Distal radial approach for neurointerventional diagnosis and therapy

Background: The transradial approach results in fewer complications at the puncture site, lower hospital costs, and greater comfort for patients. The distal transradial approach (dTRA) adds some benefits over the conventional radial approach. The objective is to describe initial experience with distal radial approach technique and the results obtained for neuroendovascular diagnostic and therapeutic procedures. Methods: Description of distal radial approach technique and obtained data from the first 3 months experience using this approach as the first choice for neuroendovascular procedures in two neuroendovascular centers. Results: Of the total of 94 procedures performed during 3 months, 67 were diagnostic and 27 were therapeutic. Eleven (16%) of the diagnostic procedures were performed through the dTRA. Of the 27 embolizations, eight (30%) were done using this approach. Every distal radial approach that was performed for diagnosis and therapeutics was successful. Conclusion: Puncture of the radial artery within the anatomical snuffbox is a radial approach variation option for diagnostic and therapeutic neuroendovascular procedures.

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Post-procedural radial artery occlusion and patency detection using duplex ultrasound vs. the reverse Barbeau test

European Heart Journal Supplements ◽

10.1093/eurheartj/suaa095 ◽

2020 ◽

Vol 22 (Supplement_F) ◽

pp. F23-F29

Author(s):

Stepan Jirous ◽

Ivo Bernat ◽

David Slezak ◽

Roman Miklik ◽

Richard Rokyta

Keyword(s):

Radial Artery ◽

Duplex Ultrasound ◽

Artery Occlusion ◽

Duplex Ultrasonography ◽

Transradial Approach ◽

Local Complications ◽

Compression Time ◽

First Choice ◽

Same Day Discharge ◽

Radial Artery Occlusion

Abstract The transradial approach is recommended as a first choice in coronary catheterizations and interventions, for among other reasons, the reduction in the number of local complications. A head-to-head comparison of the reverse Barbeau test (RBT) and duplex ultrasonography (DUSG) for the detection of post-procedural radial artery patency and occlusion has not yet been evaluated. In 500 patients from our same-day discharge program (age 65 ± 9.4 years, 148 women), radial artery patency and occlusion, compression time, haematomas, and other local complications were evaluated. Radial artery patency was confirmed in 495 patients (99.0%), and complete radial artery occlusion (RAO) was detected in 2 (0.4%) patients using both methods. In 3 patients (0.6%), the RBT was negative, while incomplete RAO was detected by DUSG. Superficial haematomas (˃ 5 but ≤10 cm) were found in 27 (5.4%) patients. There were no other local complications. Detection of radial artery patency and occlusion using the RBT and DUSG was comparable. The incidence of RAO in our study was extremely low. Thanks to its simplicity, the RBT has the potential to be used as the first method of detection of radial occlusion after coronary catheterizations.

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The Rationale for Radial Artery Access in Neurointerventional Surgery

Radial Access for Neurointervention ◽

10.1093/med/9780197524176.003.0001 ◽

2021 ◽

pp. 1-8

Author(s):

Samir Sur ◽

Stephanie H. Chen ◽

Pascal M. Jabbour ◽

Eric C. Peterson

Keyword(s):

Radial Artery ◽

Collateral Circulation ◽

Interventional Cardiology ◽

Transradial Approach ◽

Radial Approach ◽

The Core ◽

Radial Access ◽

Ischemic Complications ◽

Basic Concepts ◽

Arterial Anatomy

Over 20 years of investigation and experience have gone into pioneering the radial approach for cardiac interventions. This has shown the technique to be superior to the traditional transfemoral technique for a variety of reasons. Neurointerventionalists have until recently been unaware of this innovation and are only starting to use it in their practice. Most of the data from the interventional cardiology journey into radial access is unknown to the neurointerventionalist audience, and concepts that underpin radial access are unfamailiar. Even basic concepts such as radial arterial anatomy, collateral circulation of the hand, and low rates of ischemic complications have been siloed in the cardiology literature. The core rationale for the transradial approach is reviewed.

