4 20 16 Radial Intervention Syllabus
2016-04-20
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4/20/2016 Radial Approach: Concepts and Technique Aaron M. Fischman MD Icahn School of Medicine at Mount Sinai Mount Sinai Health System New York, NY @MountSinaiIR Disclosures Advisory Board: Terumo Interventional Systems, Embolx, Inc. Consultant: Terumo, Celonova Biosciences, Neuwave Medical, Surefire Medical Speaker: Terumo, Merit Medical, Surefire Medical Research Support: BTG, Merit Medical, Surefire Medical I AM A RADIALIST! @MountSinaiIR Why Radial? Fewer vascular complications Greater patient satisfaction Immediate ambulation Procedure cost savings Long term cost savings? Less pain and anesthesia? LESS INVASIVE! Bertrand et al. Comparison of transradial and femoral approaches for percutaneous coronary interventions: a systematic review and hierarchical Bayesian meta-analysis. American heart journal. Apr 2012;163(4):632648. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. Journal of the American College of Cardiology. Dec 18 2012;60(24):2481-2489. Mehta et al. Effects of Radial Versus Femoral Artery Access in Patients With Acute Coronary Syndromes With or Without ST-Segment Elevation. Journal of the American College of Cardiology. 10/12 2012. Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison. American heart journal. 09/01 1999;138(3 Pt 1):7-7. @MountSinaiIR 1 4/20/2016 Background 1953 – femoral artery access Sven Seldinger 1989 – first diagnostic angiogram via radial artery Dr. Lucien Campeau 1992 – first angioplasty via radial artery Dr. Ferdinand Kiemeneij -the "father of transradial intervention” 1993 – first coronary stent via radial artery Dr. Ferdinand Kiemeneij @MountSinaiIR Background @MountSinaiIR Background – RIVAL Study Over 7000 patients randomized Reduced cardiac mortality in STEMI patients @MountSinaiIR Metha et al. Radial vs. Femoral Artery Access in STEMI, JACC Vol. 60, 24: 2012 2 4/20/2016 RIVAL Study: Women Women higher risk of vascular complication, radial safer than femoral Women have more benefit with TRA than men, but more crossover 86% preferred radial over femoral @MountSinaiIR Pandie et al. JACC: Interventions, April 2015 Background – MATRIX Study 8404 patients randomized Reduced all-cause mortality and major bleeding in ACS patients Valgimigli et al. Radial vs. femoral access in patients with ACS undergoing invasive management: a randomized multicenter trial. The Lancet, March 2015 @MountSinaiIR Metaanalysis of Randomized Trials @MountSinaiIR 3 4/20/2016 Background “TRA is superior to … should be considered the preferred access site for percutaneous coronary intervention.” Ratib K, Mamas MA, Anderson SG, et al. Access Site Practice and Procedural Outcomes in Relation to Clinical Presentation in 439,947 Patients Undergoing Percutaneous Coronary Intervention in the United Kingdom. J Am Coll Cardiol Intv. 2015;8(1_PA):20-29. @MountSinaiIR ESC Guidelines 2015 @MountSinaiIR Where should we access? FEMORAL BRACHIAL @MountSinaiIR 4 4/20/2016 Where should we access? RADIAL FEMORAL BRACHIAL @MountSinaiIR Where should we access? RADIAL FEMORAL @MountSinaiIR Why Radial? – It hurts less! @MountSinaiIR 5 4/20/2016 Why Radial? – Recovery is easier Leave recovery room sooner @MountSinaiIR Recovery Room @MountSinaiIR Radial Lounge @MountSinaiIR 6 4/20/2016 Why Radial? It’s cheaper! @MountSinaiIR Cost Comparison at