Sang-Yong Yoo, M.D.
Department of Cardiology
Ulsan college of Medicine
Gangneung Asan Hospital

Meta-analysis of 12 randomized trials (1989 ~ 2003)
◦ 0.3% vs. 2.8% (transradial vs. transfemoral)
◦ 1 arteriovenous fistula
◦ 1 perforation of brachial artery requiring surgery
◦ 1 hematoma >3cm
◦ 2 others
Agostoni P, et al. JACC 2004;44:349-56

Randomized trial (2006 ~ 2008)
◦ First randomized trials (n=1,124) comparing access site complications after
coronary procedures via transradial versus transfemoral access with a closure devices.
◦ 0.58% (3 patients in 512) vs. 3.71% (transradial vs. transfemoral)

No beating radial artery pulse without forearm ischemia
Brueck M, et al. JACC 2009;2:1047-54
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

Vagal reactions
Radial artery spasm
Radial artery occlusion
Bleeding/Dissection/Perforation
Radial artery fistula
Pseudoaneurysm
Chronic pain/neuralgia
Cerebral embolism
Others

During sheath insertion, procedural
hypotension requiring treatment with
atropine occurs frequently.
Hildick-Smith DJ, et al. Int J Cardiol 1998;64:231.

May be exacerbated by verapamil.
 Decreasing
pain and anxiety
Between 1 to 3 hours before the start of a procedure
A eutectic mixture of
local anesthetic
(EMLA) cream
(lidocaine 2.5% and
prilocaine 2.5%)
가격: 수가 6,000원, 보험상한 3,960원
Kim JY J Invasive Cardiol 2007;19:6-9.

22%
8% onmed.) - Kiemeneij F, et al
(
(N=100)
(CCI 2003;58:281–284)

22.2% - The SPAMS study
(N=1,219)
(CCI 2006;68:231-235)

Fukuda, et al diagnosed RAS through
radial artery angiography and found
that RAS occurred in most patients
through transradial approach.
(Jpn Heart J 2004; 45: 723-731)

The SPASM study found that young and
female were the independent predictors of
RAS.
(Catheter Cardiovasc Interv 2006; 68: 231)

Saito et al found that the inner diameter of
radial artery was an independent predictor
of RAS.
(Catheter Cardiovasc Interv 1999; 46: 173)

In vitro studies showed that patients with
diabetes had serious endothelial
dysfunction and the radial artery was prone
to spasm.
(J Am Coll Cardiol 2007; 50:1047)

Kiemeneij F pointed out, a
straightforward, accurate, single
puncture will lower the risk of spasm.
(J Invasive Cardiol 2006;18:159.)

In the introduction of Turkey experience,
Vefali and Arslan deemed that the best
measure to prevent RAS was the least
number of access attempts.
(Turk Kardiyol Dern Ars 2008;36:163.)
p=0.001
p=0.003
25%
20.4%
20%
15%
p=0.804
10%
5%
0%
3.8%
4.4%
Nitroglycerin+Verapamil
Nitroglycerin
None
Radial artery spasm
Chen CW Cardiology 2006;105:43-47.
“Cocktail”= 200ug Nitroglycerin+ 5mg Verapamil
Maximal pullback force (Kg)
0.8
0.76
0.7
0.6
0.53
0.5
0.4
0.3
0.2
0.1
0
Cocktail
No cocktail
Kiemeneij F CCI 2003;58:281-284.
Catheter Cardivasc Interv 2006;68:231-235.
45%
OR 2.87; 95% CI 2.07-3.97, p<0.001)
39.9%
40%
35%
30%
n=783
25%
Short
sheath
(13cm)
Long sheath
(23cm)
20%
19.0%
15%
Hydrophilic
coated
Uncoated
Hydrophilic
coated
Uncoated
10%
5%
0%
Hydrophilic-coated
Uncoated
Radial artery spasm
Rathore JACC Cardiovasc interv 2010;3:475-83.
Smaller catheter
 Restricting catheter maneuvers and
exchanges
 Use an exchange length hydrophilic
guidewire that is maintained in a
stable position in the ascending aorta
to prevent spasm at radial or brachial
artery.

