameter of 2.8 mm in female.I
`and 3,1 mm in males, the radial artery is compatible with 61"
`sheaths. The artery is accompanied by a pair of venae comi-
`tantcs throughout its whole course, which can be used to per-
`form right heart catheterization (RHC).”"°
`Several anatomic characteristics explain the marltct
`safety advantage of the radial artery over the femoral artcr';
`approach. The flat, bony prominence of the radius provide:
`ease of compression and hemostasis after sheath removal; tl‘tl
`vast collateralization of the radial artery through the palma
`arch prevents ischemia of the hand; because the puncture sin
`is not overlying a joint, motion of the hand or the wrist doe
`not increase the risk of bleeding; and because of the absenct
`of major adjacent nerve structures. there is no rislt of neuro
`logic sequelae,20 in contrast, the ulnar artery is deep lying
`mobile, adjacent to the ulnar nerve, and consequently no
`
`. 17m.
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`ideal for first-line vascular access. Despite this, ulnar access
`has been used successfully for coronary procedures, without
`evidence of an increased rate of complications when com—
`pared with TRA.21 The ulnar artery should not be used after
`a failed ipsilateral radial attempt because of a possible small
`risk of complete obstruction ofcirculation to the hand,
`The interventions] cardiologist should be aware of rela—
`tively uncommon anatomic anomalies that. may impede the
`advancement of catheters to the aorta or increase the rislt of
`failure or complications. Variations include tortuous radial
`configurations, stenoses, hypoplasia. radioulnar loops, aber-
`rant right subclavian artery Carter-ta lusoria), and abnormal
`origin of the radial artery.“-” In a series of 1.540 transradial
`procedures, anatomic anomalies were found in about 15% of
`cases. A high radial artery origin at the level of the mid or
`upper humerus was found in 7% of cases and was associated
`with a failure rate of 4.6%, a loop in the proximal radial artery
`was found in- 2.3% of cases and associated with a high failure
`rate of37.l%, severe iortuosity was found in 2 %, and other
`miscellaneous anomalies in 2.5% of cases. These anomalies
`are usually unilateral, therefore vascular access crossover to
`the left radial artery may be indicated in cases of extreme tor-
`tuosity or angulated radial loops.” Significant subclavian or
`brachlocephalic toriuosiiy is present in about 10% of cases
`and is usually associated with advanced age, short stature,
`and longstanding history of hypertension, However, subcla—
`vian tortuosity is rarely a cause of procedural failure because
`it can be easily negotiated by the use of deep inspiration or
`supportive guidewires.” In rare cases ((1%), the right sub—
`clavian artery arises directly from the distal segment. of the
`posterior aspect of the aortic arch and has a retroesophageal
`course toward the right upper extremity. This anomaly is
`known as arteria lusoria and represents a formidable chal—
`lenge for advancing a catheter from the subclavian artery to
`the ascending aorta. This anomaly is mostly asymptomatic
`but can be associated with dysphagia.22
`
`Preprocedure Assessment—Testing
`for Dual Circulation to the Hand
`""11 Patients undergoing TRA procedures in the catheteriza-
`11011 laboratory should be assessed and undergo preparation
`according to a standardized protocol. Depending on the oper-
`ator's Preference, the gtoins can be prepped along with the
`W515. Placement of intravenous lines in the vicinity of the
`Wrist should be avoided. Sedation is strongly recommended
`to. decrease catecholamine release that can potentially con—
`mbutfl to radial spasm.
`There is significant variability in the vascular anatomy
`:{nlhe hand. The superficial paimar arch that connects the
`of c“ and radial arteries is complete in approximately 80%
`fists and the predominant blood supply to the band is
`
`thought to be from the ulnar artery in the majority oi'cases.“
`In 1929, Edgar Van Nuys Allen introduced a "compression
`test” to diagnose arterial occlusion resulting from thrombo—
`angiitis obliterans or Energer disease. The test consists of
`simultaneously compressing the ulnar and the radial arter—
`ies at the level ofthe wrist for approximately 1 or 2 minutes,
`the patient closes the hand tightly to squeeze as much blood
`out as possible, then quickly opens the hand and extends the
`fingers; then the operator releases compression of the ulnar
`artery and waits for the hand to regain color. In individuals
`with integrity of the hand circulation and a patent palmar
`arch, the pallor of the hand is quickly replaced by blushing
`of higher intensity than normal in about 5 to 9 seconds.
`Because the Allen‘s test is largely subjective and yields more
`than 30% of falsely abnormal results, Barbeau and cowork-
`ers modified the test by attaching a pulse oximeter to the
`thumb to record oxygen saturation and plethysmography.
