`
`Grossman & Baim’s
`Cardiac Catheterization,
`Angiography,
`and Intervention
`
`EIGHTH EDITION
`
`EDITOR
`
`MAURO MOSCUCCI, MD, MBA
`Professor of Medicine
`
`Chairman, Department of Medicine (Acting)
`Chief, Cardiovascular Division
`University of Miami Miller School of Medicine
`Miami, Florida
`
`&. Wolters Kluwer Lippincott Williams & Wilkins
`
`Health
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`7th edition © 2006 by LIPPINCOTT WILLIAMS & WILKINS
`6th edition © 2000 by LIPPINCOTT WILLIAMS & WILKINS
`5th edition © 1996 by WILLIAMS & WILKINS
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`
`Library of Congress Cataloging-in-Publication Data
`Cardiac catheterization, angiography, and intervention,
`Grossman & Baim'’s cardiac catheterization, angiography, and intervention / editor, Mauro Moscucci, MD, MBA,
`ptofessor of medicine, chairman, Departmentof Medicine, University of Miami Miller School of Medicine, Miami,
`Florida. — Eighth edition.
`pages cm
`Includes bibliographical references and index.
`ISBN 978-1-4511-2740-9 (hardback)
`1. Cardiac catheterization. 2, Angiography, 1. Moscucci, Mauro, editor of compilation.II, Title, 11, Tithe: Grossman
`and Baim's cardiac catheterization, angiography, and intervention.
`RC6B3.5,C25C38 2013
`616.1'20754—de23
`
`2013025399
`ssSSSSSSSShhaae
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`Care has been taken to confirm the accuracy ofthe information presented and to describe generally accepted
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`quences from application of the information in this book and make no warranty, expressed or implied, with respect
`to the curtency, completeness, or accuracy of the contents of the publication. Application af the information in a
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`The authors,editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in
`this text are in accordance with current recommendations and practice at the time of publication, However, in view of
`ongoing research, changes in government regulations, and the constantflow of information relating to drug therapy
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`new or infrequenUy employed drug,
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`Contents
`
`
`
`Contributors—vii
`Preface to the Eighth Edition
`xi
`Preface to the Website to the Eighth Edition
`Acknowledgments xv
`
`xiii
`
`3.
`
`Blase A, Carabello and William Grossman
`
`139
`SECTION Il BASIC TECHNIQUES
`6. Percutaneous Approach, Including Transseptal and Apical Puncture
`Claudia A. Martinez and Mauro Moscucci
`7. Radial Artery Approach
`170
`Mauricio G. Cohen and Sunil V. Rao
`8. Cutdown Approach: Brachial, Femoral, Axillary, Aortic andTransapical
`Ronald RP. Caputo, G. Randall Green, and William Grossman
`9. Diagnostic Catheterization in Childhood and Adult Congenital Heart Disease 208
`Gabriele EgidyAssenza, James E. Lock, and MichaelJ. Landzberg
`SECTIONII] HEMODYNAMIC PRINCIPLES
`223
`10. Pressure Measurement 223
`Mauro Moscucei and William Grossman
`11. Blood Flow Measurement: Cardiac Output and Vascular Resistance
`Mauro Moscucci and William Grossman
`12. Shunt Detection and Quantification 261
`William Grossman and Mauro Moscucci
`13. Calculation of Stenotic Valve Orifice Area
`
`1
`SECTION | GENERAL PRINCIPLES
`1, Cardiac Catheterization History and Current Practice Standards
`Mauro Moscucci
`2. Cineangiographic Imaging, Radiation Safety, and Contrast Agents
`e
`Stephen Balter and Mauro Moscucei
`Integrated Imaging Modalities in the Cardiac Catheterization Laboratory 44
`Robert A, Quaife and John D. Carroll
`4. Complications
`77
`Mauro Moscucci
`5. Adjunctive Pharmacology for Cardiac Catheterization
`Kevin Croce and Daniel |. Simon
`
`1
`
`17
`
`106
`
`!
`
`139°
`
`191
`
`245
`
`272
`
`xvii
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`14.
`
`Pitfalls in the Evaluation of Hemodynamic Data
`Zoltan G. Turi
`
`284
`
`SECTION IV ANGIOGRAPHIC TECHNIQUES 295
`
`15.
`
`16.
`
`17.
`
`18.
`
`19.
