This document discusses radial artery occlusion (RAO) after transradial catheterization and strategies to prevent it. RAO is asymptomatic in most cases due to collateral hand circulation. The risk of RAO can be reduced by using hydrophilic sheaths, patent hemostasis techniques during compression, and compression devices like TR bands. One study found RAO rates decreased from over 10% to under 6% by implementing hydrophilic sheaths, TR bands, and patent hemostasis protocols. Further reductions may be possible with smaller devices and long term antithrombotic therapy after RAO. Precise Doppler ultrasound is needed to accurately assess radial artery patency.

1. Radial artery occlusion after
catheterization.
Can we effectively prevent it?
Škvařil J, Daníčková K, Broulíková K,
Horáková S, Malý M
Ústřední vojenská nemocnice Praha

2. Disclosure: Jan Škvařil, MD
Dr. Škvařil has no relevant financial interests
to disclose
Ústřední vojenská nemocnice Praha

3. History
Transradial selective coronarography.
Campeau L. 1989
Transradial PCI .
Kiemeneij, GJ. Laarman. 1992 Amsterdam
Coronary stenting transradially.
Kiemeneij, GJ. Laarman. 1993 Amsterdam.
Outpatient PCI transradially.
Kiemeneij, GJ. Laarman, 1994
Ústřední vojenská nemocnice Praha

4. Femoral x radial access
Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact
on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J 2009;157: 132– 40.
Ústřední vojenská nemocnice Praha

5. Femoral x radial access
Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact
on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J 2009;157: 132– 40.
Ústřední vojenská nemocnice Praha

6. Radial access – drawbacks
- Lower primary success rate. Cross-over more frequent
- Radiation exposure
- Iatrogenic radial artery occlusion (RAO)
„asymptomatic loss of pulsation“
Ústřední vojenská nemocnice Praha

7. Radial access – drawbacks
- Lower primary success rate. Cross-over more frequent
- Radiation exposure
- Iatrogenic radial artery occlusion (RAO)
„asymptomatic loss of pulsation“
Ústřední vojenská nemocnice Praha

8. Hand vascular supply
Arteria radialis, arteria ulnaris, arteria interossea
Superficial and profound palmar arch
Ústřední vojenská nemocnice Praha

9. Hand vascular supply
Thanks to character of hand vascular supply RAO is asymptomatic as a rule.
„Asymptomatic loss of pulsation “
Ústřední vojenská nemocnice Praha

10. RAO. Clinical course, significance
Symptoms:
painful forearm and thenar, loss of handgrip force and paresthesia
critical limb ischemia extremely rare (individual cases, patients
with end stage kidney disease. Systemic tissue disease).
Symptom free:
Repeated access, other access sites saving (radial artery harvest)
Prevention of RAO x treatment of RAO
Ústřední vojenská nemocnice Praha

11. RAO assessment
1) Physical exam. Palpation. Allen s test
2) Pletysmography
3) Point US
4) Duplex US
Ústřední vojenská nemocnice Praha

12. RAO assessment
1) Physical exam. Palpation. Allen s test
2) Pletysmography
3) Point US
4) Duplex US
Ústřední vojenská nemocnice Praha

13. Allen´s test
( palpation, event. with pletysmography)
Ústřední vojenská nemocnice Praha

14. RAO assessment
Total
U.S.A.
Europe
Japan
RAO assesment before hospital discharge (%)
NO
52.5
51.9
59.0
36.0
Method (%), if YES
Doppler
7.1
7.6
7.5
0.0
Oximetry/pletysmography
5.5
11.4
5.1
0.0
Palpation only
55.2
44.3
49.8
79.1
(source: Bertrand OF, Rao SV, Pancholy S, Jolly SS, Rodés-Cabau J, Larose E, Costerousse O, Hamon M, Mann T. Transradial
approach for coronary angiography and interventions. Results of the first international transradial practice survey. JACC Cardiovasc
Interv. 2010;10:1022-31)