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Distal transradial access in the anatomical snuffbox for diagnostic cerebral angiography

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-014718 ◽

2019 ◽

Vol 11 (7) ◽

pp. 710-713 ◽

Cited By ~ 33

Author(s):

Marie-Christine Brunet ◽

Stephanie H Chen ◽

Samir Sur ◽

David J McCarthy ◽

Brian Snelling ◽

...

Keyword(s):

Radial Artery ◽

Cerebral Angiography ◽

Hospital Costs ◽

Artery Occlusion ◽

Patient Comfort ◽

Complication Rates ◽

Transfemoral Approach ◽

Transradial Approach ◽

Access Site Complication ◽

Patient Demographics

BackgroundThe transradial approach for endovascular angiography and interventional procedures is superior to the traditional transfemoral approach in several metrics, including lower access-site complication rates, higher patient satisfaction, and lower hospital costs. Interventional cardiologists have begun to adopt the distal transradial approach (dTRA) for coronary interventions as it has an improved safety profile and improved procedural ergonomics. Adaptation of dTRA for neuroendovascular procedures promises similar benefit, but requires a learning curve.ObjectiveTo report the first use of dTRA for diagnostic cerebral angiography and demonstrate the feasibility and safety of a dTRA.MethodsA retrospective review of our prospective institutional database of consecutive cases of cerebral DSA performed via dTRA between August 2018 and December 2018 was performed. Patient demographics, procedural and radiographic metrics, and clinical data were recorded.Results85 patients were identified with an average age of 53.8 years (range 18–82); 67 (78.8%) patients were female. 78 patients underwent successful dTRA diagnostic cerebral angiography, with a mean of five vessels catheterized and average fluoroscopy time of 12.0 min, or 2.6 min for each vessel. Seven patients required conversion to transfemoral access, with the most common reason being inability to advance the wire and radial artery spasm. There were no complications.ConclusiondTRA is associated with decreased rates of radial artery occlusion, ischemic hand events, as well as improved patient comfort, faster periprocedural management, and cost benefits. Our preliminary experience with dTRA for diagnostic cerebral angiography demonstrates excellent feasibility and safety in combination with relative efficiency.

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Abstract WMP2: Pearls and Pitfalls of the Transradial Approach for Neurointerventions: Lessons Learned After 570 Cases

Stroke ◽

10.1161/str.51.suppl_1.wmp2 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Ahmad Sweid ◽

Omaditya Khanna ◽

Somnath Das ◽

Julie Kim ◽

Darcy Curtis ◽

...

Keyword(s):

Radial Artery ◽

Lessons Learned ◽

Fluoroscopy Time ◽

Access Site ◽

Safe Alternative ◽

Transradial Approach ◽

Access Site Complication ◽

Wide Range ◽

Therapeutic Procedures ◽

Web Device

Background and Purpose: Trans radial catheterization is an alternate route of access that has started to gain more widespread use for neuroendovascular procedures. There are several randomized controlled trials from cardiac field that had established its safety and efficacy. We present our institution’s experience in performing neuroendovascular interventions via a transradial approach. Methods: We conducted a retrospective analysis and identified 570 patients who underwent consecutive neuroendovascular interventions via radial artery access. Data collection was performed on indication for procedure, sheath size, catheter type, number of vessels selectively catheterized, fluoroscopy time, procedure duration, radiation exposure, conversion to femoral approach, access site complication, and procedure success. Results: Of 570 patients with an average age of 59.4 years ± 14.7, 406 (71.2%) underwent diagnostic angiograms and 164 (28.7%) underwent therapeutic procedures. The overall mean number of vessels catheterized was 2.9 ± 1.7 per procedure. The RCCA was the most frequent selectively catheterized artery; 340 (22.9%), followed by LCCA; 306 (20.6%), RICA; 250 (16.8%), LICA; 238 (16.0%), RVA; 159 (10.71%), LVA; 76 (5.1%), RECA; 61 (4.1%), and lastly the LECA selectively catheterized in 54 (3.6%). The average amount of contrast given was 83.4 cc ± 51.Successfully completed therapeutic procedures included aneurysm simple coiling (34 patients), stent assisted coiling (30 patients), flow diversion (34) patients), ICA balloon angioplasty and stenting (20 patients), Web device (8), AVM embolization (14), IAC for retinoblastoma (1 patient), and stroke thrombectomy (23 patients). The average duration was 72 mins ± 43, and average fluoroscopy time was 13.20 mins ± 11.20. Seventeen patients (3.2%) required conversion to transfemoral access. Twelve minor complications (2.3%) were reported including mild oozing after deflation of the balloon, ecchymosis, mild swelling. No major complications were encountered. Conclusions: Radial artery catheterization is a safe and effective access site to perform a wide range of diagnostic and therapeutic procedures. Complication and conversion rate are low making it a safe alternative.

