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| {{Infobox Artery |
| | __NOTOC__ |
| Name = {{PAGENAME}} |
| | {{Radial artery catheterization}} |
| Latin = A. Radialis |
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| GraySubject = 151 |
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| GrayPage = 592 |
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| Image = Gray1237_svg.png |
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| Caption = Palm of left hand, showing position of skin creases and bones, and surface markings for the volar arches. |
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| Image2 = Gray528.png |
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| Caption2 = [[Ulnar artery|Ulnar]] and radial arteries. Deep view. |
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| BranchFrom = [[brachial artery]] |
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| BranchTo = |
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| Vein = [[radial vein]] |
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| Supplies = |
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| MeshName = Radial+Artery |
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| MeshNumber = A07.231.114.740 |
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| }} | |
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| {{SI}} | | {{SI}} |
| | {{CMG}}; '''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.; {{AO}} |
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| '''Editors-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]],
| | Synonyms and Keywords: Radial first, Radialfirst, Radialfirst, Radial approach, Right radial, Left radial, Go radial |
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| ==Advantages of the Radial Approach to Cardiac Catheterization==
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| # Reduced bleeding
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| # Early patient ambulation
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| # Greater patient satisfaction
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| # Absence of retroperitoneal hematomas, femoral pseudo aneurysms, arterial / venous fistulas
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| # Reduced length of stay
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| # Improved access in the obese patient
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| In a meta-analysis of publications from 1980 to 2008, radial artery catheterization was associated with a 73% relative risk reduction in the risk of major bleeding (2.3% vs 0.05%, p<0.001) compared to femoral access.
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| While the risk of the composite endpoint of death, [[myocardial infarction]] ([[MI]]) and [[stroke]] tended to be less frequent among patients undergoing radial artery catheterization (3.8% vs 2.5%, p = .058), there was no difference in mortality alone. Radial artery access also was associated with a 0.4% reduction in length of stay (p=0.001).<ref name="pmid19081409">{{cite journal |author=Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR |title=Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials |journal=[[American Heart Journal]] |volume=157 |issue=1 |pages=132–40 |year=2009 |month=January |pmid=19081409 |doi=10.1016/j.ahj.2008.08.023 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(08)00742-4 |issn= |accessdate=2010-02-23}}</ref>
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| ==Potential Pitfalls of the Radial Approach to Cardiac Catheterization==
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| # Spasm
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| # Vessel tortuosity
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| # Guide catheter support and selection may be reduced
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| # Loss of [[radial artery]] pulse in 4% of cases
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| # Potential increase in the duration of the procedure and fluroscopy time
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| # The radial artery has been instrumented should there be a desire to use it as a conduit for CABG
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| # It is the second and not the first approach learned by trainees
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| # There is a learning curve in treating spasm, navigating anatomy, and manipulating catheters
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| # Anatomically there can be a loop in the artery near the brachial in about 10% of cases
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| ==Radial Artery Anatomy==
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| ===In the Forearm===
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| * [[Radial recurrent artery]] - arises just after the radial artery comes off the brachial artery. It travels superiorly to anastomose with the [[radial collateral artery]].
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| * [[Palmar carpal branch of radial artery]] - a small vessel which arises near the lower border of the [[pronator quadratus muscle|pronator quadratus]]
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| * [[Superficial palmar branch of the radial artery]] - arises from the radial artery, just where this vessel is about to wind around the lateral side of the wrist.
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| ===At the Wrist===
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| * [[Dorsal carpal branch of radial artery]] - a small vessel which arises beneath the extensor tendons of the thumb
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| * '''First dorsal metacarpal artery''' - arises just before the radial artery passes between the two heads of the first dorsal interosseous muscle and divides almost immediately into two branches which supply the adjacent sides of the thumb and index finger; the lateral side of the thumb receives a branch directly from the radial artery.
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| ===In the Hand===
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| * [[Princeps pollicis artery]] - arises from the radial artery just as it turns medially to the deep part of the hand.
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| * [[Radialis indicis]] - arises close to the princeps pollicis. The two arteries may arise from a common trunk, the first palmar metacarpal artery.
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| * [[Deep palmar arch]] - terminal part of radial artery.
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| ==Additional images==
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| <gallery>
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| Image:Gray526.png|Diagram of the anastomosis around the elbow-joint.
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| Image:Gray527.png|The radial and ulnar arteries.
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| Image:Gray1235.png|Front of right upper extremity, showing surface markings for bones, arteries, and nerves.
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| Image:Gray417.png|Cross-section through the middle of the forearm.
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| Image:Gray421.png|Transverse section across distal ends of radius and ulna.
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| Image:Gray422.png|Transverse section across the wrist and digits.
