Radial catheterization procedure: Difference between revisions
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{{Radial artery cathetarization}} | {{Radial artery cathetarization}} | ||
{{CMG}}; '''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S. | {{CMG}}; '''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.;{{HBE}} | ||
==Overview== | ==Overview== | ||
| Line 11: | Line 11: | ||
==Procedure== | ==Procedure== | ||
# Before the start of the procedure a “time out” should be taken to revise the indication, important labs, and the patency of the wrist circulation as discussed previously. [[Allen's test]] or | # Before the start of the procedure a “time out” should be taken to revise the indication, important labs, and the patency of the wrist circulation as discussed previously. [[Allen's test]] or Barbeau test. | ||
# Make sure that all of the equipment | # Make sure that all of the equipment is ready and recheck the sizes . | ||
# The wrist should be shaved (if necessary) and cleansed in the usual sterile fashion. In addition, the groin should be prepped in case of access failure or the need for urgent [[IABP]] or a temporary venous [[pacemaker]]. | # The wrist should be shaved (if necessary) and cleansed in the usual sterile fashion. In addition, the groin should be prepped in case of access failure or the need for urgent [[IABP]] or a temporary venous [[pacemaker]]. | ||
# [[Intravenous]] (IV) line should be started on the contralateral extremity. If an IV should be placed in the intervention extremity, it must be placed proximal to wrist preferably at the level of elbow. | # [[Intravenous]] (IV) line should be started on the contralateral extremity. If an IV should be placed in the intervention extremity, it must be placed proximal to the wrist preferably at the level of the elbow. | ||
# Sterilization of the whole arm should be done using the standard sterile techniques and covered in sterile drapes except for the region of the radial artery - distal part of the palmar surface of the forearm - which is left exposed for | # Sterilization of the whole arm should be done using the standard sterile techniques and covered in sterile drapes except for the region of the radial artery - distal part of the palmar surface of the forearm - which is left exposed for easier access. | ||
# Most operators prefer to give anxiolytics e.g [[Midazolam]] (1-2 mg) before the start of the procedure to decrease patient anxiety and hence decrease radial spasm. | # Most operators prefer to give anxiolytics e.g [[Midazolam]] (1-2 mg) before the start of the procedure to decrease patient anxiety and hence decrease radial spasm. | ||
# The arm should be fully extended; slightly elevated with full supination, and the wrist | # The arm should be fully extended; slightly elevated with full supination, and the wrist hyperextended. | ||
# Palpation of the radial artery against the styloid process of the radius with middle three fingers | # Palpation of the radial artery against the styloid process of the radius with the middle three fingers to find the point of maximal impulse "PMI" is performed. | ||
# An amount of 0.5cc to 1.0 cc of local anesthetic is injected superficially over the PMI. | # An amount of 0.5cc to 1.0 cc of local anesthetic is injected superficially over the PMI. | ||
# Two techniques are used to puncture the radial artery to obtain access:- | # Two techniques are used to puncture the radial artery to obtain access:- | ||
#* Direct/single wall puncture : same used in femoral approach. | #* Direct/single wall puncture : same technique used in the femoral approach. | ||
#* Transfixation/ double wall puncture: in which a special kind of puncture needle 18-21 guage is used to puncture the vessel. An indicator at the needle cap | #* Transfixation/ double wall puncture: in which a special kind of puncture needle 18-21 guage is used to puncture the vessel. An indicator at the needle cap would show successful penetration of the artery. Penetrate the other wall of the vessel then withdraw the needle leaving the canula inside the double puncture. Slowly withdraw the canula until a pulsatile flow of blood is noticed. | ||
# An exchange length 0.035-0.038 inch J-tip guidewire is inserted. | # An exchange length 0.035-0.038 inch J-tip guidewire is inserted. | ||
# A small incision is made to the skin at the entry of the wire to | # A small incision is made to the skin at the entry of the wire to facilitate the sheath insertion. | ||
# Radial sheath of | # Radial sheath of 23 cm long and 4-6 Fr size should then be introduced. | ||
# Through sidearm of the sheath, | # Through sidearm of the sheath, 5000 IU of [[heparin]] should be administered. | ||
# To reduce spasm, 500 | # To reduce spasm, 500 mcg of [[diltiazem]] can also be administered via the sidearm. | ||
# Coronary catheters are then advanced along the guidewire into aorta | # Coronary catheters are then advanced along the guidewire into aorta. | ||
# Left and right coronary arteries are then catheterized using Judkins, Amplatz or multipurpose catheter | # Left and right coronary arteries are then catheterized using a Judkins, Amplatz or multipurpose catheter. | ||
# Hemostasis is achieved by direct pressure at the puncture site at the end of the procedure after removal of radial sheath | # Hemostasis is achieved by direct pressure at the puncture site at the end of the procedure after removal of radial sheath. | ||
# Radial pulse, and | # Radial pulse, and hand circulation should be monitored after the procedure for every 2 hours until discharge. | ||
Radial sheath kits are now available which contain hydrophilic coated sheaths in sizes 4- | Radial sheath kits are now available which contain hydrophilic coated sheaths in sizes 4-6 Fr equipped with graduated introducers, various micropuncture needles and guidewires. | ||
==Radial Compression Devices== | ==Radial Compression Devices== | ||
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In the picture below is one example of the devices used. | In the picture below is one example of the devices used. | ||
[[File:Radial compression device 1.jpeg|400px]] | [[File:Radial compression device 1.jpeg|none|thumb|400px|Radial Compression Device]] | ||
===Steps=== | ===Steps=== | ||
[[File:Untitled10.jpeg|600px|none|thumb|1. Wrap the wrist band so that the green box marker is over the radial artery puncture site.]] | |||
[[File: | |||
[[File:Radial compression device 3.jpeg|600px|none|thumb|2. Withdraw the radial sheath few centimeters so that the wrist band can fit snugly and adjust the green box to align over the point of sheath insertion.]] | |||
[[File:Radial compression device 4.jpeg|300px|none|thumb|3. Use the inflation syringe provided with the kit to inflate the wrist band by 10-15 cc of air. While inflating the band withdraw the sheath slowly and steadily using your other hand.]] | |||
[[File:Radial compression device 5.jpeg|300px|none|thumb|4. Inspect the puncture site for oozing of blood. It's helpful to deflate the wrist band by 1 cc for a second, to visualize a little oozing to assure patent circulation of radial artery. Rapidly reinflate the wrist band to stop oozing.]] | |||
5. Continuously monitor radial artery pulsation distal to the wrist band, and check pulse oximeter for intact hand circulation. | |||
6. Remove wrist band after 1-2 hours according to patient status. | |||
==Procedure Video== | |||
'''Below is a video demonstrating radial artery approach in cardiac catheterization followed by application of TR band''' | '''Below is a video demonstrating radial artery approach in cardiac catheterization followed by application of TR band''' | ||
{{#ev:youtube|XhZroo-_oUA}} | {{#ev:youtube|XhZroo-_oUA}} | ||
Latest revision as of 14:22, 5 September 2014
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.;Hesham Bahaa El-Din, M.B.B.Ch., M.Sc.
