Editorial Board Comments:

Josef Ludwig:

We are not discharging our patients the same day due to internal policy.
Sorry

Tift Mann:

The current SCAI/ACC/AHA guidelines for outpatient stenting are conservative, esp when compared to policies from other institutions around the world. However, they are the established guidelines for the US. I suspect they will evolve with time and more data.

Yves Louvard:

Same answer as Josef Ludwig, reimbursement problem in France.
But a great majority of angio are outpatient ones

Ian Gilchrist:

I send essentially all of my elective PCI's home the same day. Primary criteria is a successful PCI and social (family) support for the night after. I would agree that the SCAI paper is too restrictive, but that was written to satisfy many constituents. I have found that same day discharge is another wonderful thing to do with radial. Patients really appreciate leaving the same day. They get a good night sleep at their own home. Our NP's call them the following day to confirm their discharge instructions and that they have their prescriptions filled. Biggest problem is that once they are done as a same day, they never want to stay over night again. We have done over 300 this way with no re-admissions. Data suggests that this is safe and patient support, once you start sending them home,will give you confidence to continue. In any case, at least in the US, you will no longer get paid for an admission for an elective PCI or at worse be subject to a RAC audit.

Sunil V. Rao:

Agree with Ian. Our protocol is successful radial PCI with no post-PCI chest painor bleeding, live within 60 miles, and have home support. We have only done 5 patients since Jan 2010 when the protocol was instituted, but that is because most of our patients are coming from > 60 miles.

Samir Pancholy:

We have had the same problem with patients traveling long distances to get to the hospital and hence same day discharge has not been a feasible practice in our area.

Mitchell Krucoff:

I am sending elective PCI pts home same day if they are not complicated (simple 1 stent, even bifurcation with good angiographic result) and early cases. The pts monitored for 6 hrs in hospital. I was told payment scale is different between same day (ambulatory), <24 hrs, or >24 hrs. But so far, the hospital has no objection to send elective PCI same day.

Tak

i think the important emphasis is coronary first, access site second, with the caveat that logistically the patient lives close enough and has family at home. and in the USA there is of course the final word: medicolegal.
if the coronary result is complex, mutliple stents or in any way suboptimal, same day d/c is not a good idea.
if the coronary result is simple and excellent, then TRI access site is a clear winner if patient lives nearby and has family.
in USA, medicolegal is safe on any of 3 predicates:
1. standard of community practice
2. in accordance with professional society guidelines
3. established hospital SOP, potentially more advanced than the standard of community practice so bottom line on medicolegal is to at least have an established, written, internally hospital approved SOP....otherwise a single event can be both a personal and programmatic tragedy.

Sasko Aleksandar Kedev:

We are doing outpatient elective PCI since 2007.
Optimal PCI result and the absence of local complications are mandatory for the same day discharge strategy.
We are discussing this issue with patients and families at the admission and after intervention, leaving the opportunity for overnight hospital stay at their preference. No major medical nor legal problem so far.
Best regards,

Tejas & Sanjay:

Out patient PCI is a very good and futuristic concept. However because of the social system our patients and the relatives are not willing to take discharge after PCI on the same day. We have done a pilot study of 123 patients who were sent to their private rooms in the hospital instead of ICCU. They were kept without monitoring and were given the cell no. of the doctor on call. We received only 3 phone calls in 24 hrs of stay. It means that the concept is working well but presently it is unfortunate that we are unable to convince the patients to go home after PCI.

Editorial Board Comments:

Mitchell Krucoff:

Don’t know of documented numbers but certainly more rare with TRI than with femoral, but still incidence is not zero.

Important to remember to use both saline and atropine as needed, especially in setting where we have given verapamil and/or nitroglycerine to avoid radial spasm.

Actually we routinely monitor HR and BP before sheath insertion, as these parameters are also required documentation for conscious sedation procedures.

This discussion belongs in a larger context: some people vagal at the sight of a needle, or during venipuncture...i think the bottom line is that vagal with TRI is far more rare than with FA, but more than zero.

Josef Ludwig:

I think we making a mouse to become an elephant. To the best of my knowledge-correct me- if I wrong vasovagal reaction is a clinical symptome with feeling bad oale patient cold sweat and drop of bot blood pressure and heart rate. If a.ybidy accuses radial puncture to be the bad boy then he has to look at bot HR and BP before and after punctering. Honestly, who of all the experts messure BP before the arterial sheath is in And can scientifically argue it was rhe puncture or sheath insertion. In my opinion it is not vasovagal it is rather a very vague comment to have frequenty vasovagal reactions. Never saw any in thousand of live cases or during Allens manoever

David Hildicksmith:

I think you all have selective memories. Vasovagal reactions are commoner at the wrist. You can even get them when dowsing the wrist itself with antiseptic in very nervous patients.

OK if you hit the artery cleanly you get no vasovagal, but if you miss and hit something else, vasovagal reactions are commoner. I can't believe any of you is saying anything different!

Yves Louvard:

I have probably datas in one of my very old presentation (94-95 ...)

But things have changed since that time:
- I am more quiet and patients may feel it when doing radial
- sheath are less aggressive
- in France when we work with an anesthetist in the cath lab there is a preliminaryvisit and specific drugs are prescribed ...
- I remember a paper by Peter Ludman showing more pain for the radial ... it was in middle age ...

I agree with David ... without anesthetist in the cath lab this is driven by pain as you know ... Radial approach needs a better preparation of the patient.

Sunil V. Rao:

I have seen this twice, both times in men (we are wimps!). Both times occurred in the setting of the patient being anxious and one of them recurred when navigating a forearm loop. Both resolved quickly with 0.5 mg atropine. We have had several instances of vagal reactions during femoral sheath removal, and none with radial sheath removal. I think it's more common with manual pressure on the femoral artery but I have no data to back that up.

David,
It's interesting that your experience is so different from everyone else. Do you happen to know of any references? It's quite possible that I have attributed any relative hypotension during radial access to sedation or SL TNG, etc. instead of a vagal reaction.

Tak Kwan:

Dear all,
TEJAS's lab uses no sedation! Is any difference?
I also has no recall of the vagal reaction even though there was extreme pain occasionally during shealth removal.

Ian Gilchrist:

It has been my experience that these reactions are lacking at the wrist level although vagal like reactions during acute procedures such as inferior wall MI's still occur. The literature has several references to vagal reactions on the order of 5% in transradial series, but I just have not had that experience and thought I would ask your thoughts/experiences.

James Tift Mann:

Polled the guys that know ie the techs!! 30 techs in 8 labs(both rad and fem): overwhelming majority responded most vagals occur with femoral sheath PULL post cath.

Samir Pancholy:

I do not think anyone has specifically looked at the difference, but in general I have rarely seen true vasovagal reaction from TRA. The couple that I remember are triggered by nitroglycerin and not pain.
I pretreat with Atropine 1 mg before cocktail, if heart rate is less than 45. Although this is not very frequent it may be further lessening the vasovagal trigger.