`in a study including 1,010 patients, Barbeau and colleagues
`described faur reading patterns: no damping of the pulse
`waveform immediately after 2 minutes of radial compres-
`sion, positive ortimetry (Type A, frequency 15%); damping
`of the pulse waveform and positive oxinictry, followed by
`complete recovery within 2 minutes of compression, (Type
`B, frequency 75%); loss of pulse waveform, negative oxim-
`etry, with partial progressive recovery of the pulse wave—
`form and oximetry within 2 minutes of compression (Type
`C, frequency 5%); loss of pulse waveform, negative oxim-
`etry. without recovery of either pulse waveform or oxim—
`etry after 2 minutes of compression (Type D, frequency 5%)
`(Figure 7.1). After analyzing these patterns in the right and
`left wrists of the study participants, only 1.5% showed a
`bilateral Type D pattern and these patients did not undergo
`TRA procedures.
`In summary,
`this study sugge'sts that
`almost all patients are eligible for TRA procedures without
`risk ofischemic complications to the hand.” Some operators
`have challenged the utility of testing the collateral circula-
`tion of the radial artery, stating that the presence of a rich
`collateral system and the presence ofinterosseous branches
`that supply circulation to the hand could possibly allow to
`tolerate concomitant radial and ulnar artery occlusion}6 It‘i
`addition, there is no evidence indicating that the modified
`Allen’s tcsi predicts hand ischerttia after TRA procedures,
`HUWever. as part of the catheterization laboratory routine
`in most sites, a modified Allen's test using pulse oximetry
`and plethysmography is usually performed and the results
`documented.
`
`Patient Positioning—Right versus
`Left Radial Access
`
`TRA can be performed through the left or the right radial
`artery. Due to ergonomic considerations. most Operators pre—
`fer using right TRA. Regardless of the side of choice, a com-
`fortable position for the patient and the operator is crucial
`for successfully performing TRA procedures. The patient is
`
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`
`
`
`RadialCompression
`
`F: e
`
`
`_ Testing for dual Circulation to the hendThe Barbeau Grading System for assessment of collateral circu-
`lation of the palmar arch.The presence of an arterial waveform on plethysmography (even if delayed
`or with reduced amplitudel and an oxygen saturation above 90% (Grades A, B, and Cl confirm the
`presence of dual circulation to the hand.
`
`positioned supine on the angiographic table. With right-sided
`Tim, an arm hoard extension is attached to the right hand
`side of the table. lntportantly, there should be a platform that
`extends from the distal portion of the patiean hand to the
`table controls so that equipment can be placed in this area.
`Arm boards are commercially available in different shapes
`and designs. Many laboratories have opted for
`trapezoid-
`shaped acrylic glass board, with the narrow end tucked under
`the mattress at the shoulder level and the broad area at the
`
`wrist level (Figure 7.2). The patient's right arm is placed
`on the board and abducted at a 30° angle. The right wrist is
`placed in a hypcrextended position using commercially avail-
`able splints or a rolled towel behind the wrist with the fingers
`taped to the arm board. A pulse oximeter probe can be placed
`in the right thumb for continuous monitoring of the circula—
`tion to the hand throughout the procedure (Figure. 7.3).1‘50th
`groins may be prepped as well, depending on the anticipated
`need for femoral access.
`
`For left "IRA, the setup is completely different and varies
`widely across catheterization laboratories. As with right TRA,
`the operator stands on the right side of the patient for left
`TRA to avoid disruption of the traditional laboratory setup.
`
`The patient is positioned supine on the table and a custom
`arm rest, made of foam or pillow material, is attached to the
`left side of the table to elevate and prenate the left arm and
`guide the forearm toward the midsection of the patient’s body
`and place the wrist over the leg where it can strapped to a
`splint (Figure 7.2).
`It has been shown that the prevalence of subclavian
`tortuosity and radial loops is three times higher in the
`right upper extremity." With right "IRA the catheter has
`to pass through the right suhclavian artery and the bra-
`chiocephalic trunk before reaching the aortic root. These
`two areas of bifurcation can increase technical. difficulty,
`especially when these vessels are atherosclerotic, tortuous,
`and calcified. Since the left subclavian artery arises directly
`from the aorta, the path followed by the catheter in the left
`radial route into the ascending aorta is more straightfor-
`ward, often resulting in less complex catheter manipula-
`tion. In addition, left TRA should be strongly considered
`in patients who have undergone coronary artery bypass
`grafting (CABG), because it provides direct access to the
`left internal mammary artery (LIMA). Certainly, the LIMA
`can also be cannuiated from the right radial route. but this
`
`
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`.‘Figm Positioning of the arm for right or left radial access. A.The right arm is placed on the board abducted
`at a 30° angle. B.The left arm rest on a large pillow placed on a regular arm board that guides the fore—
`arm towards the midsection of the patient’s body, placing the left wrist on top of the left groin.
