0:01

So, what are the major advantages

0:02

of radial artery access?

0:03

Post procedure, patients are able to

0:05

immediately ambulate, whereas the common

0:07

femoral access requires patients to lie flat

0:09

for hours, about four to six hours, typically.

0:12

And this is potential for sort

0:13

of earlier discharge, right?

0:14

You get, maybe put on a little band, sort

0:16

of compress or apply pressure, you know,

0:19

for 15 minutes, and then get even a stasis.

0:22

You don't need to suffer the

0:24

expense of a closure device.

0:26

The access site complications are much

0:28

lower, typically, at the site itself,

0:31

and there's an improved sense of privacy.

0:32

It's not sort of a catheter or sheath or

0:34

pressure in your groin, which some may feel

0:37

is a little bit more invasive than a hole

0:39

in pressure or compression on the wrist.

0:42

So, what are three major disadvantages

0:44

of radial artery access?

0:46

Stroke, you know, crossing the common

0:49

carotid, the vertebral arteries, has

0:52

some sort of measurable risk of stroke.

0:54

That is really not the case with

0:56

common femoral artery access.

0:57

Unless you enter, you know, the arch and

1:01

you're performing an arch procedure, the

1:02

postoperative compartment syndrome could result.

1:06

Hand ischemia is also something that can result.

1:08

And here we see an example of an arterial

1:10

dissection and thrombosis of the radial artery in

1:13

a patient who previously had radial artery access in

1:16

the setting of coronary artery catheterization.

1:19

So, we decide to proceed with

1:20

this radial artery access.

1:21

And so what we do, we measure the caliber

1:23

of the radial artery with ultrasound.

1:25

We look at the vessel, make sure that,

1:27

you know, it's 3 millimeters or more.

1:29

Okay, because less than that would be contraindicated.

1:31

Make sure that the selling end technique is

1:33

alive and well and ready to rock and roll.

1:35

And so, you know, a short 21-gauge needle, echogenic tip.

1:37

(Repeated time code; should be removed.)

1:39

We got our little mandrel, 0.018 inch wire.

1:41

(Repeated time code; should be removed.)

1:42

It's ready to rock.

1:43

Then we have our sheath, our nice tapered sheath

1:46

that we would like to place and we want it to be

1:48

nice and maneuverable and soft, but supportive,

1:52

you know, for our radial artery access.

1:54

So, at the end of the day, we want to have a nice

1:56

hydrophilic sheath, and that will help reduce and

1:59

decrease sort of nice, normal access-related pain.

2:04

The presence of this hydrophilic sheath sort of

2:06

reduces spasm as well, and any risk for radial

2:10

artery occlusion that could possibly result.

2:12

Sometimes individuals may consider, you

2:14

know, using some nitroglycerin that can actually

2:17

maximally dilate the artery and minimize pain

2:19

as well, associated with radial artery access.

2:23

So, what we decide to do here is once

2:25

we proceed with radial artery access, we're

2:27

thinking, alright, so we get access.

2:30

What do we want to do?

2:30

How do we want to mitigate any issues?

2:33

We want to give a little antithrombotic,

2:35

we want to give an antispasmodic, and we

2:37

want to deliver all that via the sheath.

2:39

So, what some people may do is they may give some

2:42

heparin, they may give some verapamil, some

2:46

nitroglycerin. Those are sort of the cocktails

2:49

that are typically administered.

2:52

Pulse oximetry remains on the thumb to

2:55

monitor hand perfusion during the procedure.

2:57

So, out of sight is not out of mind.

2:59

We want to make sure that even though

3:00

the patient passed the Barbeau test, we

3:02

want to keep that in mind as a potential

3:05

confounding issue during our procedure.

3:07

We also want to note that the radial artery

3:09

is smaller than the common femoral artery, and

3:10

so we want to note that the limits to sheath

3:13

size are essentially less than 7 centimeters.

3:17

So, what are some complications

3:18

of radial artery access?

3:19

We talked about stroke.

3:21

We mentioned it, and it's not really seen typically

3:24

with common femoral artery access, but some would

3:25

say it can happen, and I would say okay, agreed.

3:30

The other point would be with radial artery

3:31

access, we're going to think about hand ischemia,

3:33

and again, the beauty of the Barbeau test is

3:35

that's going to really reduce the population

3:37

of individuals that are going to be more

3:39

likely to suffer from hand ischemia in the

3:41

absence of that collateral circulation between

3:44

the radial artery and the ulnar artery.

3:47

We want to think about pseudoaneurysms,

3:48

contained ruptures, we want to think about

3:49

hematomas, we want to think about hemorrhage,

3:51

think about vessel spasm and pain, you know,

3:54

and of course, radial artery occlusion,

3:56

which we've talked about mitigating.

3:58

And of course, compartment syndrome is

3:59

something that is just not a good look,

4:01

and so we want to be mindful of that.

4:04

So, there is a 2016 meta-analysis of 24

4:07

trials that studied about 22,000 individuals

4:11

that included the four large contemporary

4:13

trials of acute coronary syndrome patients.

4:16

And what they noted was the following: when you

4:18

look at femoral artery

4:20

access, radial artery access was actually

4:22

associated with a significantly lower

4:24

risk of major bleeding, all-cause

4:27

mortality, and major adverse cardiovascular,

4:30

as well as major vascular complications.