John Coppola:

I do not believe I have seen a vasovagal reaction I believe the nitro may decrease bp and this quickly reverses with fluid

Olivier F Bertrand:

I have faced some when crossing and straightening loops in the arm, usually associated with some pain I remember also of 1 big guy during radial artery puncture...
Corrected rapidly with 0.5 or 1 mg atropine

Sasko Aleksandar Kedev:

I could not recall on true vasovagal reaction associated with radial artery puncture and sheath removal. There were some vagal like reactions during TRA carotid stenting and RCA reperfusion.

Howard A Cohen:

I have been reading the responses with interest. In my experience I would have to say that I have noted hypotension and bradycardia infrequently, but perhaps more than others have noted it. I think we are dealing with a multi-factorial issue here. I do not believe that there is more pain with TR access, and I am sure that we would all agree that it is clearly more comfortable for the patient from start to finish. I do not believe that I have ever noted a "vaso-vagal" reaction with sheath removal or insertion per se. Remember that all our patients are receiving a spasmolytic cocktail that may accentuate this problem. When hypotension and bradycardia occur, it is after the administration of nitroglycerine and vasodilators. This is more of a problem when the patient has been NPO prior to the procedure and has not been appropriately hydrated prior to coming into the cath lab.
Hydration and pretreatment with atropine would certainly help to avoid this problem. We do not pretreat any patients with atropine as the problem is relatively infrequent. When this does occur, it is readily reversible with the usual measures.

Tejas & Sanjay:

Dear All,
We have a little different perspective for this problem. Vasovagal reactions with TRA normally occur in the beginning of development of a new program. There are four important causes.

1. Multiple punctures to get the radial site access can lead to pain spasm and vasovagal reaction.
2. If you are a new operator you encounter difficulty while working through bad tortuosities and loops. This can lead to excessive instrumentation in that region leading to pain and vasovagal reaction.
3. Intraradial injection of heparin or diltiazem can rarely lead to severe buring sensation and vasovagal reaction because of acidic nature of the solution.
4. If the intervention is significantly prolonged and there are repeated exchanges of guide catheters, while pulling the sheath back rarely there is significant spasm and pain leading to vasovagal reaction.

All these issues are common during first 200-300 cases. Once you overcome these issues the incidence is extremely low. With transfemoral approach the incidence remains the same with the first case and also after several thousand cases.

Take home message:

1.Make sure that most of your radial punctures are first prick.
2.Anticipate and diagnose tortuosities and loops very quickly.
3.Give heparin through intravenous root.
4.Dont be casual in selection of guide catheters and try to complete the procedure in as short time as possible.

Editorial Board Comments:

Josef Ludwig:

We use only 0.2mg nitro, even in patients with low blood pressure as well as in patients with severe aortic stenosis. Never saw a catastrophe within the last 15 yrs.

Mitchell Krucoff:

We also use this dose of tng, however if the resting bp is less than 100mmHg I routinely accompany with a brisk 500cc bolus of saline as the tng mediated drop in bp is frequently volume related.

Yves Louvard:

We are using 3 mg Verapamil even in acute MI cases. No problem since 15 years.

Jean Francois:

We do use a cocktail of local ia nitro and verapamil without major systemic effect.

Ian C. Gilchrist:

Couple of ideas:

At least in the US we have a calcium channel blocker, nicardipene, that has no effect on the AV or SA nodes. It is approved by the FDA for HTN control. There is literature that shows its affect on the radial and mammary arteries is as good or better than than the other calcium channel blockers without the heart block; also literature to support its use in no-reflow. We use it in 200 microgram doses using that in the radial to start. It also works in coronaries for no-reflow and in higher dosages is an effective IV antihypertensive. I have used it in profound shock directly into the coronary arteries without systemic effects and had resolution of no reflow that reversed the shock state. Use in the radial artery at doses <500 micrograms should not effect the BP.

Local nitrates good be used, but they are very short acting. BP might return quickly but so might the spasm.
Might also raise temperature of cath lab to reduce temperature induced vascular tone. You might be hotter, but the patients vessels will be more dilated.

Tift Mann:

we looked at the hemodynamic response to the radial cocktail several years ago and found a significantly smaller effect of IA verapamil on MAP as opposed to ntg. we thus began using verapamil 3mg alone given immediately after sheath insertion. we have since had no problem with either low BP or bradycardia, including after repeat doses(with are rarely necessary).

Samir Pancholy:

Usually we give 200 mcg of TNG and 5 mg of Diltiazem. If vitals are a problem, we use Diltiazem alone. Its slower onset of action and sustained effect give a good combination of avoidance of abrupt hypotension, and spasm prevention while exchanging.

In STEMI with SBP less than 80 mmhg I give no vasodilator to start, go with the guide catheter based on ECG, and have had no entrapment etc.

Agree with Ian, Cardene is nice, but expensive.

I believe CCB are more important for an average prophylactic cocktail, and nitrates are useful for treating spasm once it has occurred

Sunil Rao:

I've have switched over completely to verapamil 3 mg from NTG based on Tift's data that show a greater increase in radial diameter with little effect on systemic BP compared with NTG. Given the local effects of this low dose I have no concerns about systemic BP.

Olivier Bertrand:

Vera 2.5 mg for us for 15 years.

Tejas Patel & Sanjay Shah:

We follow the following protocol:

1. If the blood pressure is about 100mm Hg then we dont change our regular regimen that is 200mg of NTG + 5mg biltizem intra radial irrespective of status of the coronary and status of ventricular function (normal or abnormal)
2. If the blood pressure is less than 90mm Hg and if the ventricular function is normal then we push the fluids to raise it to 100 or above and then follow the same regimen.
3. If the blood pressure is less than 90mm Hg and if the ventricular function is significantly impaired then we prefer to start vasopressure to raise the BP to 100 or above and if patient has acute MI or severe unstable angina then we deploy IABP and once patient is on IABP we follow the same regimen.

Editorial Board Comments:

Josef Ludwig:

I start with C: during the past 15 yrs doing TRA I saw about 5-10 out of 30,000 procedures
B) I try to bend my wire and bring down a Judkind right and exchange via an Amplatz stiff wir. Of not extra back-up caths for left hardly work and we use Judkins left 4, not 3,5.
A) i my wire goes permsnently down to descending aorta I perform a Very often we suspected a lusoria which was not found after angiography

Has anybody tried 5 in 6 with guideliner? Just an idea.

Tift Mann:

Abhaichand et al found the incidence of AL to be 0.3% and this coincides with the experience in our lab. the dx is made with a simple subclavian arteriogram- usually a hand injection is sufficient. the anomaly can usually be traversed with an acute-angled catheter ie JL3.5 and a standard J wire or wholey wire. cannulation of coronaries difficult and it may be best to use alternative access such as left radial.

Olivier F. Bertrand:

Agree with Tift.

There seems to be anatomical variations with AL, i.e. left positionning of subclavian art and aorta....

From our experience in more than 70,000 cases, there have been only a few cases...

One patient came in a few years ago in acute MI and was treated by femoral approach as soon as the physician noted the anomaly. I had to treat a non-culprit lesion a few days later and did it very easily by left radial approach...At that time, I explained to the patient that he had an anatomical variation that explained why I did use the left....He smiled and told me that one of my colleagues had spent about 3 hours in an earlier procedure doing it by right radial...

