Approach Considerations

The left or right radial artery can be used for cardiac catheterization. The standard equipment setup in most catheterization laboratories facilitates right radial artery access, which tends to be used more frequently.

In a 2019 systematic scoping review (inception to September 2018) of MEDLINE and EMBASE comprising 19 publications with 4,212 participants that evaluated distal transradial access for cardiac catheterization, the investigators found an overall 95.4% success rate and a 2.4% complication rate.^[68] There was no significant difference in complication rate between distal transradial access and conventional transradial access, with the primary complication being bleeding/hematoma. Radial occlusion occurred in 1.7% of patients who underwent transradial access.^[68]

Transradial Catheterization

Under sterile conditions, the radial artery is accessed with a 20- to 21-gauge needle, and a 5F-6F sheath is advanced into the artery over a wire using the Seldinger technique.

Vasodilators (usually verapamil and nitroglycerin) are administered to reduce radial artery spasm.^{[69, 70]}

Hydrophilic sheaths are generally used to minimize trauma to the radial artery. An anticoagulant (usually unfractionated heparin [UFH] or bivalirudin) is given to prevent radial artery thrombosis.^[71] A 2017 systematic review and meta-analysis found that observational studies suggest a benefit of higher-dose vs lower-dose UFH in reducing post-transradial cardiac catherization radial artery occlusion, but the findings were less clear in randomized trials.^[72] In a 2019 single-center study that evaluated radial artery occlusion in 686 patients who underwent diagnostic cardiac catherization and received either 100 IU/kg UFH (high dose) or 50 IU/kg UFH (standard dose), investigators found an independent association between lower rates of radial artery occlusion and high-dose UFH.^[73]Only 36 of the 686 patients (5.2%) experienced radial artery occlusion as detected by vascular Doppler ultrasonography.^[73]

A guidewire is then advanced from the radial artery to the ascending aorta.

Catheters are advanced over the guidewire and used for coronary angiography and/or coronary intervention. Specialized catheters shaped to aid in engaging the coronary arteries from the transradial approach have been developed, although traditional coronary catheters can also be used.

After the procedure, the sheath is removed and pressure is held over the arteriotomy site to achieve hemostasis. Several devices have been developed to assist in maintaining pressure on the wrist; most are bands that allow easy modification of hemostatic pressure.

Medication

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Media Gallery

Transradial cardiac catheterization. Radial artery loop: Radial loops are a common arterial anomaly. Most radial loops can be traversed with a guidewire and a sheath advanced beyond the loop to proceed with angiography. The radial loop pictured is an extreme example. A decision was made to use a different arterial access site in this case.
Transradial cardiac catheterization. Radial artery spasm (1 of 3): Contrast injection shows severe spasm in the radial artery.
Transradial cardiac catheterization. Radial artery spasm (2 of 3): After intra-arterial injection of nitroglycerin and verapamil, the radial artery spasm is relieved.
Transradial cardiac catheterization. Radial artery spasm (3 of 3): After relief of spasm with vasodilators, an introducer sheath has been easily advanced into the radial artery.
Transradial cardiac catheterization. Tortuous subclavian artery (1 of 2): Tortuosity of the subclavian artery can make catheter manipulation difficult.
Transradial cardiac catheterization. Tortuous subclavian artery (2 of 2): Successful coronary angiography was performed in this case despite the severe tortuosity of the subclavian artery.
Transradial cardiac catheterization. Radial loop (1 of 3): This radial artery loop was encountered after placement of an an access sheath in the radial artery at the wrist. This common arterial anomaly presents a challenge to performing transradial catheterization, but it can usually be traversed using a guidewire.
Transradial cardiac catheterization. Radial loop (2 of 3): A 0.014 inch guidewire has been advanced across the radial loop. This will allow advancement of a catheter above the loop.
Transradial cardiac catheterization. Radial loop (3 of 3): A catheter has been advanced beyond the radial loop to the ascending aorta. Successful coronary angiography was performed.