Overview
The transradial approach (TRA) for coronary/cardiac catheterization is slightly more challenging than the transfemoral route. It requires more maneuvers and catheter steering along the course of the radial artery to reach the level of the coronary sinus in the ascending aorta. The right transradial approach is usually preferred over the left side due to the ease of accessibility for the operating physician.
Catheter/GuideWire Selection
Catheter selection is an important key in the success of the procedure. Standard catheters (e.g Judkin's Left and Judkin’s right) can be used for the TRA. However due to the common anomalies that could be seen along the course of the radial, subclavien, and axillary arteries, special “dedicated Radial Catheters” had been developed (e.g. Tiger, Jacky, and Kimmy). The most commonly used guidewires are those with hydrophilic coating, due to the expected tortuosity of the arterial course.
Procedure
- Before the start of the procedure a “time out” should be taken to revise the indication, important labs, and the patency of the wrist circulation as discussed previously. Allen's test or Barbeau test.
- Make sure that all of the equipment is ready and recheck the sizes .
- The wrist should be shaved (if necessary) and cleansed in the usual sterile fashion. In addition, the groin should be prepped in case of access failure or the need for urgent IABP or a temporary venous pacemaker.
- Intravenous (IV) line should be started on the contralateral extremity. If an IV should be placed in the intervention extremity, it must be placed proximal to the wrist preferably at the level of the elbow.
- Sterilization of the whole arm should be done using the standard sterile techniques and covered in sterile drapes except for the region of the radial artery - distal part of the palmar surface of the forearm - which is left exposed for easier access.
- Most operators prefer to give anxiolytics e.g Midazolam (1-2 mg) before the start of the procedure to decrease patient anxiety and hence decrease radial spasm.
- The arm should be fully extended; slightly elevated with full supination, and the wrist hyperextended.
- Palpation of the radial artery against the styloid process of the radius with the middle three fingers to find the point of maximal impulse "PMI" is performed.
- An amount of 0.5cc to 1.0 cc of local anesthetic is injected superficially over the PMI.
- Two techniques are used to puncture the radial artery to obtain access:-
- Direct/single wall puncture : same technique used in the femoral approach.
- Transfixation/ double wall puncture: in which a special kind of puncture needle 18-21 guage is used to puncture the vessel. An indicator at the needle cap would show successful penetration of the artery. Penetrate the other wall of the vessel then withdraw the needle leaving the canula inside the double puncture. Slowly withdraw the canula until a pulsatile flow of blood is noticed.
- An exchange length 0.035-0.038 inch J-tip guidewire is inserted.
- A small incision is made to the skin at the entry of the wire to facilitate the sheath insertion.
- Radial sheath of 23 cm long and 4-6 Fr size should then be introduced.
- Through sidearm of the sheath, 5000 IU of heparin should be administered.
- To reduce spasm, 500 mcg of diltiazem can also be administered via the sidearm.
- Coronary catheters are then advanced along the guidewire into aorta.
- Left and right coronary arteries are then catheterized using a Judkins, Amplatz or multipurpose catheter.
- Hemostasis is achieved by direct pressure at the puncture site at the end of the procedure after removal of radial sheath.
- Radial pulse, and hand circulation should be monitored after the procedure for every 2 hours until discharge.
Radial sheath kits are now available which contain hydrophilic coated sheaths in sizes 4-6 Fr equipped with graduated introducers, various micropuncture needles and guidewires.
Radial Compression Devices
Radial Compression Devices are used for hemostasis after the removal of the radial sheath. In the picture below is one example of the devices used.
Steps
5. Continuously monitor radial artery pulsation distal to the wrist band, and check pulse oximeter for intact hand circulation.
6. Remove wrist band after 1-2 hours according to patient status.
Procedure Video
Below is a video demonstrating radial artery approach in cardiac catheterization followed by application of TR band {{#ev:youtube|XhZroo-_oUA}}