So as always rule of KISS

Sunil Rao:

Great dialogue!

We have been transradial since 2006 and have yet to see one (although we are a moderate volume lab).

Perhaps it's worth pooling these data together for a worldwide experience paper? If we can find correlates, then one could argue for routine left radial approach in patients with features suggestive of AL.

Yves Louvard:

I have seen myself probably 35-40 of these Lusoria (certainly double for the center including the 11 of initial Abhaichand's paper)
I remember only one failure where the Lusoria was taking off from the proximal descending aorta...
I never spent 3 hours on this problem which can be solved with "shaped catheters, JL ..", an hydrophilic 0.035" wire (Terumo) and then an exchange 0.035" wire. The left radial approach solve the problem of course. And the femoral, but it is forbidden by our religion (patient safety ! ). Collect the cases ? some will be missing after 16 years of radial, but we can try if somebody wants to do it, I can ask to one of our fellows...
The interest is of course to define which catheter is the best ...more interesting will be designing specific catheters for example from virtual reality (from CT san ...) but this is not a market ...I propose the SunilYves catheter !

Ian C. Gilchrist:

I agree with the comments so far. As long as you have a catheter with a shape directional bend, the turn can be made. I have used a pigtail located right at the subclavian/aorta junction and had it point a hydrophilic wire back up the aorta. The Advantage type wire works with a very hydrophilic, low mass leading tip that does not completely over power the catheter shape. The reminder of the catheter transitions into a more substantial wire so as to form the support to make the curve passable as well as not permitting catheters to prolapse down the aorta. Pre-formed Judkin’s catheters delivered directly to the coronaries before removing the angiographic wires has worked well for me.

This is a rare finding so if it does not suit the operator to find a solution, the left wrist is a fine option.

Samir Pancholy:

Great comments. I have had a few cases total, and for some reason, three cases this year that I remember. We have used LIMA catheter to direct the guidewire, and on one occasion each , Tiger and VTK catheter. Once in the ascending aorta, EBU (0.5 size larger.) works well for LCA. For RCA we have used a MAC 4 or AL. LARA curve by medtronic also has a favorable shape that has worked.

A dedicated catheter is a good idea.

Mitchell W Krucoff:

Very interesting to read about cumulative experience, as the entity itself is obviously rare. I have only seen one case, but it was in the first months of my conversion to radial, and i have to admit it took me a while to figure out what was going on. I got the wire around by "walking" a 5 French Tiger over a Wholey wire onto which i placed a steerable "J" tip, advancing the wire, then the catheter, then the wire, etc etc. I could not actually intubate either the RCA or the LCA with the Tiger, and after several exchanges managed to get both with a 5 Fr AL2. I was very glad that this case had normal coronaries, eg that once the diagnostic was complete i did not have go on to a PCI!

my one and only so far...

one additional point that several of our experts have made, not only for AL but in general: IF you are going to abandon the right radial, convert to the left radial, not the femoral!

Tejas Patel & Sanjay Shah:

True arterial lusoria is a difficult but a very interesting anatomy to deal with. In over 31,000 transradial cases we have come across this situation only 43 times (0.13%). All these cases have been well documented angiographically. In the world literature, the incidence mentioned is between 0.2 to 1.7% which seems to be significantly high and difficult to understand. It is possible that, many cases of “Pseudo-arteria lusoria” (significantly dilated and distorted aortic route mimicking arteria lusoria anatomy) must have been included to have the incidence as high as 1.7%.

In first 2000 transradial cases only, we developed a protocol to deal with this situation and it still remains the same with us. The protocol is divided into two parts. (1) Entering the ascending aorta through arteria lusoria and (2) the cannulation of the coronary arteries.

(1) Entering the Ascending Aorta :
Step 1
The catheter and guidewire have a tendency to enter the descending aorta. If this happens, withdraw the catheter and the guidewire together as an assembly.

After asking the patient to take deep breath, gently push the 0.035” standard guidewire. If the guidewire enters the ascending aorta effortlessly, you can then push the catheter over the guidewire.

Step 2
If Step 1 is not successful, keep the guidewire in the descending aorta. Remove the Judkins right or left catheter, or the first catheter you tried. Take a LIMA diagnostic catheter, put it into the descending aorta over the guidewire, and try the same maneuver. In many cases, you will be successful in entering the ascending aorta.

Step 3
If the LIMA catheter fails, then a Simmon catheter can be used to enter the ascending aorta.

Step 4
If the 0.035” standard guidewire has a tendency to slip into the descending aorta, the second choice is a 0.032” or a 0.025” hydrophilic Terumo Glidewire. The slippery Terumo wire facilitates relatively easy entry into the ascending aorta in challenging situations.

Note :
• Always work in the 40-degree LAO view.
• Do not use super-stiff guidewires unless you have entered the ascending aorta.

(2) Cannulation of the Coronary Arteries :
Once the guidewire and the catheter are in the ascending aorta, cannulate the left or right coronaries in the usual fashion.

It is relatively easy to cannulate the coronaries. If there is a challenge, follow these steps :

Step 1
Remove the standard 0.035” guidewire or the Terumo Glidewire, whichever you used first.

Step 2
Using a 0.035” super-stiff guidewire, make a loop of wire in the ascending aorta, and slowly negotiate the catheter over it so that you can make a loop of the assembly (catheter and guidewire).

Step 3
Slowly pull the guidewire slightly inside the mouth of the catheter and pull the assembly back. This usually cannulates the left coronary artery.

For cannulation of the right coronary artery, slowly and gently rotate the assembly clockwise.

For diagnostic procedures, use a Judkins left, Optitorque TIG, or an Amplatz left catheter to cannulate the left coronary ostium. Use a Judkins right or an Amplatz left catheter to cannulate the right coronary ostium.

For intervention in he left coronary arteries, choose any extra back-up guiding catheter as your first choice. If this is not successful, use a Judkins left or an Amplatz left guiding catheter.

For intervention in the right coronary arteries, Amplatz right is the first choice. If this does not succeed, a Judkins right or an Amplatz left catheter can be used.

Note :
At any stage during cannulation of the coronary ostium, do not push too much or the assembly may flip into the descending aorta.

These steps may seem complicated, but arteria lusoria is very rare, and patience and perseverance can help you complete the procedure in the usual fashion. If the first few attempts to enter the ascending aorta are unsuccessful, gracefully switch to the left radial or to the femoral route. Once you beat the learning curve, it is possible to work through this anatomy in practically hundred percent cases.

It is a great idea to pull the data from all of us to publish a combined experience.

Kintur Sanghvi:

It is clear that all of us want to have a very fruitful conclusion from this discussion. If we can come up with data to guide current and future radialist on how to deal with AL, it will help forward our “Radial” religion and reduce complications for our patients.

All though opinions in this discussion are coming from the world’s best and most experienced radial operators, some of the opinions are differing from each other.