Mount Sinai FEMORAL 5F standard sheath 19g needle 5F Sos 80cm Closure Device RADIAL 5F Glidesheath Microneedle 5F glide cobra 100cm (or 110 Sarah radial) TR Band Approx. $230 Approx. $130 Estimated direct cost savings in 26 months – $80,000 Indirect costs were not measured @MountSinaiIR Fischman et al. Scientific Sessions Abstract, SIR 2013. April 17, 2013 Origins of TRA at Mount Sinai in NYC Brachial access complications! Neuropathy Brachial hematoma with arm injury Extended hospital stay @MountSinaiIR 7 4/20/2016 Femoral Access is easy until it is not……. @MountSinaiIR Rest pain after TACE – Angioseal @MountSinaiIR Adoption of TR Technique in USA 2013: 1 in 6 coronary PCI is TR 2015: 1 in 4 coronary PCI is TR estimated Alfonso, Cohen, Cardiac Interventions Today, June 2014 @MountSinaiIR 8 4/20/2016 TRA in IR Classic IR Textbook Published Sept 2013 What is going on here???? @MountSinaiIR Background 177 cases via the radial artery July 1999 to October 2002 65/70 patients (92.9%) replied that they would request transradial approach next time @MountSinaiIR J Clin Gastroenterol 2003;37:412–417 Early experience: TACE – What did we learn? 100cm is not long enough in 20% of cases Glide cobra is “too floppy” Sarah/Jacky needs to be on the shelf!!! Need longer microcatheters @MountSinaiIR 9 4/20/2016 Advantages of TR Approach Obese patients Patients with groin sensitivity No closure device Less bleeding complications Immediate ambulation @MountSinaiIR Visceral Arteries – “It’s all about the angle” @MountSinaiIR Radial vs. Femoral Approach @MountSinaiIR 10 4/20/2016 Disadvantages of TR Approach Arterial size, spasm Anatomic variants Severe tortuosity Cone Beam CT is more difficult, but not impossible! @MountSinaiIR Potential Complications Hematoma Radial artery spasm Pseudoaneurysm AV fistulas Vessel perforation Dissection Radial arteritis – forearm pain with normal pulse Treated with NSAIDS or steroids Compartment syndrome – rare Radial artery occlusion (1-3%) – asymptomatic Stroke risk? @MountSinaiIR Stroke Risk Metaanalysis of over 11,000 patients TF vs TR in cardiology No difference Anecdotal in IR – Close to 4000 cases in the US None reported Use good judgement Patient selection Consider how often you form femoral catheters in the arch @MountSinaiIR Int J Cardiol. 2013 Oct 15;168(6):5234-8. Epub 2013 Aug 14. Meta-analysis of stroke after transradial versus transfemoral artery catheterization. Patel VG1, Brayton KM, Kumbhani DJ, Banerjee S, Brilakis ES. 11 4/20/2016 Complications Need to do Barbeau test! @MountSinaiIR Radial Artery Occlusion Asymptomatic in Barbeau A-C More common in women Incidence increases with sheath size Incidence decreases with radial artery size Can be accessed thru occlusion Technical expertise minimizes Some people use anticoagulation to treat, but not really evidence based ???? @MountSinaiIR Contraindications Radial artery too small < 2mm Larger sheath needed (greater than 7F) AV fistula / dialysis patient Severe aortic tortuosity Barbeau D waveform @MountSinaiIR 12 4/20/2016 Barbeau Test – Pulse Oximetry @MountSinaiIR Barbeau Test – Pulse Oximetry No damping of pulse tracing immediately after radial artery compression – 15% Damping of pulse tracing – 75% Loss of pulse tracing followed by recovery of pulse tracing within 2 minutes – 5% Loss of pulse tracing without recovery within 2 minutes - 5% @MountSinaiIR Barbeau et