`
`Coronary Angiography 295
`Mauro Moscucci
`
`335
`Coronary Artery Anomalies
`Paolo Angelini and Jorge Monge
`Cardiac Ventriculography 354
`Mauro Moscucci and Robert C. Hende!
`
`Pulmonary Angiography 370
`Kyung Cho and Nils Kucher
`399
`Angiographyof the Aorta and Peripheral Arteries
`Michael R. Jaff, John Rundback, and Kenneth Rosenfield
`
`SECTION V EVALUATION OF CARDIAC FUNCTION 431
`
`20.
`
`21,
`
`Stress Testing During Cardiac Catheterization: Exercise, Pacing,
`and Dobutamine Challenge
`431
`William Grossman and Mauro Moscucci
`
`Measurementof Ventricular Volumes, Ejection Fraction,
`Mass, Wall Stress, and Regional Wall Motion 456
`Michael A. Fifer and William Grossman
`
`Evaluation of Systolic and Diastolic Function of the Ventricles
`and Myocardium 467
`William Grossman and Mauro Moscucci
`
`23.
`
`Evaluation of Tamponade, Constrictive, and Restrictive Physiology 489
`Mauro Moseucci and Barry A. Borlaug
`
`SECTION VI SPECIAL CATHETER TECHNIQUES 505
`
`24,
`
`25.
`
`Evaluation of Myocardial and Coronary Blood Flow
`and Metabolism 505
`Morton J. Kern and Michael J. Lim
`
`545
`Intravascular ImagingTechniques
`Yasuhiro Honda, Peter J. Fitzgerald, and Paul G. Yock
`Endomyocardial Biopsy
`576
`Sandra V. Chaparro and Mauro Moscucci
`Percutaneous Circulatory Support: Intra-aortic Balloon Counterpulsation,
`Impella, TandemHeart, and Extracorporeal Bypass
`601
`Daniel Burkhoff, Mauro Moscucci, and Jose PS. Henriques
`
`SECTION Vil
`
`INTERVENTIONAL TECHNIQUES 627
`
`28.
`
`29,
`
`Percutaneous Balloon Angioplasty and General Coronary Intervention 627
`Abhiram Prasad and David R. Holmes
`
`Atherectomy, Thrombectomy, and Distal Protection Devices
`Robert N. Piana and Jeffrey J. Popma
`
`665
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`xix
`
`30.
`
`Intervention for Acute Myocardial Infarction
`William O‘Neill
`
`697
`
`31. Coronary Stenting 710
`Ajay J. Kirtane and Gregg W. Stone
`32. General Overview ofInterventions for Structural Heart Disease
`Mauro Moscucci, John D. Carroll, and Jahn G. Webb
`33. Percutaneous Therapies for Valvular Heart Disease 772
`Ted Feldman and Mauro Moscucci
`34, Peripheral Intervention
`805
`Mehdi H. Shishehbor and Samir R. Kapadia
`Intervention for Pediatric and Adult Congenital Heart Disease
`Robert J. Sommer
`
`35.
`
`760
`
`838
`
`36. Cardiac Cell-Based Therapy: Methods of Application
`and Delivery Systems
`871
`Joshua M. Hare, Arnon Blum, and Alan W. Heldman
`37. Aortic Endovascular Grafting 891
`Arash Bornak, Gilbert R. Upchurch, and Omaida C. Velazquez
`38. Pericardial Interventions: Pericardiocentesis, Balloon Pericardiotomy,
`and Epicardial Approach to Cardiac Procedures
`904
`Mauro Moscucci and Juan F Viles-Gonzalez
`
`39.
