Get Schooled at TRU: Questions and Answers From Transradial University

Since the benefit of bivalirudin with percutaneous coronary intervention (PCI) is to decrease bleeding complications, does it make sense to use heparin with transradial PCI, given the cost savings? It seems unlikely that bivalirudin would be of benefit given the extremely low rate of access problems with the radial artery.

It’s important to realize that there are several sites of bleeding in patients undergoing PCI and especially in patients with acute coronary syndromes (ACS). Access site bleeding accounts for the majority of bleeding in patients undergoing PCI, but the next most common site is gastrointestinal (GI) bleeding. GI bleeding is highly correlated wicth mortality and is not impacted by access site choice. In order to achieve “zero bleeding risk,” it’s best to combine an access site strategy (radial) with a pharmacological strategy (bivalirudin).

Sunil V. Rao MD, FACC FSCAI
Associate Professor of Medicine, Duke University Medical Center

I typically use right radial access even when patients have LIMA grafts, because I believe that my radiation exposure (as opposed to total fluoroscopy time) is increased by using left radial access and leaning across the patient (I am 5’7” tall). I only use the left side when I must, as I find standing on the patient’s left side with the monitor at his or her feet to be more awkward. What are your favorite catheters for left subclavian access via the right radial?

When accessing the left subclavian and LIMA from the right radial, I tend to start with an IMA catheter. I like to use a Glidewire (0.035 angled) in order to have somewhat more ease of engagement, support and tracking. Generally, this catheter works for me; however, if the takeoff of the LIMA is angled unfavorably, then switching to something else that will have a more favorable angle is reasonable. In my opinion, it’s important to remember that excessive manipulation in the arch or in the subclavian can lead to untoward events, so maintaining a relatively low threshold to switch to the left radial or femoral approach is reasonable.

Daniel H. Steinberg, MD
Medical University of South Carolina

What is the guiding catheter of choice for transradial interventions for each of the coronary arteries?

For the left coronary artery, I use the EBU 3.5. Recently I have been using the EZ Radial Left by Medtronic. This comes in short, regular, and long tip versions. The regular is the standard size. If the root is large, then I will use a long tip. At times, I have found that the JL3.5 will work well for the left system.

John T. Coppola, MD, FACC
NYU Langone Medical Center

Please discuss radial access setup through the left radial.

Our institution uses the left radial artery frequently. We access the artery by standing on the left side of the patient with the arm extended. Once the sheath is in, we bring the arm parallel to the body and raised up on pillows. We then move to the patient’s right side and do the procedure by reaching across the body. In non-emergent cases, where groin access for a support device is unlikely, we add additional operator radiation protection by draping a lead shield across the patient’s groin so the operator’s hands are protected. We avoid the practice of draping the patient’s hand across their chest, as this makes it difficult for patients to keep the arm still. Of course, in obese patients, reaching across the body can be problematic, so we tend to use the left arm on smaller patients, particularly small, elderly patients, as the data suggest these are the patients with the highest failure rates from the right side.

Christopher T. Pyne, MD
Lahey Clinic, Heart & Vascular Center – Burlington

For patients on coumadin, is there any particular cut-off number for the PT-INR that precludes radial access?

There is data that supports the safety of transradial access for patients on oral anticoagulation. It has, therefore, become reasonable for interventionalists to continue warfarin — particularly in patients with high-risk thrombotic conditions — throughout the catheterization. Our laboratory has no “cut-off” for the INR for a transradial procedure, but we try to keep patients in their usual therapeutic range. Obviously, the physician should weigh the risks and benefits of continued warfarin in all aspects of the case, but there is data to support continued oral anticoagulation with the radial approach, and physicians are becoming more comfortable with it.

Christopher T. Pyne, MD
Lahey Clinic, Heart & Vascular Center – Burlington

What catheter/vendor do you use for lower extremity angiography via the radial artery? I don’t currently stock anything long enough to reach the iliac bifurcation.

There are a few catheters that I stock in my lab specifically for this purpose. First of all, when trying to get to the legs from the arm, using the left radial approach will often save 10-15 cm as compared to the right radial approach. If you are worried that the catheter won’t reach, then start with the left radial approach.

Most commonly I use a 4 or 5 Fr (125 cm) multipurpose diagnostic catheter (Cordis Corporation). Unless the patient is over 5’10”, I am able to get into the common or external iliac from the right radial approach (further if I use the left radial approach). I can do power injections from that location and can visualize to the feet. The other catheter that I have used on taller patients or when I need to get further down the leg is the CXI catheter family (Cook Medical). They come in 2.6/4 Fr, 90/135/150 cm lengths, and angled/straight tip. I have done both hand injection and low-pressure, power injection with these catheters. With the 150 cm length, one should be able to reach well into most patients’ legs. From a cost perspective, I usually start with the MP and if I need more length or cannot see to the leg, will go to a 4 Fr (150 cm) angled-tip CXI.

Adhir R. Shroff, MD, MPH
University of Illinois — Chicago Jesse Brown VA Medical Center

Some patients complain of forearm discomfort after the case. How do you handle that call from the nurse?

Assuming you have a low index of suspicion for a complication, we treat this conservatively with acetaminophen. Some of our nurses will apply a warm compres to the forearm. In our experience, it resolves in 60-90 minutes.

Jack J Hall, MD, St. Vincent Heart Center, Indianapolis

What about radiation exposure?

Always try and position the arm parallel, and not perpendicular, to the body. This location brings the wrist to below the level of the groin, further from image intensifier.
Consider adding extension tubing between the manifold and catheter; This further distances the operator from radiation source (at the level of patient’s foot). Place a three-way stopcock between extension tubing and catheter so the catheter can torque freely via the swivel.

Jack P. Chen, MD, FACC, FSCAI, FCCP, Saint Joseph’s Heart and Vascular Institute, Atlanta