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| </gallery>
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| ==Contraindications to Utilization of the Radial Approach to Cardiac Catheterization==
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| # [[Cellulitis]] or other infections over the [[radial artery]]
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| # Absence of palpable [[radial artery]] pulse
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| # Positive [[Allen test]] (see below), indicating that only one artery supplies the hand
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| # Coagulation defects (relative)
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| ==Performance of the [[Allen Test]] Before the Procedure==
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| The hand is normally supplied by blood from the ulnar and radial arteries. The arteries undergo [[anastomosis]] in the hand. Thus, if the blood supply from one of the arteries is cut off, the other artery can supply adequate blood to the hand. A minority of people lack this dual blood supply. An [[Allen Test]] should be performed before the procedure to confirm that there is sufficient blood flow in the [[ulnar artery]] should there be a loss of patency in the [[radial artery]] due to either thrombosis or spasm which can result in gangrenous finger or had loss. People who have a single blood supply in one hand often have a dual supply in the other, allowing the practitioner to take blood from the side with dual supply. This test is named after [[Edgar Van Nuys Allen]].<ref>{{WhoNamedIt|synd|189}}</ref>
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| The utility of the Allen's test has been questioned,<ref name="pmid11081899">{{cite journal |author=Jarvis MA, Jarvis CL, Jones PR, Spyt TJ |title=Reliability of Allen's test in selection of patients for radial artery harvest |journal=Ann. Thorac. Surg. |volume=70 |issue=4 |pages=1362–5 |year=2000 |month=October |pmid=11081899 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(00)01551-4}}</ref> and no direct association with ischemic complications of radial artery cannulation have ever been demonstrated. In 1983, Slogoff and colleagues reviewed 1,782 radial artery cannulations and found that 25% of them resulted in complete radial artery occlusion, without apparent adverse effects.<ref>Slogoff s, Keats AS, Arlund C. On the safety of radial artery cannulation. Anesthesiology 1983; 59:42-7</ref> A number of reports have been published in which permanent ischemic sequelae occurred even in the presence of a normal Allen's test.<ref>Thompson SR, Hirschberg A: Allen's test re-examined. Crit Care Med 16:915, 1988</ref><ref>Wilkins RG: Radial artery cannulation and ischaemic damage: A review. Anaesthesia 40:896-899, 1985</ref> In addition, the results of Allen's tests do not appear to correlate with distal blood flow as demonstrated by fluorescein dye injections<ref>McGregor AD: The Allen test-an investigation of its accuracy by fluorescein angiography. J Hand Surg [Br] 12:82-85, 1987</ref> or photoplethysmography.<ref>Stead SW, Stirt JA: Assessment of digital blood flow and palmar collateral circulation. Int J Clin Monit Comput 2:29, 1985</ref>
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| Modifications to the test have been proposed to improve reliability.<ref name="pmid17643672">{{cite journal |author=Asif M, Sarkar PK |title=Three-digit Allen's test |journal=Ann. Thorac. Surg. |volume=84 |issue=2 |pages=686–7 |year=2007 |month=August |pmid=17643672 |doi=10.1016/j.athoracsur.2006.11.038 |url=http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(06)02283-1}}</ref>
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| Despite this lack of association with outcomes, the Allen Test is often performed in clinical practice.
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| === How to Perform The Allen Test ===
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| 1) The hand is elevated and the patient/person is asked to make a fist for about 30 secs.
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| 2) Pressure is applied over the ulnar and the radial arteries so as to occlude both of them.
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| 3) Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails).
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| 4) Ulnar pressure is released and the color should return in 7 secs.
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| Inference: Ulnar artery supply to the hand is sufficient and it is safe to cannulate the radial artery
| | ==[[Radial artery cathetarization overview|Overview]]== |
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| If color does not return or returns after 7 seconds, then the ulnar artery supply to the hand is not sufficient and the radial artery therefore cannot be safely cannulated.
| | ==[[Radial artery|Radial Artery Anatomy]]== |
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| | ==[[Radial Catheterization Advantages|Advantages]]== |
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| ==Choosing the Left or Right Side for the Radial Approach== | | ==[[Radial catheterization pitfalls|Potential Pitfalls]]== |
| If the internal mammary artery must be canulated, then the left radial artery should be used.
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| ==Obtaining Radial Access== | | ==[[Radial catheterization contraindication|Contraindications]]== |
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| ==Initial Insertion of the Catheters== | | ==[[Radial catheterization allen's test|Pre-procedure Assessment]]== |
| To reduce spasm, 500 micrograms of [[diltiazem]] can be administered via the sidearm prior to insertion of the right and left sided catheters.
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| ==Catheter selection== | | ==[[Radial catheterization procedure|Procedure]]== |
| Many operators choose to start with the right coronary artery as the right sided catheter may allow for directing the wire as you make your way up around the arch. Once the wire is around the arch, it should remain there for exchanges. A JL 3.5 catheter may be used to engage the left coronary artery when catheterization is performed from the right arm.