`
`is significantly more challenging from a technical stand-
`point with a potential risk of anabolic stroke due to catheter
`manipulation and exchanges in the aortic arch. Random”
`izetl data comparing right versus left radial access sug-
`gested that using left TRA during the learning curve may
`be advantageous as it allows novice operators to acquire the
`skills and confidence required for transradial procedures
`more quickly than the right radial route. in the TALENT
`trial (Transradial Approach {Left versus. Right] and Pro—
`cedural Times during Percutaneous Coronary Procedures)
`1,500 patients were randomized to right or left TRA, The
`SILIClY found that among trainees, left TRA was associated
`with a significantly shorter learning curve, with progres—
`Sive reductions in cannulation and fluoroscopy tithes as the
`Operator volume increased, compared to right TRA.19-29
`
`Radial Puncture
`
`There are a number of TRA kits available in the market. in gen—
`eral, these kits include a rnicropurtcture needle, a short 0,018
`to 0.021 inch wire, and an arterial sheath with or without
`
`hydrophilic coating of shorter (10 to 13 cm) or longer (23 cm)
`length. Sorne operators advocate the use of longer sheaths to
`avoid difficulties with catheter manipulation should spasm-1
`occur, but a randomized trial comparing sheath lengths on
`arterial spasm showed no effect of longer sheaths on reducing
`spasm.” On the other hand, hydrophilic coating allows easier
`Sheath removal and is clearly associated with less spasm and
`patient discomfort.Jl However, in the past decade, Kozak and
`colleagues reported sterile abscesses in the wrist alter the use
`of a particular transradial sheath brand. These abscesses were
`
`
`
`
`
`Positioning of the hand fortransradial access. A.The hand is hyperextended with use of a rolled towel
`behind the wrist and tape holding the fingers, B. or with use of a dedicated positioning splint.
`
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`— Transradiai access technique (Step 1). After sterile preparation and draping. the wrist area is locally
`anesthetized with lidocaine using a 256 needle and a small 3 cc syringe.
`
`later found to be a foreign-body reaction to the hydrophilic
`coating of the sheaths."1 Conservative management ruling out
`the presence of infection, local wound care with drainage in
`case of abscess formation. and reassurance are recommended
`for the management of this complication. Sterile abscesses are
`rarely found in contemporary practice as the hydrophilic coat-
`ing causing the problem has been modified, although a recent
`isolated case of sterile abscess has been reported with new
`sheaths.” A recent study randomized 790 patients undergo-
`ing TRA P61 in a 2X2 factorial design to shorter (13 cm) or
`longer {23 cm) sheaths with or without hydrophilic coating.
`Hydrophiiie-eoated sheaths were associated with a significant
`reduction in radial spasm (19.0% versus 39.9%, P <’. 0.001)
`and patient discomfort (15.1% versus 28.5%, OR 2.27, P 4:
`0.001), whereas sheath length did not have any effect in the
`occurrence of spasm or patient discomfort.JD In addition.
`the operator may consider using smaller diameter sheaths as
`5F sheaths are associated with lower incidence of radial artery
`
`occlusion (RAD) than 6F sheaths.“ Therefore. in current prac—
`tice, shorter 5F hydrophilic—coated sheaths are preferred.
`It is important to administer sedation to avoid the release
`of catecholamines associated with the emotional stress and
`
`fear that patients usually experience before the procedure.
`which can contribute to radial artery spasm. The site of access
`is approximately 2 cm proximal to the radial styloid process,
`not at the wrist. The radial artery is most superficial in this
`area. Once the patient is prepped in sterile fashion, this area
`is anesthetized with approximately 2 to 3 cc of 1% lidocaine
`injected with a small syringe and a 25G needle (Figure 7.4).
`Usually, the arterial puncture is performed with either a short
`2.5 cm, stainless steel. llG needle or a micropuncturc [V cath-
`eter that consists of a fine metal needle and a 22G Teflon cath—
`
`eter that allow the passage of a 0.018 to 0.021 inch guidewit‘e.
`While feeling the pulse with one hand, the operator advances
`the needle into the radial artery at a 30° angle with the other
`hand (Figure 7.5). Most operators prefer one of two different
`
`
`
`
`
`
`m Transradial access technique—front wall technique (Step 2). With the front wall technique, a short 2.5 cm
`21 G stainless-still needle is used to puncture the radial artery.
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`IN“ Transradial access technique-front wall technique {Step 3i.The needle is advanced into the radial
`artery.The blood return indicates the intraluminal needle position.The blood return is rarely pulsatile
`or brisk.