Editorial Board Comments:

Samir Pancholy:

I agree. The risk of embolization to the renal graft by femoral route logically would be expected to be higher than radial access. With low profile equipment and patent hemostasis etc, the risk of sacrificing the radial by accessing it is small and clearly worth avoiding the risk of instrumentation around the renal graft pedicle.

Ian C. Gilchrist:

I would second the other remarks. Since pre-transplant procedures tend to be only diagnostic I use 4 French catheters and minimize the trauma to the radial. We also have an active liver transplant service and radial is very good for these patients as they often have low platelet counts and elevated clotting times that are not easily corrected for femoral access.

Tak Kwan:

1. Agree with Sam and Ian's comments.

2. If the radial occlusion rate is acceptable, should it be not a relative contradiction in pts with AV fistula on hemodialysis?

Sunil Rao:

Excellent discussion so far.

At TCT last year, there were 2 abstracts from Europe looking at the transradial diagnostic and PCI in patients who had AV fistulae in the ipsilateral arm. All procedures were successful and there were no reports of graft loss. It's not a randomized trial, but chances are that such a trial would be difficult to do.

Regarding the question from Professor Ludwig, I think that radial should be the preferred route for all of the reasons outlined thus far.

Jean Francois:

Interesting question and historically would have gone with the femoral route but now with smaller catheter do not believe it is a contraindication to go from radial. Actually agree could be the most favorable route!

Yves Louvard:

True Josef !
Our nephrologists ask us to perform angio and PCI from radial approach.
The risk of hemorrhage with Femoral approach is high.
The occlusion rate after radial approach can be reduced to less than 1% with patent artery compression, and there is no serious data about any problem with creation of a fistula (like for radial and graft ...).

Kintur Sanghvi:

First I wanted to discuss briefly some basic information about the AV grafts, which may help some of the readers.

An arteriovenous (AV) fistula for hemodialysis can be created using native (primary or autogenous) vessels: For long-term dialysis, a native or autogenous AV fistula has the longest patency rates among the access options, lowest rates of local or systemic infection, lower rates of thrombosis and the delivered dialysis dose is superior to tunneled cuffed dual lumen catheters and comparable with grafts. These fistulae are typically fashioned to connect the radial artery to the cephalic vein, the brachial artery to the cephalic vein, or the brachial artery to a basilic vein.

A synthetic bridge conduit, typically a polytetrafluoroethylene (PTFE) graft: The preponderance of hemodialysis access in the US consists of synthetic AV fistulae, primarily PTFE grafts. The reasons for this practice (of course we like it all easy) include the following: bridge grafts are technically easier to create and manipulate than native fistulae, lower initial nonfunction rates and the grafts can be used earlier postoperatively compared with native fistulae, which require 1–4 months to mature

There are few published reports of using radial access safely and successfully for endovascular intervention of the AV grafts/shunts to treat a stenotic or occluded dialysis access or to expand the shunts that failed to mature. (Reference: Nephrol Dial Transplant. 2009 Aug;24(8):2497-502. Epub 2009 Mar 3). I have used radial for the similar procedure twice with success. Dr Smiraldy, a vascular surgeon in Scranton primarily uses radial approach for all dialysis access interventions.

With this information, I think it is very reasonable to prefer radial access with up to 5 Fr catheters to perform pre-transplant left heart catheterization in a patient who has upper arm dialysis access. Particularly it would be safer then manipulating through the generously populated calcified ahteromatous plaques in the aortoiliac system of ESRD patients who have a kidney transplanted to iliac system.

Josef Ludwig:

Thanks for your responses. TIME to do a study and time to come to a consensus.

The experts of transradialWORLD, have the chance and obligation to rule out guidelines.

Never understood why there is European bifurcation club and Japanese CTO club. But, no world radial club to gain importance and recognition.

Kintur Sanghvi:

Absolutely agree with you.
I will discuss with our website staff and may be we can all contribute to a central database/ protocol related to this particular issue and come up with a fast conclusion. I hope this idea is not over ambitious.

Tejas Patel:

I completely agree with all of you that there should not be any issue about working through radial route in this sub set of patients. However in India most nephrologists would discourage us for the usage of radial artery for the reasons best known to them.

Editorial Board Comments:

Josef Ludwig:

Do not see the problem of upsizing. Works like fem. We work with 6 F in men also for diagnostic and perform ad hkc procedures, thus, upsizing is rare. In woman with 5 F. We inject 0.4 mg nitro before changing. IF you use Terumo pediatric sheath a standard 0.34 wire not works. You have to take 6F Terumo fem sheath or a 0.22 wire. 7 F question has been answered extensively last week.

Ian C. Gilchrist:

Up sizing is a trivial exercise. I use a .035 inch wire to exchange all my angiographic catheters. If I need to up size between a catheter exchange I pull the initial radial sheath (usually a micropuncture kit’s device), remember to hold pressure at the entry site when the sheath is absent, and insert a sheath whose dilator will pass over the .035 inch wire (ie femoral type sheath system). You then remove the dilator and pass up your next larger catheter without ever loosing central wire access. I do this with a standard 180 cm wire (jetting catheters), but if you like long wires the process is the same. No need to downsize to a .021 or smaller to get a micropuncture sheath in once you have access.

As far as 7F sheaths, I have not used one in years despite 95% radial. Five French is a great way to do procedures once you are comfortable with the technique (advanced technique). If you routinely use 5F, then 6F is more than large enough for special projects.

Hydrophilic sheaths have advantages, but there was a recent study that showed that the length of the sheath was not associated with benefit. I would stay short to minimize bulk in the artery.

I am sure there are multiple opinions on this point.

Mitchell W. Krucoff:

I largely agree with ian.

I am less comfortable with 5Fr guides routinely, esp multi-wire cases.

His description of upsizing sheath etc without losing control of central access is excellent. Once the smaller sheath is out, I just go with the whole new sheath and dilator together in a single step.

I have never used a 7fr system from the radial. Other than triple-kiss balloon or rotoblator larger than 1.5, I haven't used a 7 fr guide from the arm or leg in many years.

I also agree with ian: I prefer hydrophilic sheaths, and shorter over longer sheaths. Only exception for latter might be a perforation scenario where the sheath is used to cover the perf site.

Ian C. Gilchrist:

That is a good point Mitch made. A long sheath when a radial perforation is suspected makes sense.

Josef Ludwig:

Since we use a special puncture technique radial artery perporation or dissection has vanished. At first glance this technique may look cumbersome, but, once Ou do it more often, you fast and safe. For those who are interested it was recently published-July 2010- in Eurointervention.

When I started radial in 1995, I had a good friend who already died and he was a world recognized pediatric interventionist. He told me that cath in premature patients via fem causes severe spasm and recommended the Terumo pediazric sheath. From then on we stick to this sheath. Thats why I mentioned this device.

Samir Pancholy:

Agree with you folks. Never have had a need to use 7 F. arm or groin.

One technical issue when upsizing from 5F to 6F over 0.035" 260 wire is you will need a regular 6F pinnacle sheath dilator put in the glidesheath 6 F introducer sheath, as the radiofocus glidesheath dilator is a 0.021" capable lumen all throughout its length. We stock separately packed 6F dilators in our lab for this purpose.