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Initial experience of subcutaneous nitroglycerin for distal transradial access in neurointerventions

Surgical Neurology International ◽

10.25259/sni_711_2021 ◽

2021 ◽

Vol 12 ◽

pp. 513

Author(s):

Maham Ahmed ◽

Stephanie Zyck ◽

Grahame C. Gould

Keyword(s):

Radial Artery ◽

Small Diameter ◽

Diagnostic Procedures ◽

Initial Experience ◽

Access Site ◽

Palmar Arch ◽

Access Site Complication ◽

Hand Ischemia ◽

Transradial Access ◽

Neurointerventional Procedures

Background: Transradial access (TRA) for diagnostic and interventional neuroendovascular procedures has gained significant popularity in recent years due to its improved safety profile and appeal to patients compared with transfemoral access. However, risks of TRA include hand ischemia in cases of poor ulnar collateral circulation and inability to cannulate the radial artery due to its relatively small diameter. By accessing the radial artery distal to the superficial palmar arch where ulnar collateral blood flow arises, in the anatomic snuffbox, the risk of hand ischemia is theoretically eliminated. The use of subcutaneous nitroglycerin and lidocaine to improve rates of success in radial artery access has been reported in the cardiac literature, however, has yet to be described for neurointerventional procedures. We discuss our technique and report our initial experience using subcutaneous nitroglycerin and lidocaine cocktail for access to the distal transradial artery in a variety of neuroendovascular procedures. Methods: A retrospective review of our institution’s database of neurointerventional and diagnostic procedures performed using dTRA was conducted, and 64 patients were identified between February and December 2020. Patient demographics, clinical data, procedural details, and radiographic information were collected and analyzed. Results: A total of 64 patients underwent neurointerventional procedures using the subcutaneous injection for dTRA access. The procedures performed included diagnostic cerebral angiograms (n = 47), stent and balloon assisted aneurysm coiling (n = 5), flow diversion (n = 2), intra-saccular device placement (n = 1), mechanical thrombectomy (n = 1), tumor embolization (n = 1), middle meningeal artery embolization (n = 2), extracranial carotid stent placement (n = 2), and arteriovenous malformation embolization (n = 3). While no complications of hand ischemia were appreciated, the access site conversion rate was 3.1%; 2 cases required a switch to femoral artery access due to proximal vessel tortuosity and aortic anatomical variations, and not due to access site complication. Furthermore, on repeat angiograms by the same proceduralist, distal TRA (dTRA) was successful in 100% of the cases. Conclusion: dTRA using subcutaneous nitroglycerin and lidocaine is a safe and effective method for neurointerventional and diagnostic procedures.

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Distal Transradial “Snuffbox” Approach

Radial Access for Neurointervention ◽

10.1093/med/9780197524176.003.0003 ◽

2021 ◽

pp. 23-30

Author(s):

Marie-Christine Brunet ◽

Stephanie H. Chen ◽

Pascal M. Jabbour ◽

Eric C. Peterson

Keyword(s):

Radial Artery ◽

Lower Risk ◽

Patient Positioning ◽

Diagnostic Procedures ◽

Interventional Cardiology ◽

Neutral Position ◽

Radial Approach ◽

Radial Access ◽

Frequent Use ◽

Distal Location

The distal radial or “snuffbox” approach is a modification of the traditional radial approach that uses a more distal location of the radial artery for puncture. The radial artery at this location is beyond the palmer arch thus puncturing has a theoretically lower risk of hand or thumb ischemia. In addition, the hand is positioned in the neutral position so it is more comfortable for the patient. Finally, the compression times are shorter so the patient can be discharged earlier after diagnostic procedures. This was originally an interventional cardiology innovation because of the frequent use of left radial access in interventional cardiology, but the approach has benefits for right radial access in neurointervention as well. The patient positioning and technical nuances of the snuffbox approach are reviewed.