al. Am Heart J 2004;147:489–93 Portable Pulse Oximeter @MountSinaiIR 13 4/20/2016 Outpatient Office Visits @MountSinaiIR Radial Artery US studies demonstrate mean diameter of 2.6mm Range (2.2 to 3.4 mm) Outer diameter of 6F sheath - 2.6 mm Outer diameter of 7F sheath – 3.1 mm Outer diameter of 6F Glidesheath slender – 2.4 mm @MountSinaiIR New Sheath Technology Q4 2013 Thin walled sheath 4-7F sheath size Allows 1F downsizing! @MountSinaiIR 14 4/20/2016 Access Sheaths @MountSinaiIR Setup – “The Four Pillars of Radial Access” Micropuncture US guidance Hydrophilic sheath Antispasmodic “cocktail” @MountSinaiIR Setup - Arm Positioning Left wrist used for all interventions below diaphragm Prop arm above left groin Use towel roll and arm board if necessary @MountSinaiIR 15 4/20/2016 Setup – Prone Positioning Kwon, S. W., et al. (2012). "Prone position coronary angiography due to intractable back pain: another merit of transradial approach compared to transfemoral approach." J Invasive Cardiol 24(11): 605-607 @MountSinaiIR Technique – Vessel Access @MountSinaiIR Access Technique @MountSinaiIR 16 4/20/2016 Sonivate – Finger US probe @MountSinaiIR Tools – Longer Guiding catheters @MountSinaiIR Where to Access? @MountSinaiIR 17 4/20/2016 PRE-DILATE Protocol @MountSinaiIR 40mg of lidocaine cream (EMLA) PLUS 30mg of nitroglycerin ointment PRE-DILATE Protocol @MountSinaiIR Navigating the Descending Aorta Reverse Curve Cobra Sarah/Jacky Use an .016 wire to “flop down” @MountSinaiIR 18 4/20/2016 Navigating the Descending Aorta - Sarah @MountSinaiIR Navigating the Descending Aorta – Reverse Curve, Pigtail @MountSinaiIR Navigating the Descending Aorta - Microwire @MountSinaiIR 19 4/20/2016 Be Wary of Collaterals! @MountSinaiIR Secure Hydrophilic Sheath @MountSinaiIR Celiac/SMA Catheterization @MountSinaiIR 20 4/20/2016 Catheter Selection @MountSinaiIR Technique - Catheters Used 5F Sarah Radial 110cm (Terumo) 5F Cobra 100cm (Terumo) 5F Jacky Radial 110cm (Terumo) 4F Aqua 125cm (Cordis) 4F Cobra 100cm (Cordis) 5F Envoy 100 Guidecath (Cordis) 5F JR4 100cm (Cordis) 5F MPA 100cm (Cordis) 5F Bern 120cm (Penumbra) 5F Sherpa AL1 Guide (Medtronic) 5F Sherpa HS1 Guide (Medtronic) 5F Launcher Guide (Medtronic) Other shapes (Champ, MP1, RDC, MAC, IMA, SCR, SCL) Longest Lengths in our lab: Guiding sheath: 110cm Guiding catheter: 125cm Diagnostic catheter: 150cm @MountSinaiIR Toolbox Tips 110 cm ideal length for visceral arteries 110 Optitorque PIGTAIL is awesome! Microcatheters should be 150cm, not 130 cm Glidesheath Slender Extra “cocktail” for spasm or small arteries Ultrasound the arm to look for radial loops? Don’t be afraid to go ulnar if the radial is small @MountSinaiIR 21 4/20/2016 65 y/o male with CMI , in-stent restenosis, proximal lesion ICAST Covered Stent 6F Cook Sheath 90 cm, 110 cm @MountSinaiIR Techniques in Vascular and Interventional Radiology 2015 @MountSinaiIR Equipment in 2016 @MountSinaiIR 22 4/20/2016 Radial Loop @MountSinaiIR Radial Loop – “.016 wire technique” @MountSinaiIR .016 Microwire Brachial Loop Be Careful! Severe spasm can compromise flow to the hand @MountSinaiIR Watch the pulse oximeter 23 4/20/2016 Closure Technique – “Patent Hemostasis” @MountSinaiIR “Patent Hemostasis” Maintain “nonocclusive pressure! Should be able to feel a distal RA Pulse @MountSinaiIR Samir Pancholy, et al Catheterization and Cardiovascular Interventions 72:335–340 (2008) Setup for Cone Beam CT @MountSinaiIR 24 4/20/2016 CT and 3D Roadmapping @MountSinaiIR Cone Beam CT – TRA Specific Protocol @MountSinaiIR Open Trajectory CBCT Courtesy of Philips @MountSinaiIR 25 4/20/2016 What can’t we do? SFA and below Stent and balloon systems Brachial artery occlusions 400, 500 cm wires? Extra table? Extra fellows to hold wires? @MountSinaiIR Catheter Length Issues @MountSinaiIR The Mount Sinai Experience – 4 years 2000 TR interventions since April 2012 Over 1500 Liver Directed Therapies Over 180 Uterine Fibroid Embolizations Overwhelming Patient Satisfaction >90 % Patient preference for TR over TF Very low complication rate Repeat interventions common @MountSinaiIR 26 4/20/2016 Adverse Events – Overall 0.3% Minor Complications: 22 Grade I access site hematomas (2.2%) 4 Grade II access site hematomas (0.4%) 11 cases of RAO (1.1%) 3 Cases requiring TFA crossover All asymptomatic Most reaccessed for repeat procedure 5 cases of RA Thrombosis (.5%) 3 Radial Arteritis (0.3%) 2 extended bleeding (0.2%) 2 mild hand pain/weakness (.2%) 2 Severe Vasospasm (.2%) Major Complications: 1 Large hematoma (0.1%) TFA Crossover required 1 radial artery pseudoaneurysm (0.1%) Treated with thrombin injection 1 seizure (possibly verapamil?) (0.1%) No additional Adverse Events at 30 days 1 Case requiring TFA Crossover TR band used 12-24 hrs 1 Case Requiring TFA Crossover 3 microperforation of branch vessel (0.3%) Causing pain <= 24 hours @MountSinaiIR Fischman et al. Scientific Sessions Abstract, SIR 2013. April 17, 2013 Fischman et al. AIM- RADIAL2013. September 2013 Posham et al. JVIR 2015, in press Featured Abstract, Scientific Sessions, SIR 2015 JVIR -December 2015 1,531 procedures in 946 patients 98.2% technical success 0.13% Major Complications (1 PSA, 1 seizure) 2.4% minor complications (hematoma, RAO , arm pain, spasm) 1.8% Crossover rate @MountSinaiIR Posham R, Biederman DM, Patel RS, Kim E, Tabori NE, Nowakowski FS, Lookstein RA, Fischman AM. Transradial Approach for Noncoronary Interventions: A Single-Center Review of Safety and Feasibility in the First 1,500 Cases. J Vasc Interv Radiol 2015: Dec 16. Epub. PMID 26706186. Closure – Monitoring Site @MountSinaiIR 27 4/20/2016 TRA in Thrombocytopenia – CVIR 2015 85 procedures in 64 patients with plts <50,000 97.6% TS No major AEs 5.9% minor access site hematoma 27.1% platelet transfusions @MountSinaiIR Titano JJ, Biederman DM, Marinelli BS, Patel RS, Kim E, Tabori NE, Nowakowski FS, Lookstein RA, Fischman AM. Safety and Feasibility of Transradial Access for Visceral Interventions in Patients with Thrombocytopenia. Cardiovasc Intervent Radiol 2015: Dec 22. Epub. PMID 26696230. Mt. Sinai Experience : TRA in Morbid Obesity 22 interventions 17 patients Median BMI 42.7 100% tech. success NO complications @MountSinaiIR Not just for cardiologists anymore……. Partial splenic embolization Renal embolization Renal angioplasty/stenting Iliac artery stenting Mesenteric angioplasty/stenting, IVUS Internal Iliac artery embolization Uterine artery embolization Carotid artery stenting RCC met to shoulder – embolization Dialysis intervention Gastric Embolization Prostate Embolization Hand AVM Embo Type I Endoleak Trauma GI Bleeding (Lower and Upper Transplant Renal Interventions Vertebral Interventions @MountSinaiIR 28 4/20/2016 Where are we headed in 2016 and beyond? Randomized studies specific