Tejas Patel:

I agree with Ian & Mitch. For the exchange of sheath we use the exchange length wires.Nothing much to say. As of now I had no opportunity to use 7F introducer sheath. However if I am compelled to use it I will do a radial angiogram and if I find the radial artery size good enough for 7F sheath without hesitation I will use it.

Yves Louvard:

1. If you are using a 0.035 wire you can insert a femoral sheath without any problem after removal of a 5F ...If you use a 0.025 wire take a     bigger radial sheath: VERY easy

2. In a study I made, IN France (males and females), a long time ago, the % of radial arteries (after nitrates) accepting:
    5F = 100 %
    6F = 86.9 %
    7F = 76.9 %
    8F = 64.7 %
    Mean radial artery diameter: 2.9 +- 0.6 mm

3. Terumo have long sheathes ( 20 cms ?), they are not VERY lubricious But why using 7F for Rota ?, for ULM ? A 1.75 mm burr is 6F     compatible, most left main stenting techniques (excepted SKS) are 6F compatible ...

But why using long sheathes ? A 6F sheath is in fact 8F in diameter which is acceptable on 7 cms, but sometimes not on 20 or more cms ! So for 7F approach (9F diameter...)!

Editorial Board Comments:

Sunil Rao:

We have a protocol for same day discharge but only a minority of our patients qualify due to the distance they travel. Our current proportion of same day discharge is < 5%.

Mitchell W. Krucoff:

Important to remember that same day discharge is about more than just the vascular access site.

Safety is first and foremost dependent on the coronary anatomy and intervention itself, including both the quality of the PCI result and the transition to optimal adjunctive medical regimen.

In the USA, hospital administrators may also be sensitive to the fact that reimbursement levels may drop for same day compared to overnight stay. So if TRI is directly associated with increase in same day PCI, it may be perceived as dropping hospital revenues.

So rather than having TRI become leverage for more smae day PCI, may be preferable to recognize that TRI is better for vascular access in all PCI, same day or not.

Jean-Francois Tanguay:

Good question...as our 'elective PCI' population is much smaller but pending several variables such as age, time of the day and how far the patient comes from, we send 15-25% of our low risk elective case home the same day.
We started several years ago with a nursing follow-up program to assess safety and feasibility.

Sanjay Shah:

Same day discharge is not advisable for cardiac safety reasons (arrhythmias , subacute thrombosis are not related to vascular access).

David Hilton:

I attached our paper from 4 years ago. This followed a publication of elective same day discharge in the 90s , all radial. We have sent >70% home for many years. The reason it is not done in many jurisdictions is because the payer won't pay for same day so the real question is not how many actually go home but rather how many could .

View Paper

Same_Day_Discharge_
Radial_PCI_._Smal

Kintur Sanghvi:

In agreement with Mitchell’s comments, we discharged a couple of transradial Renal artery interventions on the same day and the Hospital was sensitive about the same-day discharge. Patients are sent home the same day after IVUS or FFR via radial but no PTCA or stenting; however, I may or may not discharge the patient if the same procedure was done through femoral.

We need an effort by the interventional community and hospitals to change the scenario of the reimbursement for patients being discharged the same day. Ultimately the advantage of the cost saving with radial approach should translate to health care dollars saved, with patients being discharged the same day, particularly for the uncomplicated peripheral PCIs and Type A or type B elective coronary interventions done via radial. These procedures are a great portion of procedures done in US cath labs.

Tak Kwan:

Dear all,
Agree with Kintur.
I routinely discharge simple PCI patients (type A) home same day via transradial, if we did the case before 2 pm. I don't think I will do the same transfemorally. Reimbursement is the major problem as we all agreed. Safety is not concern if we select low risk patients and monitor patient for 6 hr. Recently, we wrote an Editorial about it in July issue of Journal Invasive of Cardiology.

Tejas Patel & Sanjay Shah:

We have done a pilot study of outpatient PCI by not discharging the patients from the hospital but sending them to the rooms rather than ICCU.
100 such patients were kept in the rooms without cardiac monitor and they were given telephone numbers of ICCU as well as doctors on duty. It worked out very well without any major issues. However till this date except for very few cases we have not started discharging the PCI patients on the same day.

Josef Ludwig:

In Germany presently PCI patients stay overnight. Mere angiography patients can leave after 6 hours usually. However, we keep them all overnight. It is a matter of in-hospital administration matters.

Samir Pancholy:

I have sent very few PCI patients home the same day, but I think this will soon change especially when guidelines become more inclusive and bundled payment etc encourages it I certainly believe that TRI patients are much better suited for same day discharge compared to TFI patients.

Editorial Board Comments:

Josef Ludwig:

No need to check, in kauasians 6 French works in 99 percent of male and 5 in women. 7 French is suitable for terrorists.

Next generation experts will work with 4F guides and 2F diagnostic (Japanese slender club) I am sure.

Ian C. Gilchrist:

I think you get a sense of the vessel diameter by palpation and experience. The need for 7F is almost never in my experience. I use 5F as standard PCI and 6F for special occasions. 4F for diagnostic in the USA. While smaller guides have a different feel than larger guides, they are usually just as successful. If you truly need a large bore catheter, then you may need to use the groin.

Tift Mann:

One ca assess radial diameter with doppler after sl ntg but I am not aware of any radialiat that uses the technique. We never use 7F even with carotid stenting. Further, with the increasing concerns about radial artery injury and occlusion, 5F is our default strategy and we use 6F only for complex cases.

Tak Kwan:

All diagnostic is 5 F; Most PCI is 5F and 6F for complex cases. 7F is unusual and only in big radial artery in man (by palpation) and no need for Doppler.

Tejas Patel:

Clinically there is no precise way to assess the diameter of radial artery. More than 95% of the radials will easily accept 6F sheath. In muscular or athletic people with big wrist even 7F sheath can easily be introduced. I agree with Dr. Tift Mann about the role of vascular Doppler to measure the radial artery diameter. However it is not practical in all the cases.

Editorial Board Comments:

Josef Ludwig:

I not familiar with Tiger. Sorry. I do left with JL 3.5 or Ludwig left by Cordis. The RCA I do with MP and also LV by Hand injection. Or More frequebtly use JR for LV and RCA. But, You need good flat panel immage quality. N.B. Prefer now JR and JL. Despite there is Ludwig left available. Sorry for my own cath.

Kintur Sanghvi:

A single diagnostic catheter for left, right and LV (available in 5 Fr):

Tiger (Tremor) Jackie (Terumo) and Sarah (same shape as Jackie with a little bigger secondary curve) are available in US market. (we have them in our lab).

We routinely do LV angiogram with hand injection with one of this catheter. It is adequate in most of the cases.

Crossing Aortic valve with JR catheter is easiest from right radial followed by Jackie. If you are switching from fem to rad, JR4 and JL3.5 are better choice to start with.