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Access-site complications of the transradial approach: Rare but still there.

Current Cardiology Reviews ◽

10.2174/1573403x16999200819101923 ◽

2020 ◽

Vol 16 ◽

Author(s):

Stelina Alkagiet ◽

Dimitrios Petroglou ◽

Dimitrios N. Nikas ◽

Theofilos M. Kolettis

Keyword(s):

Radial Artery ◽

Artery Occlusion ◽

Tissue Loss ◽

Access Site ◽

Transradial Approach ◽

Financial Benefits ◽

Eversion Endarterectomy ◽

Life Threatening ◽

Sheath Insertion ◽

Venous Fistula

: In the past decade, the Transradial Approach (TRA) has constantly gained ground among interventional cardiologists. TRA's anatomical advantages, in addition to patients' acceptance and financial benefits, due to rapid patient mobilization and shorter hospital stay, made it the default approach in most catheterization laboratories. Access-site complications of TRA are rare, and usually of little clinical impact, thus they are often overlooked and underdiagnosed. Radial Artery Occlusion (RAO) is the most common, followed by radial artery spasm, perforation, hemorrhagic complications, pseudoaneurysm, arterio-venous fistula and even rarer complications, such as nerve injury, sterile granuloma, eversion endarterectomy or skin necrosis. Most of them are conservatively treated, but rarely, surgical treatment may be needed and late diagnosis may lead to life-threatening situations, such as hand ischemia or compartment syndrome and tissue loss. Additionally, some complications may eventually lead to TRA failure and switch to a different approach. On the other hand, it is the opinion of the authors that non-occlusive radial artery injury, commonly included in TRA's complications in the literature, should be regarded more as an anticipated functional and anatomical cascade, following radial artery puncture and sheath insertion.

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Propensity-adjusted cost analysis of radial versus femoral access for neuroendovascular procedures

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016728 ◽

2020 ◽

pp. neurintsurg-2020-016728

Author(s):

Joshua S Catapano ◽

Andrew F Ducruet ◽

Stefan W Koester ◽

Tyler S Cole ◽

Jacob F Baranoski ◽

...

Keyword(s):

Hospital Stay ◽

Hospital Costs ◽

Length Of Hospital Stay ◽

Diagnostic Procedures ◽

Femoral Access ◽

Catheter Size ◽

The Mean ◽

The Difference ◽

Procedure Type ◽

Angiographic Findings

BackgroundTransradial artery (TRA) access for neuroendovascular procedures is associated with fewer complications than transfemoral artery (TFA) access. This study compares hospital costs associated with TRA access to those associated with TFA access for neurointerventions.MethodsElective neuroendovascular procedures at a single center were retrospectively analyzed from October 1, 2018 to May 31, 2019. Hospital costs for each procedure were obtained from the hospital financial department. The primary outcome was the difference in the mean hospital costs after propensity adjustment between patients who underwent TRA compared with TFA access.ResultsOf the 338 elective procedures included, 63 (19%) were performed through TRA versus 275 (81%) through TFA access. Diagnostic procedures were more common in the TRA cohort (51 of 63, 81%) compared with the TFA cohort (197 of 275, 72%), but the difference was not significant (p=0.48). The TRA cohort had a shorter length of hospital stay (mean (SD) 0.3 (0.5) days) compared with the TFA cohort (mean 0.7 (1.3) days; p=0.02) and lower hospital costs (mean $12 968 ($6518) compared with the TFA cohort (mean $17 150 ($10 946); p=0.004). After propensity adjustment for age, sex, symptoms, angiographic findings, procedure type, sheath size, and catheter size, TRA access was associated with a mean hospital cost of $2514 less than that for TFA access (95% CI −$4931 to −$97; p=0.04).ConclusionNeuroendovascular procedures performed through TRA access are associated with lower hospital costs than TFA procedures. The lower cost is likely due to a decreased length of hospital stay for TRA.

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