`
`921
`Interventions for Cardiac Arrhythmias
`Haris M. Haqqaniand Francis £. Marchlinski
`
`SECTION VII| CLINICAL PROFILES
`
`943
`
`943
`40. Profiles in Valvular Heart Disease
`Ted Feldman, William Grossman, and Mauro Moscucci
`41. Profiles in Coronary Artery Disease
`970
`Robert N. Piana and Aaron Kugelmass
`42. Profiles in Pulmonary Hypertension and Pulmonary Embolism 991
`Scott H. Visovatti and Vallerie V. Mclaughlina
`43. Profiles in Cardiomyopathy and Heart Failure
`James C. Fang and Barry A. Borlaug
`44. Profilesin Pericardial Disease
`1045
`John F Robb, Roger J. Laham, and Mauro Moseucci
`45. Profiles in Congenital Heart Disease
`1060
`Gabriele Egidy Assenza, Robert J. Sommer, and Michael J. Landzberg
`46. Profilesin Peripheral Arterial Disease
`1078
`Christopher J. White and Stephen R. Ramee
`
`1011
`
`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 performedvia theleftradialartery
`with minimal occurrence of complications.’ Subsequently in
`1993, Kiemeneij performed percutaneous coronary interven-
`tions (PCI) using 6F guiding catheters in a time when most
`interventional procedures were performed with larger 8F
`catheters.* Since then, transradial access (TRA) has continued
`to gain popularity in some regions of Europe, Canada, South
`America, Japan, andother sites outside of the United States
`where TRA is used in more than 60% ofthe cases.* 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
`transfemoral access.‘® However, a relatively steep learning
`curve, increased radiation exposure, incompatibility of the
`radial artery with sheaths larger than 6F required for large
`rotablator burrs and complex bifurcation stenting, and higher
`access failure rates have been cited as reasons for not system-
`atically adopting TRA." An early analysis of the American
`College of Cardiology National Cardiovascular Data Reg-
`istry (ACC/NCDR) of procedures performed between 2004
`and 2007 demonstrated a minimal use of TRA 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 predictorofadverse
`outcomes post-PCl,” wider access to training opportuni-
`ties, and the inception of dedicated micropuncture needles,
`hydrophilic-coated sheaths, and radial hemostasis devices.
`A morerecent analysis including 1,776,625 patients treated
`at more than 1,200 U.S. hospitals demonstrated a significant
`uptake in TRA use from 1.3% in 2007 to 12.7% in 2011."
`
`The ACC/AHA/SCAI guidelines now include TRA as a class
`(IA recommendation with a level of evidence A to decrease
`access site complications.” A class A 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 PCI, if performed by
`an experienced radial operator."
`
`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 radiusto the forepartol
`the styloid process in the wrist and is smaller in caliber thar
`the ulnar artery, It then winds backward, around thelatera,
`side of the carpus. The distal portion of theartery in the fore-
`arm is superficial, being covered by the integument and the
`superficial and deep fascia, lying between the tendons of the
`brachioradialis and flexor carpi radialis over the prominence
`of the radius. With an average diameter of2.8 mm in female:
`and 3.1 mm in males, the radial artery is compatible with 61
`sheaths, The artery is accompanied by a pair of venae comi
`tantes throughout its whole course, which can be used to per
`form right heart catheterization (RHC),""”
`Several anatomic characteristics explain the markec
`safety advantage of the radial artery over the femoral arteri
`approach. Theflat, bony prominence of the radius provide:
`ease of compression and hemostasis after sheath removal, thi
`vast collateralization of the radial artery through the palma
`arch prevents ischemia of the hand; because the puncturesit’
`is not overlying a joint, motion of the hand or the wrist doe:
`not increase the risk of bleeding; and because of the absenc'
`of major adjacent nerve structures,there is no risk of neuro
`logic sequelae.” In contrast, the ulnar artery is deep lying
`mobile, adjacent to the ulnar nerve, and consequently no
`
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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.”! The ulnar artery should not be used after
`a failed ipsilateral radial attempt because of a possible small
`tisk of complete obstruction of circulation to the hand,
`The interventional cardiologist should be aware ofrela-
`tively uncommon anatomic anomalies that may impede the
`advancementof catheters to the aorta or increase the risk of
`failure or complications. Variations include tortuous radial
`configurations, stenoses, hypoplasia, radioulnar loops, aber-
`rant tight subclavian artery (arteria 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% ofcases and was associated
`with a failure rate of 4.6%, a loop in the proximalradial artery
`was foundirr 2,3% of cases and associated with a highfailure
`rate of 37.1%, severe tortuosity 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
`brachiocephalic tortuosity is present in about 10% of cases
`and is usually associated with advanced age, short stature,
`and long-standing history of hypertension, However, subcla-
`vian tortuosity is rarely a cause of proceduralfailure 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 segmentof the
`posterior aspect of the aortic arch and has a retroesophageal
`course toward the right upper extremity. This anomaly is
`knownasarteria 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.”
`
`Preprocedure Assessment—Testing
`for Dual Circulation to the Hand
`All patients undergoing TRA procedures in the catheteriza-
`hon laboratory should be assessed and undergo preparation
`according to a standardized protocol. Depending on the oper-
`ator's preference, the groins can be prepped along with the
`Wnsts, Placement of intravenouslines in the vicinity of the
`Wrist should be avoided, Sedation is strongly recommended
`- decrease catecholaminerelease that can potentially con-
`tribute to radial spasm.