A single Guide catheter for left, right and LV:

Tiger guide is available in 6 Fr size (we have it in our lab, and I start STEMI case with it)

I do not know if PaPa Guide is commercially available? We have it in our lab in 5 fr size. Patel Pancholy (PaPa) curve (Medtronic) is the other single guide for LV, Left and Rt coronary. I have little difficulty using that guide for left, but in my opinion its probably the best curve for RCA from right radial.

Samir Pancholy:

In the US a 5F Tiger and Jackie diagjostic catheters are available. Tiger guide is not available yet. Your choices for universal guide in US are Kimny, PAPA or PAPA1, and in some instances MAC ( which is the old Patel curve). These are guides especially PAPA, PAPA1 and MAC are available in 5 and 6F.

Sunil V. Rao:

The Tiger, Jacky, and Sarah diagnostic catheters are available in the US from Terumo. One can also use a Multipurpose A2 or B2 as a single catheter strategy. There are two studies that have been presented but not yet published suggesting that a routine left radial approach may shorten procedure times in patients who are older than 75 years and shorter than 5'5", potentially due to less tortuosity of the subclavian artery.

Mitchell W Krucoff:

Dr's. Rao and Pancholi have summarized nicely.

Both 5 Fr and 6 Fr Tiger diagnostic catheters are available, from Terumo, in the USA, but guide shapes are only in 6 Fr so far, and even with "power" position have limited backup. the one very nice aspect of the Terumo 6 Fr outer surface is its lubriticity--we have used it even when there was a good bit of spasm around a 5 Fr diagnostic, and yet this 6 Fr guide went easily.

For diagnostic I use the Tiger as first choice at this time, 5 Fr in women and 6 Fr in most men. using this one catheter also helps me get a better feel for what to do next if there is a takeoff I cannot cannulate--eg whether to go to a judkins, amplatz or multipurpose.

Hildick-Smith David:

My suggestion to you is, don’t bother.

A “one-catheter” approach only works in 80% of cases.

Its fun, but its not really clinically useful to try with one catheter, it will inevitably not be quite right for either LCA or RCA in a proportion of cases.

JL3.5, JR4, Pig.

Josef Ludwig:

I completely agree with Dave. Do not make things even more simple! (A. Einstein)

Tejas Patel:

A "Tiger" equivalent catheter in 5 or 6 F which can be used left and right diagnostic catheterisation as well as intervention is a dream situation. But the dreams do not always come true. It is important to understand that Tiger is a reasonably good catheter for diagnostic coronary procedure. However it is a weak 'backup' curve for intervention. There is another drawback of Tiger catheter is the tip faces towards LMCA roof leading to difficult coaxial alignment. We are trying to develop PAPA and PAPA1 curves (Medtronic) to overcome the drawbacks of Tiger and after further refinement I am sure that these curves will be reasonably good for left and right interventions. Repeated changes of diagnostic or guide catheters can lead to radial artery spasm but if done carefully a couple of exchanges are alright. Up to an extent I agree with Dave.

Josef Ludwig:

Indeed 1 cath strategy is not meaningful, but, the solution was done decades ago by Sones. U only need it longer as from brachial and is time consuming even in expert hands. 2 caths and less radiation dose is best in my opinion.

Yves Louvard

I have sustained and published a long time ago the "look for the perfect multipurpose catheter" with multipurpose Sones, AL2, 3D (my catheter lost with Bard, it was good, JL, tiger ... Today after at least 15.000 transradial angiographies, I am using ...JL, JR ...like Josef ...sometimes, only to remember good old times and in absence of fellows I use AL2.

The reasons:

- frictions are not always spasm and the diameter matters more that one or several catheters and shapes ...
- spasm is very rare today as we are working quickly on well prepared patients in a quiet and a highly successful ambiance (important for next   patients) and have specific techniques for catheter exchange.
- it is not increasing procedural and X Ray times

It does mean that we won't have next year the ideal catheter.

Editorial Board Comments:

Josef Ludwig:

I have no experience at with this type of cath. For 15 yrs wd use JR or MP for diagnostic as first choice. In certain circumstances AL 1 or 2. The modern soft tip cath rarely cause disection, and, of note before the 5 in 6 device came to market 5 F deep intubation was an ellegant tool for better support in difficukt PCI cases. In summery do not be too afraid.

Sunil V. Rao:

The Tiger catheter can occasionally dive deeply into the RCA. The way to avoid this is to torque it clockwise and not pull back or only pull back minimally so it sits oblique to the RCA ostium. Since the catheter has a sidehole, placing it oblique to the RCA ostium will allow good filling of the artery without a risk for dissection. It does take some practice.

Ian C. Gilchrist:

I am not familiar with that curve, but as mentioned by Dr. Ludwig, the smaller sized catheters are far more benign than the history of dissection established by the stiffer 8 F systems that are referenced in the literature. My suggestion to our trainees is not to encourage deep intubation, but if it occurs the first reaction should be to relax and the doctor take a deep breath. If the pressure waveform is okay and the tip appears co-axial in the vessel use it for angiography. To reflex and pull the catheter out may set you up for once more deep intubation with the next attempt. It is the moment of uncontrolled entry into the coronary that poises the greatest risk (although with small diameter, flexible tips this risk is very small) and if you have already passed that point, you should take advantage of it assuming the tip is in a reasonable lumen location.

To avoid deep intubation a second time, I have noted that if you enter the RCA from the opposite direction from how you deeply intubated it often controls the entry better.

Tak Kwan:

I have a large experience in using the Optitorque catheter which either a Tiger or Jacky Catheter. Similar to any catheter, if not careful in engagement, dissection/spasm will occur. In engaging the RCA, I usually slowly turn clockwise and keep the catheter downward, of course pay extra attention to avoid the sudden "deep throat". It should not take a long learning curve to do it.

Samir Pancholy:

In our experience, Tiger catheter is very safe from a dissection risk standpoint. It tends to frequently engage the conus and needs to be "straightened out " with the stiff end of the J wire to access the right. It tends to deeply engage RCA but if coaxial there is no problem. In fact the Tiger guide is a very good RCA guide for this reason .

Tiger diagnostic could also be used non-coaxially to opacify the coronary as it has a tip side hole.

Josef Ludwig:

A good idea which I learned from Dr Louvard for deep intubation for better PCI support of RCA was clockwise rotating down the RCA. Thus, backwards if your diagnostic runs down deeply, consequently should be counterclockwise pull back Never did, but seems logical

Tejas Patel:

I agree that right JR catheter does not dive deeply while cannulating RCA. However while using 5F TIG catheter (Terumo) one has to be careful for 2 problems

1. Sometimes it may dive deep into RCA and can damage the ostium or create a dissection.

2. It has a tendency to selectively hook the conal artery and if the catheter is not removed timely the contrast hold-up can lead to ventricular     fibrillation.

The answer for the 1st issue is while cannulating RCA the TIG catheter tip should be kept very much on the aortic valve and very slow clockwise rotation should be done. Sometimes even with this manoeuvre the catheter tip moves much faster than expected and in that case a slow clockwise rotation should be combined with a little bit of counter clockwise rotation. Thus clock-counter clock movement done slowly will give you a better control of the tip movement and will eliminate chance of ostial injury or dissection or deep diving. The answer for the problem 2 is when you know that you have cannulated conal artery and there is hang up of contrast, you immediately remove the catheter and again try to hook the RCA. If by chance it again cannulates the conal it is being identified by damping of the pressure tracing. Don’t inject the contrast and use the opposite end (stiff end) of 0.032" Standard guidewire and push it carefully up to the primary curve of the catheter. It will open up the curve and successfully cannulate the RCA ostium.

