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Radial Access

Radial access is a technique used in minimally invasive procedures where a catheter is inserted into the radial artery in the wrist, offering a safer and more comfortable alternative to traditional femoral access. Often enhanced by the use of a radial cocktail—a combination of medications that help dilate the artery and reduce vasospasm—this approach improves patient outcomes and procedure efficiency. Radial access is increasingly preferred for procedures like coronary angiography and angioplasty due to its lower risk of complications, such as bleeding or hematoma, and shorter recovery times. This technique allows for quicker mobilization and increased patient comfort, making it an excellent choice for both diagnostic and interventional treatments.

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Ep 443 Innovative Approaches in Radial to Peripheral Interventions with Dr. Amit Srivastava

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Pre Radial Access Procedure Prep

Pre-Procedural Evaluation

• Evaluate circulation of ulnopalmar arch with modified Allen or Barbeau test
• Type D is only contraindication for radial access (some institutions forgo Barbeau test because of ulnar-palmar collateralisation)
• Is patient on dialysis or nearing dialysis and may need radial artery for potential access
• US to evaluate the size of the radial artery - 2 mm is reasonable minimal diameter

Left vs right radial artery
Left:
• Catheter will only cross left vertebral artery
• Extra working length of catheter
• Less chance of radial loop or difficult anatomy
Right:
• Can position arm by side which closely approximates femoral set up
• Helpful for neurointerventional procedures involving carotids or intracranial vasculature

Radial Access Podcasts

Listen to leading physicians discuss radial access on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Radial Access Procedure Steps

Day of Radial Access Procedure

• 30 mg of topical nitroglycerin to left wrist
• EMLA cream (lidocaine 2.5% and prilocaine 2.5%) to left wrist
• Apply 30 minutes prior to procedure and cover with tegaderm

Position

• Wrist extended with palm facing up
• Arm abducted vs adducted - operator preference
Access:
• 2 cm proximal to the radial styloid
• Puncture angle of ~ 30-45°
• Recommend a radial access kit: many products available.
• US guidance with single wall puncture using 21g needle
Insert 0.018" guidewire
Visualize wire with any signs of resistance
Important to use hydrophilic sheath - make sure sheath is wet to activate coating

Radial Access Tips

• Dermatotomy typically unnecessary
• Do not overuse lidocaine. Can spasm radial artery
• Keep patient calm and room warm

Radial Cocktail

• Some operators do not use
• Many combinations of drugs: 2.5 mg verapamil, 200 µg of nitroglycerin, 3000 units heparin
• Hemodilution - draw up the radial cocktail in a 20 or 30 ml syringe and dilute the radial cocktail with arterial blood from recently placed sheath. Administer slowly during diastole.
• Consider securing sheath to wrist - can cut "X" in tegaderm and place over sheath

Radial Access Articles

Read our exclusive BackTable VI Articles for quick insights on radial access, provided by physicians for physicians.

Post-Procedure

Key Concept

• Patent hemostasis (non-occlusive) minimizes risk of radial artery occlusion

Sheath Removal

• Radial compression device following procedure: many products
• Tip: partially removing sheath 1-2 cm and place gauze proximal to access site: will allow room for compression band and wick away oozing during sheath removal/band placement
• Slowly inject air into band (usually ~15 ml) while removing sheath - confirm no oozing
• Remove 1 ml of air incrementally until oozing at access site occurs
• Inject 1-2 ml of air
• Confirm radial pulse is present following compression band placement - evaluate waveform

Deflation Protocol

• Depends on patient, procedure and sheath size
• For routine procedure without anticoagulation and 5 Fr access sheath a reasonable protocol is as follows: begin deflation 30-60 minutes after band placement, remove 3 cc of air Q5 minutes until sheath deflated. If bleeding occurs during deflation, reinflate band with air until hemostasis achieved and restart deflation protocol in 20 minutes.
• Observe patient for 30 minutes before discharge
• Check pulse and site before discharge

Discharge Instructions

• No lifting above 2 lbs x 24 hours
• No strenuous activity x 24 hours
• Keep bandage on for at least 24 hours.
• Ok to shower, but do not submerge access site for 48 hours

Radial Access Demos

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Radial Access Tools

Check out radial access apps, calculators, and decision aids to assist you in your day to day practice.

References

[1] Scalise RFM, Salito AM, Polimeni A, et al. Radial Artery Access for Percutaneous Cardiovascular Interventions: Contemporary Insights and Novel Approaches. J Clin Med. 2019;8(10):1727. Published 2019 Oct 18. doi:10.3390/jcm8101727
[2] Ferrante G, Rao SV, Jüni P, et al. Radial Versus Femoral Access for Coronary Interventions Across the Entire Spectrum of Patients With Coronary Artery Disease: A Meta-Analysis of Randomized Trials. JACC Cardiovasc Interv. 2016;9(14):1419‐1434. doi:10.1016/j.jcin.2016.04.014
[3] Bishay VL, Biederman DM, Ward TJ, et al. Transradial Approach for Hepatic Radioembolization: Initial Results and Technique. AJR Am J Roentgenol. 2016;207(5):1112‐1121. doi:10.2214/AJR.15.15615
[4] Fischman AM, Swinburne NC, Patel RS. A Technical Guide Describing the Use of Transradial Access Technique for Endovascular Interventions. Tech Vasc Interv Radiol. 2015;18(2):58‐65. doi:10.1053/j.tvir.2015.04.002
[5] BackTable, LLC (Producer). (2018, April 4). Ep 26 – Radial vs. Femoral Access in IO Procedures [Audio podcast]. Retrieved from https://www.backtable.com/shows/vi
[6] BackTable, LLC (Producer). (2018, June 27). Ep 30 – Transradial Access: Basic to Advanced [Audio podcast]. Retrieved from https://www.backtable.com/shows/vi

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