`Thereis significant variability in the vascular anatomy
`eg hand, The superficial palmar arch that connects the
`ar and radialarteries is complete in approximately 80%
`Sases and the predominant blood supply to the handis
`
`thoughtto be from the ulnarartery in the majority ofcases.*
`In 1929, Edgar Van Nuys Allen introduced a “compression
`test” to diagnosearterial occlusion resulting from thrombo-
`angiitis obliterans or Buerger disease. The test consists of
`simultaneously compressing the ulnar and theradialarter-
`ies at the level of the wrist for approximately | or 2 minutes,
`the patient closes the hand tightly to squeeze as much blood
`outas possible, then quickly opens the hand and extendsthe
`fingers; then the operatorreleases compression of the ulnar
`artery and waits for the handto 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 higherintensity than normal in about 5 to 9 seconds.
`Because the Allen's testis 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.
`Ina study including 1,010 patients, Barbeau and colleagues
`described four reading patterns: no damping of the pulse
`waveform immediately after 2 minutes of radial compres-
`sion, positive oximetry (Type A, frequency 15%); damping
`of the pulse waveform and positive oximetry, 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 patternsin 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 suggésts that
`almostall patients are eligible for TRA procedures without
`risk of ischemic complications to the hand.” Someoperators
`have challenged the utility of testing the collateral circula-
`tion of the radial artery, stating that the presence ofa rich
`collateral system and the presence of interosseous branches
`that supply circulation to the hand could possibly allow to
`tolerate concomitant radial and ulnar artery occlusion.”* In
`addition, there is no evidence indicating that the modified
`Allen'stest predicts hand ischemia after TRA procedures.
`However, 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. Thepatient is
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`172
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`Radial Compression
`
`Ee:
`
`
`
`
`
`‘Figure7.1.Testing for dual circulation to the hand.The Barbeau Grading System for assessmentof collateral circu-
`
`lation of the palmar arch. The presence of an arterial waveform on plethysmography (even if delayed
`or with reduced amplitude) and an oxygen saturation above 90% (Grades A, B, and C) confirm the
`presenceof dual circulation to the hand.
`
`positioned supine on the angiographictable. With right-sided
`TRA, an arm board extension is attached to the right hand
`side of the table. Importantly, there should be a platform that
`extends from the distal portion of the patient's 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-
`shapedacrylic glass board, with the narrow end tucked under
`the mattress at the shoulderlevel 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 hyperextended position using commercially avail-
`able splints or a rolled towel behind the wrist with the fingers
`tapedto the arm board, A pulse oximeter probe canbe placed
`in the right thumbfor continuous monitoring of the circula-
`tion to the hand throughout the procedure (Figure 7.3), Both
`groins may be prepped as well, depending on the anticipated
`need for femoral access.
`Forleft TRA, the setup is completely different andvaries
`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 offoam or pillow material, is attached to the
`left side of the table to elevate and pronate the left arm and
`guide the forearm toward the midsectionof 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 TRA the catheter has
`to pass through the right subclavian artery and the bra-
`chiocephalic trunk before reaching the aortic root. These
`two areas of bifurcation can increase technicaldifficulty,
`especially when these vessels are atherosclerotic, tortuous,
`and calcified. Since the left subclavian artery arises directly
`from the aorta, the path followed by the catheterin theleft
`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 cannulated from the right radial route, but this
`
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`‘Figure7.2, Positioning of the arm for right orleft 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 ofthe left groin.
`
`is Significantly more challenging from a technical stand-
`point with a potential risk of embolic stroke due to catheter
`manipulation and exchanges in the aortic arch. Random-
`ized data comparing right versus left radial access sug-
`gested that using left TRA during the learning curve may
`be advantageousas 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 orleft TRA. The
`study found that amongtrainees, left TRA was associated
`with a significantly shorter learning curve, with progres-
`sive reductionsin cannulation andfluoroscopy times as the
`operator volume increased, compared to right TRA.*8??
`
`Radial Puncture
`
`There are anumber of TRA kits available in the market. In gen-
`eral, these kits include a micropuncture 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. Some operators advocate the use of longer sheaths to
`avoid difficulties with catheter manipulation should spasm
`occur, but a randomized trial comparing sheath lengths on
`arterial spasm showed noeffect of longer sheaths on reducing
`spasm.” On the other hand, hydrophilic coating allows easier
`sheath removalandis clearly associated with less spasm and
`patient discomfort.*' However, in the past decade, Kozak and
`colleagues reported sterile abscesses in the wrist after the use
`of a particular transradial sheath brand. These abscesses were
`
`
`
`Positioning of the hand for transradial 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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`‘Figure7.4.Transradial access technique (Step 1). After sterile preparation and draping,the wristarea is locally
`
`anesthetized with lidocaine using a 25G needle and a small 3 cc syringe.