to IR (particularly in Interventional Oncology) Quality of life surveys (IPAD and SMS) Training courses/CME for IR Catheter and Guide design underway….. Glue Embolization of bleeding renal mass @MountSinaiIR Final Thoughts Patients request radial approach! IR trainees benefit greatly from learning radial techniques Most catheters are designed for femoral approach Partnership with industry is critical Training programs Catheter and equipment development New procedures lend well to TR THE TIME IS NOW! @MountSinaiIR TREAT – TransRadial Endovascular Advanced Therapies @MountSinaiIR CME Course – 2nd annual “First Ever” in IR May 2016 Live Cases Dedicated to TRA Embolization Course Directors: Aaron Fischman MD, Rahul Patel, MD 29 4/11/2016 Transradial Approach for Mesenteric Interventions Dr Darren Klass MBChB MD MRCS FRCR FRCPC Clinical Assistant Professor University of British Columbia Overview: LA mixture 100mcg GTN 9mL 1% Lidocaine 10mL syringe Inject along length of RA under Palpation for length of needle (4cm) LA mixture 100mcg GTN 9mL 1% Lidocaine 10mL syringe Tumescent anaesthesia Inject along length of RA under Palpation for length of needle (4cm) Tumescent anaesthesia Single wall 60 degree puncture No skin nick Single wall 60 degree puncture No skin nick Sheath and cocktail injection Insert radial sheath Inject antispasmodic Flush sheath and connect to infuser US evaluation of RA or 2mL angiogram Insert catheter preloaded with wire 1 4/11/2016 Anti-spasmodic cocktail 200mcg GTN 2000IU Heparin 2.5mg Verapamil Hemodilute with aspirated blood to 20mL and slowly reinject ▣5fr Sheath workhorse ‘’ Sheath Selection ▣6fr for specific indication □Radial spasm □Small target vessel ▣7fr □Avoid unless procedure dictates – advanced cases Advanced cases: Technical considerations Room Set up Issues around hemodynamics 2 4/11/2016 Approach to advanced cases: ▣Assess anatomy carefully □Origins of vessels □Tortuosity □Distance to target ▣Inventory □Longer delivery systems □120cm minimum □Wire lengths □Monorail vs OTW Access: Decide on sheath size prior to puncture Assess size of the RA Decide whether the vessel can accommodate sheath Guide catheter vs Sheathless guidecath RA size and sheath compatibility RA size 10mm proximal to styloid (n=250) 3.1 ± 0.6 mm in men 2.8 ± 0.6 mm in women11 Ext diameter 6-F sheath is 2.52 mm 86% men and 63% of woman suitable for 6Fr sheath Sheathless guide - outer diameter 1.5 F smaller than the analogous sheath capable of accommodating a guide catheter of the same caliber. Saito S et al Catheter Cardiovasc Interv. 1999;46:173-178. 3 4/11/2016 Terumo Slender Asahi Sheathless Guidecath Eaucath (100cm) Sheathless PV (120cm) Sheathless Guidecath Ability to deliver balloon mounted stents Saves repeated exchanges along the RA Allows for easy cannulation of visceral vessels Y90 administration Needs a hemostatic valve FLO 30 HVA 100 4 4/11/2016 Advanced cases: ▣Once you have decided the case requires a larger bore sheath, change the cocktail when inserting the sheath. 