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| ==Achieving hemostasis after Radial Artery Catheterization== | | ==[[Radial catheterization hemostasis|Achieving Hemostasis after Radial Artery Catheterization]]== |
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| ===Instructions for the use of the TR Band=== | | ==[[Radial catheterization complications|Complications]]== |
| # Radial arterial sheath removal after cardiac catheterization or PCI, or peripheral angiography with or without intervention will be performed by trained personnel
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| # Radial sheaths placed by cardiologists must be removed by a trained or supervised Cardiology Fellow or attending. Radial sheaths placed by a vascular surgeon must be removed by a Vascular surgery attending, fellow, PA, NP or trained surgical resident as designated by vascular MD’s.
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| # Radial artery sheaths will be removed in the Cardiac Catheterization Laboratory prior to transfer to a medical surgical inpatient unit. A radial artery sheath may be removed in the ICU or VICU setting.
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| #This device is placed on the hyper extended wrist and tightened via a Velcro band.
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| # A small green box indicates where the band should be placed proximal to the radial percutaneous site. Single wall stick; place the green dot on the TR Band about 3-4 mm proximal to the skin insertion site. Double wall stick; place the green dot just 1 mm or two proximal to the skin insertion site
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| # The TR Band inflator syringe is filled with 18 cc of air and slowly injected into the one-way side port which inflates the balloon overlying the radial artery.
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| # Concomitantly, the radial sheath is slowly pulled out completely, as the balloon is inflated to the maximum of 18 cc of air.
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| # Then slowly, withdraw air back out via the syringe, 1cc at a time, until the operator observes for blood leaking out from the puncture site, at which time, 1 cc of air is re-injected into the balloon and the syringe is disconnected.
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| #Keep the plunger in place with your thumb when inflating/deflating the TR band. Releasing the plunger will cause air to expel out of the band to quickly
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| #Remember to keep the syringe for later deflation
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| #Application tips to remember:
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| #Make sure the radial artery insertion site is 3 or more cm proximal to the wrist crease. If the site and thus the band are too close to the wrist, it may slip if the wrist bends
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| #Make sure the site is cleaned with sterile saline and dried completely before the band is placed on the wrist
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| #Place the green box proximal to the sheath insertion site(Terumo logo closest to the patients little finger)
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| #Pulling the sheath slowly as you are simultaneously inflating the TR Band to 18 cc’s. You should be completely removing the sheath at about the same time you hit 18cc’s.
| | ==[[Best practices for transradial angiography and intervention|Best Practices for Transradial Angiography]]== |
| #Once all 18cc’s are in the band and the sheath is removed, you slowly about 1cc per second begin reducing the amount of air in the band while visualizing the access site for a blood flash
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| #Once you visualize a blood flash you immediately put 1 to 2cc’s back into the band and disconnect the syringe confirming that the blood has ceased.
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| #If the air is released slowly out of the band, there is no need for gauze to be positioned under the TR Band. If you are removing the air slowly and at first sight of a blood flash 1 to 2 cc’s is put back into the band you will have a dry field. You want to have complete visualization of the access site, you do not want a gauze pad to block your visualization of the arteriotomy.
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| #Also, there is no need to make a skin nick when introducing the sheath (unless completely necessary). The Glidesheath is hydrophilic coated and has a near seamless transition and will not require a nick for insertion. The TR Band is designed to provide the least amount of pressure to gain hemostasis while maintaining flow through both the radial and ulnar arteries. The TR Band is not designed to provide hemostasis for both the arteriotomy of the access site as well as a large skin nick. That is why with the design of both these products a skin nick is not needed and you should never experience a situation in which you would need more than 18cc’s of air, which is occlusive pressure.
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| ==Complications of Radial Catheterization==
| | {{Coronary Angiography}} |
| Optical coherence tomography (OCT) has been used by Yonetsu et al to define the damage to the radial artery in 73 arteries of 69 patients <ref>Yonetsu T, Kakuta T, Lee T, et al. Assessment of acute injuries and chronic intimal thickening of the radial artery after transradial coronary intervention by optical coherence tomography. Eur Heart J. 2010;Epub ahead of print.</ref>. 32% of patients developed intimal tears and 16% of patients developed medial dissections. Repeat catheterization was associated with increased fibro-intimal hyperplasia. Cardiac catheterization via the radial approach may render the [[radial artery]] unsuitable for [[coronary artery bypass grafting]]. There can be a loss of pulse in about 4% of cases. Use of smaller guide catheters and sheathless guides may potentially reduce the risk of these complications.
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| ==References:==
| | [[Category:Angiopedia]] |
| {{reflist|2}}
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