This is a genuine real world issue and beginners must know the troubleshooting.

Mitchell W Krucoff:

There have been many very excellent comments on this, so i can add only a little:

1. No question that there is a trade-off between universal catheters like the TIG vs. using JR/JL catheters. in favor of the JR/JL includes the less     aggressive tendencies toward conus and deep cannulation of RCA body than we see with the TIG. However this approach also uses more     catheter exchanges, may promote more radial spasm, etc. Learning to control the TIG removes these extra steps, and is the approach that I     favor in my personal practice.

2. We frequently put in 6 Fr sheath, and in male patients i tend to use 6 Fr TIG, rather than 5 Fr, which to my touch has more direct control.

3. I think Tejas's description of very controlled torque (clock but then counter, to control the speed of tip movement and buildup of torque)     keeping the TIG deep in the cusp is exquisite and critical.

4. When this approach still finds only the conus, i do find there are times when slightly increasing the amount of pullback i apply while torquing     can "flatten" the tip or "verticalize" the catheter, allowing me to rotate into the RCA ostium rather than the conus--this is very similar to what     is done with the stiff end of the wire, but using limited pullback rather than the stiff end of the wire.

Finally, least importantly perhaps, is that this upward reach of the TIG that must be managed to avoid the conus is actually quite nice for non-dominant rights with high takeoffs!

Great dialogue all!

Kintur Sanghvi:

Straightening of the secondary curve to some extent by pulling on the catheter with the index finger and the thumb while fixing the catheter between the palm and ring finger (like we straighten the J wire) helps take the tip of the TIger out of the Conus and it will advance in to RCA. Like Sam said, 6Fr Tiger catheter may be a good guide for Inferior STEMIs. For using 6Fr Tiger guide, one is better off following all the care Dr Patel described.

The "Jackie" and "Sarah" catheter (Terumo) the tip is very flimsy, atraumatic but at the same time not as stable on torque. Even 10-20 degree torque at times can move the tip from left to right coronary cusp. This shape is better than TIger to cross the AV and perform LV angio. "Sarah" tends to go in to LCX selectively, but essentially atraumatic tip. I have used it once to my advantage to perform FFR of intermediate lesion through very torutous LM/LCX anatomy.

For someone switching from Femoral to Radial, I feel it is better to start with JL3.5, JR4. The second choice would be TIger. Jackie shape requires real fine movements, that shall be the last choice.

Editorial Board Comments:

M. W. Krucoff:

This is a really key question that affects our patients, our practice and this whole field.

samir should probably jump in, as best work available is their "patent hemostasis" experience, which we consider to be the standard at this time. our approach uses the TRI band and a pulse oximeter with continuous waveform display on finger of the intervention hand. we attach the TRI velcro band so that it is firm but not too tight, then inflate with 15 cc air. we then slowly deflate until there is visible bleeding, easy to see through the transparent TRI band. we then add back 3 cc of air, so the bleeding stops.

the next steps are the key: with the TRI band inflated to hemostasis, we compress the ulnar artery and watch the pulse ox waveform. if it is flat line, we deflate one cc of air and test again. we continue this process until we have visible hemostasis, but also some pulse ox evidence of flow when the ulnar is compressed.

one trick in compressing the ulnar: find an ulnar position that does not actually require you to touch the TRI band. if you put pressure on the TRI band while compressing the ulnar, your assessment of radial flow can be distorted.

there are some patients where you simply cannot find both hemostasis and radial flow. as samir can detail, these sites are high risk for long term occlusion.

finally, what are the real rates of radial occlusion, with how many repeat procedures, and over what period of time is not well reported. these data should be considered a very high priority for the radialist community to responsibly gather and report.

Samir Pancholy:

I totally concur with Mitch's comments.

Besides heparin , and lowest pissible profile hardware, patent hemostasis is a must. He has described the technique very well.

We have observed RAO rates to be very subset dependent. In diabetic females you will probably see the most occlusions and in large men probably the least. When heparin is used and especially patent hemostasis is used these variables loose their statistical significance as predictors of RAO, but there is still a trend towards their association.

In our latest observation RAO, plethysmography/ultrasound documented, occurs in 2-3% of patients after 5 or 6 F access.

We are investigating a few other strategies to further lower this number.

Yves Louvard:

For me 3 major concerns:

- Avoid stressing the radial artery diameter (mean diameter in a French series 2.9 mm ID): downsizing, sheathless.

- Heparin: never less than 5000 U for a midsized patient (adapt?) for a coronary angiography, ACT > 300 sec for PCI.

- Controlled short compression: short flow occlusion (20 minutes?) and then 2 hours compression with antegrade flow (doppler, plethysmo, oxymetry ...).

With this the occlusion rate is < 1% (See Monsegu J on Pubmed medline).

1. Vascular approaches and closure devices for percutaneous coronary intervention. Monsegu J, Karrillon GJ, Schiano P, Ouadhour A. Ann     Cardiol Angeiol (Paris). 2007 Dec;56(6):263-8
2. EuroIntervention. 2010 Jun;6(2):247-50. doi: 10.4244/.Adjusted weight anticoagulation for radial approach in elective coronarography: the     AWARE coronarography study. Schiano P, Barbou F, Chenilleau MC, Louembe J, Monsegu J.
3. Radial artery compression techniques. Monsegu J, Schiano P. Indian Heart J. 2008 Jan-Feb;60(1 Suppl A):A80-2. Review.
4. Interruption of blood flow during compression and radial artery occlusion after transradial catheterization. Sanmartin M, Gomez M, Rumoroso     JR, Sadaba M, Martinez M, Baz JA, Iniguez A. Catheter Cardiovasc Interv. 2007 Aug 1;70(2):185-9.
5. Left radial approach for coronary angiography: results of a prospective study. Spaulding C, Lefèvre T, Funck F, Thébault B, Chauveau M, Ben     Hamda K, Chalet Y, Monségu H, Tsocanakis O, Py A, Guillard N, Weber S. Cathet Cardiovasc Diagn. 1996 Dec;39(4):365-70.

Sunil V. Rao:

Agree.

The 3 key concepts are
a) minimize trauma (avoid spasm, large catheters in small arteries);
b) anticoagulation;
c) patent hemostasis.

With this, radial occlusion can be minimized. It likely will not be eliminated, so more research is needed in this area.

Josef Ludwig:

Completely agree this time with Yves and, above, very much hope the ideas of Japanese slender club
will come available outside Japan. 2F diagnostic and 4F for PCI.

And maybe its time to think for closure devices such as thrombin subcutaneously or fibrin plaster or modified Exoseal for radial.