200mcg GTN 5000IU Heparin 2.5mg Verapamil Hemodilute with aspirated blood to 20mL and slowly reinject Technique for sheathless guidecath insertion Insert 5Fr sheath Insert Sheathless guide Cocktail Remove 5Fr sheath 125cm catheter into upper AA Stiff exchange wire 260mm 5 4/11/2016 Need sheath 1 Fr size larger 7Fr guide catheter 8Fr sheath Creating a platform: Guide catheters 8Fr guide catheter (2.7mm OD) 6Fr sheath (2.62mm OD) Concierge Guidecath ▣100cm - limited ▣Multiple shapes ▣Ult 1/2/3 ▣JR4 ▣AR3 ▣0.057” ID ▣Surefire ▣Snare Guide catheters 6 4/11/2016 Technical considerations: ▣Guide catheters are stiffer than diagnostic. ▣More torque ▣Stable in vessels ▣Sheathless guide □Use 5Fr catheter to cannulate target vessel and advance sheathless guide over catheter and wire. Sheathless PV: ▣125cm base catheter will be too short. ▣Lose length on HVA and hub ▣150cm catheter base. □Stent and balloon delivery lengths. 7 4/11/2016 8 4/11/2016 TECHNICAL: Neuron guidecath 6Fr 110cm Penumbra suction thrombectory system Abciximab 0.25mg/KG Balloon angioplasty of kink in splenic artery 600mg loading dose Clopidogrel po 0.125mcg/kg/min for 60 mins post procedure Transradial Approach for Mesenteric Interventions Dr Darren Klass MBChB MD MRCS FRCR FRCPC Clinical Assistant Professor University of British Columbia 9 4/12/2016 Amish Patel MD Interventional Institute Holy Name Medical Center Teaneck, NJ None Understand the data regarding transradial dialysis access interventions Become familiar with tools Become familiar with common clinical scenarios and complications 1 4/12/2016 Seminal paper 11 patients 100% success Safe and feasible Mix of stenoses and occlusions 48 patients Occluded fistulae Balloon thrombectomy, Arrow-Trerotola, AngioJet 96% success 154 procedures in 131 patients Excluding those, 99% success 3-m and 1-yr patency similar to direct puncture 52 (33.8%) totally occluded AVF 2 4/12/2016 50 procedures 88% success 1, 3, 6, 12-m and 1-yr patency similar to direct puncture 7 procedures in 5 patients Thrombosed upper arm grafts 100% success Could not cross lesion most failures ADVANTAGES Single puncture Able to treat lesions at artery site, anastomosis site, or multiple sites Hemodynamic monitoring to gauge immediate success No fistula compression High clinical success rate DISADVANTAGES Puncture technique may be complex and demanding More potential for complications with repeated procedures Only small balloons can be accommodated Easy to achieve hemostasis 3 4/12/2016 Glidesheath (Terumo) 0.018” PTA Balloon 4 Fr and 6 Fr Slender Sterling (Boston Scientific) Advance 18LP (Cook) Fox or Armada Balloon (Abbott) 4 4/12/2016 5 4/12/2016 6 4/12/2016 7 4/12/2016 8 4/12/2016 Kawarada O. Transradial Intervention for Native Fistula Failure. Catheterization and Cardiovascular Interventions (2006) 68:513–520. Wu CC. Radial artery approach for endovascular salvage of occluded autogenous radial-cephalic fistulae. Nephrol Dial Transplant (2009) 24: 2497–2502. Chen SM. Outcomes of Interventions Via a Transradial Approach for Dysfunctional Brescia-Cimino Fistulas. Cardiovasc Intervent Radiol (2009) 32:952–959. Le L. Transradial approach for percutaneous intervention of malfunctioning arteriovenous accesses. J Vasc Surg (2015) 61:747-53. 