 58/F
 6 Fr sheath
 500 ug nitroglycerin

Even after the use
of a vasodilator,
RAS has been
reported in up to
20% of the patients
(Kim Sh et al. Int J Cardiol 2007; 120: 325).
Ana do lu Kar di yol Derg 2010;10:90

Incidence
◦2~10%
Prolonged cannulation
 Sheath size
 Anticoagulation
 Hemostasis

Youakim S. Occupational Medicine 2006;56:507

less than 3,000 U
◦ female
◦ radial artery
diameter (<2.7mm)

No predictive
factor of radial
occlusion in
patients receiving
5,000 U of heparin.
Post-procedural radial artery occlusion
(2 months)
80%
71%
70%
60%
p<0.05
50%
40%
24%
30%
p<0.05
20%
4.3%
10%
0%
0
2~3,000
5,000
Dose of heparin (U)
Spaulding C, et al. Cathet Cardiovasc Diag 1996;36:365
7.5%
8%
7%
6%
4.9%
5%
4%
3.5%
3%
2%
1%
0%
4, 5Fr
6 Fr
7, 8Fr
Occlusion
Saito, et al. CCVI 1999;46:173/Nagai et al, AJC 1999;83:180

Risk factors
◦ Radial artery diameter
◦ Difference in radial
artery diameter and
sheath size
◦ Diabetes mellitus
38% vs. 14% (p=0.0006)
Nagai et al. AJC 1999;83:180
a = Cross-over to femoral artery
b = p<0.05
Distal radial artery (5~25mm)
First TRI
Repeat PCI
P
Lumen area
(mm2)
5.27 ± 1.21
4.5 ± 0.99
<0.01
Intima-media
thickness (mm)
0.31 ± 0.07
MLD (mm)
2.43 ± 0.32
Yoo BS, et al. CCVI 2003;58:301
0.46 ± 0.10
2.23 ± 0.26
<0.01
<0.01
Wakeyama et al. JACC 2003;42:1109
Small pilot study
◦ not randomized, doubleblinded design
◦ symptomatic occlusion –
LMWH 4 weeks
◦ asymptomatic occlusion
– no treatment
100%
90%
86.7%
80%
70%
Patency

60%
50%
40%
30%
19.1%
20%
10%
0%
LMWH
Modified from Kim KS, et al. J Cardiovasc Ultrasound 2010;18:31
None
Zankl AR et al. Clin Res Cardiol 2010;99:841
Edgar V. N. Allen (1900-1961)
Professor of Medicine at the Mayor Clinic.
Wallach SG. Am J Critical Care 2004;13:315
But, an abnormal Allen’s test has never been
predictive of ischemic injury from an arterial
line. (J Trauma 2006;206:468.)


On the basis of the modified
Allen’s test ≤ 9 seconds
criteria, 6.3% of patients were
excluded from TRI
PL and OX type A,B, and C,
only 1.5% of patients were
excluded.
Barbeau GR, et al. Am Heart J 2004;147:489
Incidence of Radial Occlusion
12.0%
12%
10%
7.0%
8%
6%
5.0%
Perfused Hemostasis
Traditional Hemostasis
4%
1.8%
2%
0%
p<0.05
p<0.05
Early
Persistent (30 days)
Pancholy S, et al. CCI 2008;72:335

Abundant forearm branches

Anatomical variations
Luz A, et al. Eurointervention 2009;5:1
7%
2.3%
2.0%
2.5%
Types of radial anomaly and their rates of procedural failure
Lo TS, et al. Heart 2009;95:410
Avulsion of radial recurrent artery

Overzealous advancement of a wire
◦ useful in overcoming tortuous segment or
radial loops
◦ increase the risk of perforation
Type I: ≤ 5 cm
 Type II: ≤ 10 cm
 Type III: > 10 cm, but not above elbow
 Type IV: extending above elbow
 Type V: anywhere with ischemic
threat of the hand (compartment
syndrome)

Bertrand OF et al. 2009;157:164-9.