`
`access techniques (single-wall versus double-wall or back—wall
`technique), With the single-wall technique. a stainless steel
`needle is advanced through the front wall of the artery into
`the lumen; once blood is noticed in the needle hub the wire
`can be advanced (Figure 7.6). Using this technique, the blood
`return is rarely brisk or pulsatile and sometimes the wire does
`not advance freely because the bevel may be directing the wire
`toward the vessel wall. If this happens, the operator should
`never force the wire because of the risk of arterial dissection
`The needle should be carefully rotated clockwise or counter-
`clockwise until the wire can be easily advanced without resis—
`tance (Figure 7,7). With the dual-wall or back—wall technique,
`a micropuncture catheter is advanced through the front wall
`into the lumen of the artery until blood is noticed in the hull
`and then intentionally pushed through the back wall of the
`
`artery (Figure 7.8). The fine needle is removed and the small
`Teflon microcatheter is slowly withdrawn until the appearance
`of brislt pulsatile flow (Figures 7.9 and 7.10). Then, the wire
`can be freely advanced and the microcatheter exchanged for the
`arterial sheath (Figure 7.1 l). The orifice in the back wall of the
`radial artery is sealed once the sheath is in place (Figure 7.12).
`This technique has not been reported to be associated with a
`higher incidence of wrist hematornas. Proponents of the backs
`wall technique argue that this method is simpler, more repro—
`ducible, easier to teach, allows easier advancement of the wire.
`and that the arterial pulsatile blood return is easier to recognize.
`After several unsuccessful puncture attempts, there are
`instances in which the radial pulse disappears due to spasm.
`In this situation, the operator should reassess the sedation
`status of the patient, consider administering 200 to 400 mcg
`
`
`
`m Transradial access technique-front wall tech
`nique [Step 4). A 0.018 inch short guidewira is advanced
`he proximal radial artery.Then the needle is exchanged for
`without resistance through the needle intot
`a hydrophilic~coeted sheath.
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`1%: '*
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`_ Transradial access tschnique—back~wall technique (Step 2].The microcatheter and needle are advanced
`in a 30° angle through the skin into the radial artery.The presence of blood in the hub of the needle
`indicates that the artery has been punctured.The needle is advanced forward through the back wall
`of the radial artery.
`
`of subcutaneous nitroglycerin at the site of the lost radial
`pulse. and wait patiently for 5 to 10 minutes until the pulse
`reappears before attempting a new puncture.”
`Even though TRA procedures can be successfully com-
`pleted in more than 95% of cases, inability to puncture the
`radial artery has been one of the most frequent mechanisms
`associated with TRA failure.“ Therefore a consistent and
`meticulous radial artery puncture technique could not be
`emphasized more. A steep learning curve for TRA proce-
`dures has been well described. Spaulding et al., documented
`an initial access failure rate greater than 10% that decreased
`dramatically to about 2% after the first 80 cases. in addition,
`the time required for access and sheath insertion decreased
`from 10.2 t 7.6 to 2.8 i 2.5 minutes and the procedure time
`also decreased from 25.7 i 12.9 to 17.4- i 4.7 minutes after
`the first 80 cases.7 More recently, in a group of 28 operators,
`Ball and colleagues documented a stepwise reducticm ofTRA-
`PCI failure rates from 7% to 2% (P = 0.01), contrast volume
`use from 180 I 79 to 168 i 79 mL (P = 0.05), and fluo-
`roscopy times from 15 i 10 to 12 i 9 minutes (P = 0.02)
`
`with increasing procedural volumes. The odds of TM proce—
`dural failure showed a steep decline up to 50 cases, and after
`100 cases the learning curve flattened. Figure 7.13 Shows that
`reasons for failure are different according to operator volume.
`It is clear that with experience, the operator can overcome
`most hurdles and the major reasons for failure remain radial
`artery spasm and extreme vascular tortuosity.9
`
`Prevention of Radial Artery Spasm
`The radial artery has a high propensity to develop spasm due
`to its smaller caliber, large muscular media, and higher recep-
`tor—mediated vasomotion in comparison with similar arter—
`ies.“ Radial artery spasm is perhaps the most common TRA
`complication and a frequent reason for failure and crossover
`to transfemoral access?“ in the catheterization laboratory,
`spasm should be routinely prevented using a hydrophilic-
`coated sheath with the injection of a single vasodilator or a
`cocktail of vasodilators through the sidearm of the sheath
`immediately after obtaining access
`(Figure 7‘14). Most
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` Transradial access techni
`que—back-Wall technique (
`Step 3). Once the tip of microcatheter and needle
`are through the back wall of the radial arteryr the needle is removed and the microcatheter left in place
`across the radial artery.
`
`commonly use