9 4/12/2016 amishpatelmd@gmail.com 10 4/13/2016 VuMedi Webinar Radial Approach for Visceral Interventions Transradial Approach for Hepatic Interventions Marcelo Guimaraes, MD FSIR Division of Vascular Interventional Radiology Associate Professor of Radiology and Surgery Medical University of South Carolina Disclosure Consultant - Terumo Interventional Systems - Cook Medical Patents holder - Cook Medical Why Radial access? Courtesy of Marcelo Guimaraes, MUSC 1 4/13/2016 Why radial access for visceral interventions? Patient’s perspective Immediate ambulation Greater patient satisfaction Shorten length of stay Fewer access site complications (bleeding) Mobility is allowed: nausea/vomiting chronic back pain access to the restroom Why radial access? Why radial access for visceral interventions? Technical perspective “Pressure Hemostasis” concept Borderline coagulopathy in liver disease > INR, < platelets Favorable anatomy for catheterization from above 2 4/13/2016 Why radial access for visceral interventions? Work-flow/business perspective Supplies cost savings (no closure device) Quicker turn-over of recovery beds Optimization of the recovery area space Cost Analysis MUSC RADIAL FEMORAL ~ $120/case Supplies (only) savings/year: $ 48-60K COAGULOPATHY ? MANY PATIENTS HAVE COAGULOPATHY FROM LIVER DISEASE Hypersplenism Thrombocytopenia 16K, 4 packs…. 22K.?? 3 4/13/2016 Coagulopathy ? Radial access. When? Suitable for everyone? Radial access. When? Suitable for everyone? Patients > 70 years History of stroke Calcified Aortic arch 4 4/13/2016 Background 177 cases via the radial artery › July 1999 to October 2002 65/70 patients (92.9%) replied that they would request transradial approach next time J Clin Gastroenterol 2003;37:412–417 Work-up in clinic Safety check - Eligibility for TRI access Physical exam: Allen’s test Safety check - Eligibility for TRI access Physical exam: Allen’s test Edgar Van Nuys Allen, American physician, 1893-1986 5 4/13/2016 Safety check - Eligibility for TRI access TIS-936-09182015 Barbeau’s test Barbeau GR, et al. Am Heart J. 2004;147:489-493. Safety check - Eligibility for TRI access Barbeau’s test Barbeau GR, et al. Am Heart J. 2004;147:489-493. EVALUATION FOR ELIGIBILITY ANYWHERE… 6 4/13/2016 Safety check - Eligibility for RAVI access Radial artery US exam – 2 objectives Patency and Radial artery > 2.0mm (AP diameter): good for 5-Fr sheath * Female, smoker Safety check - Eligibility for RAVI access Radial artery US exam Radial artery > 2.0mm (AP diameter): good for 5-Fr sheath * Female, smoker New Sheath Technology Glidesheath Slender™ Introduce like a 5-Fr Use as a 6-Fr 1-Fr reduction in outer diameter Thin walled sheath 7 4/13/2016 New Sheath Technology Glidesheath Slender™ 4/5 Fr, 5/6 Fr , 6/7 Fr I.O. Outer diameter (O.D.) Inner diameter (I.O.) O.D. Radial access step-by-step 3 alternatives for left arm positioning: Crossing the pelvis Left side of the body 90 degrees abduction 8 4/13/2016 Radial access step-by-step Table, arm set up Arm positioning in 90 degrees abduction TIS-936-09182015 9 4/13/2016 Radiation safety • > Distance from the radiation source • Shield: between the operator and patient/radiation source 10 4/13/2016 RADIAL ACCESS – ALL SET UP? Check the BP. IV bolus of saline? Devices handy Arm positioned correctly. Hand palm gently taped Material for radial access Ultrasound Material for radial access Micropuncture kit Introducer sheath Needle 0.021” wire Shorter needle: - standard needle - “jelco” 11 4/13/2016 Material for TR visceral interventions Ultrasound Micropuncture kit Radial sheath 5-Fr (4-Fr) Jacky catheter 5-Fr 110cm 1.5 mm J GLIDEWIRE 0.035” Progreat Microcatheter 2.8 Fr, 130 cm Progreat 150 cm + Advantage microwire 0.018” 180cm TIS-936-09182015 TERUMO INTERVENTIONAL SYSTEMS VASOSPASM AND THROMBOSIS PREVENTION Medications Hand warmer? Nitro paste? Heparin: IV Bolus + additional doses as needed (3-4,000 units, 1,000 units in 30 min) Vasodilator: via radial sheath (beginning / end of the case) Nitroglycerine, 200 ug each time Importance of forearm angiograms at the beginning and and of the case Radial arteriogram after vasodilator: • Hand injection • 5-6 cc • Forceful hand injection • Catheter at the level of the brachial? 