Tejas Patel:

I learned the measures to reduce radial occlusion from the great work of Samir. We started following it and have been able to reduce radial occlusion rate from 5% to 2%. Samir should describe his method at length and I think it should be useful to all the viewers.

Editorial Board Comments:

Josef Ludwig:

IMA for LIMA. We use only left radial as we are not so acrobatic like Yves and others. My success rate is only 60 percent or less, and, in case of r failure we jeopardize both radials. For our comfort we introduce a 25 cm arroflex and thus work like right femoral.

Ps the arroflex only ca 5cm in the radial.

My left radial LIMA approach:

Tift Mann:

Ima or mann ima guide(boston) via left radial and TIG via right radial (rarely).

Ian C. Gilchrist:

Several options to consider. In general, I am presently using the IMA curve although at times the JR4 will work. In the past I have also used RLIMA’s with modest success.

The easiest approach is the ipsilateral radial, so if you have a LIMA graft, start your procedure with the left radial. Gaining access to the ipsilateral IMA is far easier from the radial than from the femoral as you are already in the subclavian artery.

The challenge is the contralateral IMA. I usually warn the patients with bilateral mammaries that I might have to use both radials to finish the case. Most patients gladly accept this over being stuck in the groin. If there are bilateral IMA’s, I usually start in the right radial as the right subclavian is often more difficult to pass up retrograde than the left. Typically the right IMA will be easily found and imaged. One then needs to get the left IMA.

The key to the left is getting a wire into and down the left subclavian. Most recently I have been using an approach with the IMA catheter resting on the inner curve of the transverse aorta and using it to point a wire up into the left subclavian. With the IMA catheter’s hooked curve, movement in or out adjusts the longitudinal position of the aim will twisting the catheter slightly changes the radial direction in the aorta so the left subclavian origin can be found. I have used standard .035 J-wires and hydrophilic wires successfully. More recently I have used an Advantage wire by Terumo that is a hybrid between the classic hydrophilic wire and a stiffer shaft of a regular wire – this allows entry into the subclavian and the a rail to slide the catheter. Regardless of the wire used, the key is to pass the wire deep down the left arm arterial tree (brachial artery). With the wire firmly placed into the distal arterial tree, you can then slide the IMA catheter from the transverse aorta up into the left subclavian and then distal to the takeoff of the LIMA. Remove the wire and then flush the catheter. Slowly then pull the catheter back towards the proximal subclavian to engage the LIMA.

Good luck.

Josef Ludwig:

It is worth to try a JL to get from r to l, and use the J stiff hydrophilix Terumo down to the cubital part and have your cimpress the cubital.

Yves Louvard:

From Left radial a mammary catheter or a modified mammary catheter (Tift Mann)
From right radial a mammary 5F catheter (special technique) ou a Yumko (available in Japan only

Mitchell W. Krucoff:

Many excellent answers already written.

I am still an "ipsilateral" guy, although with surgeons taking the left radial this will be problem for the LIMA some day.

I like the universal catheters, in particular Tiger. From the left radial, the long tip of the Tiger can frequently intubate or at least adequately opacify the LIMA. Then over the wire we try to get left and right coronary and SVGs also with the Tiger. If we need another catheter at all it is usually a multipurpose for a posterior SVG takeoff. But overall this minimizes case time and catheter exchanges.

Hildick-Smith, David:

I think we need a new catheter for this.

I find that the LIMA only goes in from the LRA in 70% of cases and the remainder need an angioplasty wire to facilitate entry as the “hook-back” is too great.

A catheter with a shorter length but sharper hook is required. Perhaps Tift Mann’s catheter does this but I have not had access to it….

Tak Kwan:

I always approach the LIMA from the left radial artery (if the surgeon did not take it out). My catheter of choice is IMA catheter then JR4. I agree with David that the selective cannulation is around 70% and may need a coronary guidewire to cannulate it selectively. We always perform it from the patient's right hand side.

Editorial Board Comments:

Tejas Patel:

I feel that Olivier Bertrand should give his inputs on it. He has designed one simple but a brilliant device. Along with his answer we will ask some good photos of device and how it works on the patients. Once we receive the reply, we immediately post it on the website.

Ian C. Gilchrist:

While we use the TR-Band, I actually believe it is not the tool but the application that matters. Anyway that you can apply enough pressure to stop bleeding but still allow distal perfusion via the radial artery will get a superior outcome – the so called “perfused hemostasis”. Whether you use a simple elastic support, hemobands, or fancier-more expensive equipment, you are paying for features and not necessarily results unless the technique or product is used correctly.

In our case, we initially used hemobands that were relatively inexpensive (and washable, too). But, despite repeated instruction, there was a desire for the staff to place these too tight and caused “handcuff injuries”. After one too many of these events, the hospital agreed to invest in more expensive product that was somewhat more forgiving.

I think the bottom line is technique for hemostasis is of prime importance. The tools you use are a secondary concern once you understand the importance of the technique.

Josef Ludwig:

We in Erlangen are conservative and tightfisted. We still use a tourniquet. And, we use it many times.

I was talking to Cordis two weeks ago to modify the exoseal device for radial. I used the 6F femoral three times and caused occlusion with the plug be inside the radial on sono. However, Cordis named me crazy and think there is no market in the US.

Reply by Ian C. Gilchirst:

There has never been any great genius without a spice of madness. “Nullum magnum ingenium sine mixtura dementiae fuit.”

De Tranquillitate Animi (XVII, 10)

We have heard that comment, “no market” for years. Some day it will be viewed as “missed opportunity”.

Yves Louvard::

I think the best way is a brief (150 minutes for 6F post PCI), monitored (patent radial artery), mechanic compression.

Well performed with the TR Band (Terumo).

We remove 2 cc every 20 minutes from the 15cc reservoir.

Mitchell W. Krucoff:

I agree with patent hemostasis absolutely, with a couple of caveats:

1. I am not a fan of added expense, but the controlled application pressure, adjustability and visibility of the TRI-band is unique and well worth     the cost.

2. Whatever system used, keeping pulse ox on the finger and testing radial patency by compressing the ulnar once the radial dressing is in     place is critical to ensuring flow during compression.

3. In some patients, patent hemostasis is simply not possible--if you allow radial flow they bleed, and if you compress enough to stop bleeding     they have no flow. So we still need some work and smart ideas to further advance optimal hemostasis devices.

My 2 cents!

David Hilton:

TR Band has replaced our old clamp in 99% of cases. Rarely because or other lines in the way we might still use the clamp we developed years ago.

Samir Pancholy:

I agree with Ian. Patent hemostasis using any device is superior to occlusive hemostatic pressure. And it does not increase bleeding complications.

Tak Kwan:

Absolutely true. Controlled hemostasis is the way to go.

Kintur Sanghvi:

Patent homeostasis, applying just enough pressure to achieve the homeostasis: is the way to go.
TR band in particular is very user friendly, easy to use for beginner, and the slow self-deflation of the pressure, theoretically may reduce radial occlusion.

At Saint Vincent we were using 4 gauze peaces and Elasto-plast. (very cheap technique) As one can not see the radial site, people have tendency to apply too much pressure because of the worry for homeostasis.