`
`
`
`
`
`later found to be a foreign-body reaction to the hydrophilic
`coating of the sheaths.” Conservative managementruling out
`the presence ofinfection, local wound care with drainage in
`case of abscess formation, and reassurance are recommended
`for the managementofthis 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 PCI in a 22 factorial design to shorter (13 cm) or
`longer (23 cm) sheaths with or without hydrophilic coating.
`Hydrophilic-coated 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 <
`0.001), whereas sheath length did not have anyeffect in the
`occurrence of spasm or patient discomfort.*? In addition,
`the operator may consider using smaller diameter sheaths as
`SF sheaths are associated with lower incidence ofradial artery
`
`occlusion (RAO) than 6F sheaths.** Therefore, in currentprac-
`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. Thesite 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 ce 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, 21G needle or a micropuncture IV 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 guidewire.
`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 twodifferent
`
`
`
`
`‘Figure7.5Transradial access technique-front wall technique (Step 2). With the front wall technique, a short 2.5 cm
`
`21G stainless-still needle is used to puncture the radial artery.
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`Figure7.6Transradial access technique-front wall technique (Step 3).The needle is advanced into the radial
`;
`artery.The blood return indicates the intraluminal needle position. The bloodreturnis 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 bloodis 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 sometimesthe wire does
`not advancefreely because the bevel maybedirecting the wire
`toward the vessel wall. If this happens, the operator should
`never force the wire because oftheriskofarterial dissection.
`The needle should be carefully rotated clockwise or counter
`clockwise until the wire can be easily advanced withoutresis-
`tance (Figure 7.7). With the dual-wall or back-wall technique,
`a micropuncture catheteris advanced through the front wall
`into the lumenofthe artery until bloodis noticed in the hub
`and then intentionally pushed through the back wall of the
`
`artery (Figure 7.8). Thefine needleis removed and the small
`Teflon microcatheteris slowly withdrawn until the appearance
`of brisk pulsatile flow (Figures 7.9 and 7.10). Then, the wire
`can befreely advanced and the microcatheter exchangedforthe
`arterial sheath (Figure 7.11). Theorifice in the back wallof the
`radialartery is sealed oncethesheathis in place (Figure 7.12).
`This technique has not been reported to be associated with a
`higherincidence of wrist hematomas. Proponents of the back-
`wall technique argue that this method is simpler, more repro-
`ducible, easier to teach, allows easier advancement of the wire,
`andthatthearterial pulsatile blood returnis 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
`
`
`
`Figure7.7,Transradial access technique-front wall tech
`
`
`nique (Step 4). A 0.018 inch short guidewire is advanced
`he proximal radial artery. Then the needle is exchanged for
`without resistance through the needle into t
`a hydrophilic-coated sheath.
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`176 .
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`‘Figure7.8Transradial access technique—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 + 7.6 to 2.8 + 2.5 minutes and the procedure time
`also decreased from 25.7 + 12.9 to 17.4 + 4.7 minutesalter
`the first 80 cases.’ More recently, in a group of 28 operators,
`Ball and colleagues documented a stepwise reduction of TRA-
`PCI failure rates from 7% to 2% (P = 0.01), contrast volume
`use from 180 + 79 to 168 + 79 mL (P = 0.05), and fluo-
`roscopy times from 15 + 10 to 12 © 9 minutes (P = 0.02)
`
`with increasing procedural volumes. The odds of TRA proce-
`dural failure showed a steep decline up to 50 cases, and after
`100 cases the learning curve flattened. Figure 7.13 shows that
`reasonsforfailure 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 vasculartortuosity?
`
`Prevention of Radial Artery Spasm
`Theradial 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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` que-back-wall technique(
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`(Figure7.10)Transradial access technique—back-wall technique (Step4),The microcatheteris retrieved very slowly
`
`until the appearanceofbrisk pulsatile blood return that confirms that the distal tip is in the lumen of
`the radial artery.
`
`
`
` Transradial access techni
`Step 3). Once the tip of microcatheter and needle
`are through the back wal