12 4/13/2016 Importance of forearm angiograms at the beginning and and of the case Arterial size, spasm Anatomic variants Severe tortuosity No flow in the introducer sheath. Now what? Importance of forearm angiograms at the beginning and and of the case Advance a microcatheter proximally and inject Nitroglycerin at the level of Brachial artery. Importance of forearm angiograms at the beginning and and of the case Resistance encountered during the aspiration of the sheath lateral check flow. Gentle hand injection... 13 4/13/2016 Importance of forearm angiograms at the beginning and and of the case Nitroglycerin injection through the sheath… Importance of forearm angiograms at the beginning and and of the case • Variations of the anatomy • Difficult anatomy Tips & Tricks Difficulty to advance the guidewire towards the shoulder? 14 4/13/2016 SMOOTH RIDE TO THE DESCENDING AORTA… 5-Fr Jacky or Sarah diagnostic catheters SMOOTH RIDE TO THE DESCENDING AORTA… 5-Fr Jacky catheter SMOOTH RIDE TO THE DESCENDING AORTA… 5 Fr Jacky catheter 0.035” 1.5m J-tip GLIDEWIRE 15 4/13/2016 SMOOTH RIDE TO THE DESCENDING AORTA… $ 39.70 0.035” 1.5mm Hydrophilic wire $ 50.33 0.035” Wholey wire TRI - liver directed therapies Bland embolization Chemoembolization Radioembolization 16 4/13/2016 Y – 90 Work-up, Infusion of MAA Tc 99 Coil Embolization of GDA, R gastric art. Infusion of MAA Tc 99 Devices: 5 Fr Jacky catheter Progreat 2.8 Fr, 130 cm with pre-loaded wire TIS-936-09182015 17 4/13/2016 Y – 90 Work-up, Infusion of MAA Tc 99 Embolization of GDA, R gastric arteries Infusion of MAA Tc 99 (simulator) SPECT nuclear medicine exam 7 days later… Radio-embolization: Y – 90 Infusion Devices: 5 Fr Jacky catheter Progreat 2.8 Fr, 130 cm with pre-loaded wire TIS-936-09182015 18 4/13/2016 Case Radial sheath removal: Inject 15 cc of air in the TB band. Keep connection tight Patent Hemostasis concept Remove the sheath slowly Patent hemostasis Have extra 5 cc of air ready to be injected while sheath is removed TIS-936-09182015 Patent Hemostasis concept 19 4/13/2016 Radial sheath removal Low Pressure Hemostasis to maintain flow through the artery Inadequate O2 wave? Deflate 0.5-1cc at the time Check O2 pulse MUSC - Nursing Protocols 5-Fr : patient is discharged in 2h Observation for 1 h Within the 2nd hour: deflation of 3-4 cc every 15’ Full deflation should be completed in 1 h Observation, reinflate as needed Alternative: deflation within the 1 h. MUSC – DISCHARGE INSTRUCTIONS 20 4/13/2016 PATIENT’S SATISFACTION… • Discharge in 1.5 - 2 h • Comfortable environment • Radial lounge: optimization - space - human resources Radial lounge MUSC ACCESS Trial – MUSC/USA TACE under Radial vs Femoral artery access Prospective and Randomized Clinical trial Study design (3 procedures): TACE #1 TACE #2 TACE #3 FEMORAL RADIAL PATIENT’S RADIAL FEMORAL SELECTION 21 4/13/2016 Radial Access Training Program Transradial Interventions Course Med University of South Carolina Charleston / SC guimarae@musc.edu 22
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