0.4% (overestimated)
Unrecognized perforation
Unsuccessful compression
Radial artery laceration during sheath insertion or removal
The tissue pressure
exceeded 100 mm Hg.
The patient’s forearm 1 hr after the transradial
intervention. The right forearm is stiffer and more
swollen than the left forearm.
we suspect that an
arterial spasm induced
by the radial sheath or
catheter resulted in
ischemia of the forearm
muscles.
The forearm muscles are swollen.
No bleeding or hematoma is noted.
The forearm muscles are greatly swollen and
partially necrosed, but hematoma or signs of
hemorrhage are not noted.
Araki T, et al. CCI 2010;75:362-365
Look under fluoroscopy during wiring.
 Don’t push – push and perforation
will happen.
 If in doubt take a picture.
 Early detection!

Rare complication
 Usually the result
of inadvertent
perforation of an
anomalous radial
artery.

87/F
• 0.3% in femoral access (Kent KC et al. J Vasc Surg
2004 diagnostic CAG via Rt. radial artery (6 Fr.) 1993;17:125), N=1,838.
2008 single vessel PCI via Rt. radial artery (6 Fr.) • Radial artery AV fistula after catheterization procedures
2010 Pulsatile mass
(4 cases were reported)
 Case 1. 64/M Pulikal et al. Circulation 2005
 Case 2. 59/M Spence et al. Can J Cardiol 2007
 Case 3. 61/M Spence et al. Can J Cardiol 2007
 Case 4. 67/M Kwac MS et al. Korean Cir J 2010

Sterile abscess
with use of
hydrophilic-coated
sheath
◦ 5% foreign body
reaction
◦ 2~3 weeks after
procedure
◦ Remnant of silicone
Several weeks after radial cardiac catheterization with a 6-F Cook
hydrophilic sheath, a sterile abscess formed between the skin and radial
artery. The patient had local pain without systemic symptoms. This was
treated with surgical drainage and local skin care with resolution over several
weeks.
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


46-year old
anesthesiologist
Allen’s test (-)
6 Fr, 23 cm sheath
10,000 U heparin
6 Fr pigtail catheter, 6 Fr
JL4
20 hr hemostasis
(Hemaband)
Over several months,
cold intolerance, burning
sensation, parasthesias,
and loss of pulse
Retire
Papadimos TJ, et al. Cathet Cardiovasc Interv 2002;57:537.

Success rate only
60% by transradial
approach
(Valsecchi O, et al.Catheter Cardiovasc Interv 2006;67:870–8.)
….the guide wire (0.035 inch; Terumo
Corp., Tokyo, Japan) was prone to
advance into the descending aorta.
After several attempts, the guide wire
passed into the ascending aorta.
However, resistance was encountered
while advancing a pigtail catheter (5Fr; Bard Inc., Murray Hill, NJ, USA).
Stasis of contrast medium was noted
after test injection of 5 mL of contrast
medium…….
J Chin Med Assoc 2009;72(7):379–381
16.0%
15.2%

14.0%
12.0%
◦ 92.1% gaseous
p=0.567
◦ 7.9% solid
10.0%
◦ more solid microemboli in
transradial 57 vs. 36,
p=0.012) in right MCA
8.0%
6.0%
◦ During catheter flushing,
ventriculography
4.0%
2.0%
0.0%
TCD (transcranial Doppler)
0
Transradial Transfemoral
New cerebral lesion (MRI)
• Cautious manipulation and gentle advancement of guidewire
and catheters especially aortic arch and aorto-subclavian
junction
• Exchange of catheters over the guidewires while leaving them in
the ascending aorta.
Lund C, et al. Eur Heart J 2009;26:1269
Meticulous technique, appropriate
preventive measures, and early
recognition of problems are
fundamental in avoiding unnecessary
morbidity and mortality associated
with these risk.
 Complications arising from radial
arterial access are infrequent and are
usually avoidable.