15. RAO. „Asymptomatic loss of pulsation„
-Artery size. Artery/instrumentarium ratio (catether, sheath)
-Instrumentarium properties (hydrophylic)
-Primary x secondary punction. Haematoma. Dissection. Injury.
-Heparin (2000 v.s. 5000 IU) or LMWH during and after procedure
-Compression device. TR band
-Time and technique of compression.(„non occlusive compression“)
-Interruption of blood flow during compression.
-Older patients, Females, lower body weight.
Sanmartin M, Gomez M, Ramon JR, et al. Interruption of blood flow during compression and radial artery occlusion after
transradial catheterization. Catheter Cardiovasc Interv 2007;70:185–189.
Ústřední vojenská nemocnice Praha

16. RAO. „Asymptomatic loss of pulsation„
-Artery size. Artery/instrumentarium ratio (catether, sheath)
-Instrumentarium properties (hydrophylic)
-Primary x secondary punction. Haematoma. Dissection. Injury.
-Heparin (2000 v.s. 5000 IU) or LMWH during and after procedure
-Compression device. TR band
-Time and technique of compression.(„non occlusive compression“)
-Interruption of blood flow during compression.
-Patients age, Females, lower body weight.
Sanmartin M, Gomez M, Ramon JR, et al. Interruption of blood flow during compression and radial artery occlusion after
transradial catheterization. Catheter Cardiovasc Interv 2007;70:185–189.
Ústřední vojenská nemocnice Praha

17. Treatment (compression) after procedure
TR Band (TERUMO)
Selective and measurable compression
Ústřední vojenská nemocnice Praha

18. Patent hemostasis
Barbeau test (modified Allen´s test)
inflation
10 ml
ulnar
compression
pulse
absence
partial
deflation
Ústřední vojenská nemocnice Praha
ulnar
compression
pulse
present

19. Patent hemostasis
Barbeau test (modified Allen´s test)
inflation
10 ml
ulnar
compression
pulse
absence
partial
deflation
Radial artery patent
Ústřední vojenská nemocnice Praha
ulnar
compression
pulse
present

20. Treatment (compression) after procedure.
RAO prevention
Patent hemostasis
(perfusion h., non-occlusive h.)
Objective:
1) Prevention of bleeding
2) Maintenance of blood flow.
Ústřední vojenská nemocnice Praha

21. Patent hemostasis and TR band importance
-Patent hemostasis + TR band = 60% decrease of RAO occurance.
-Recanalization of ~ 50% cases within 1 month regardless
of compression method used.
-Patent hemostasis > heparin admin.
-3-10% after TRA, 30-40% after prolonged monitoring CCU
Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of Radial Artery Occlusion—Patent Hemostasis Evaluation Trial (PROPHET
Study): A randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter
Cardiovasc Interv 2008:72:335–340.
Pancholy S. Impact of Two Different Hemostatic Devices on Radial Artery Outcomes after Transradial Catheterization, J Invasive Cardiol
2009; 21:101-104
Ústřední vojenská nemocnice Praha

22. Treatment (compression) after procedure
Protocol of observation
- Before procedure. Pletysmogrpahy- pulse oxymetry
- 30 minutes after procedure.
- 1. day after proc./before discharge.
Pletysmography
(false positivity possible – a.interossea)
Duplex ultrasonography (DUS)
(gold standard)
-before hospital discharge
-after 30 days
Ústřední vojenská nemocnice Praha

23. Results
1. period (6/084/09)
Age
(11/10-5/11)
n = 804
Men /Women
2. period
n = 532
514 (63,9%) / 290
314 (59%) / 218
66.9 (9,5)
67.2 (10.1)
p
NS
NS
% of PCI
35.9
28
% of F5
15.2
45.1
Hydroph. sheath
~ < 30%
~ > 90 %
dif
TR band
~ 75 – 80%
= 100%
dif
Ústřední vojenská nemocnice Praha
p < 0,05
p < 0,001

24. Results
Procedures DUS
RAO
%RAO
RAO
%RAO
Undetected
total
discharge
discharge
day 30
day 30
after 30 days
discharge
1. period (6/08-4/09)
906
804
87
10.82
46
5.79
9
2. period (11/10-5/11)
672
532
29
5.45
15
2.85
5
Ústřední vojenská nemocnice Praha

25. Results
12.00
10.00
p<0,001
8.00
p=0,001
6.00
1 .období
p=0,015
4.00
P<0,001
2.00
0.00
prop
30. den
% RAO
Ústřední vojenská nemocnice Praha
2. období

26. Questions
Further systematic follow up:
- furhter decrease of RAO in time ?
- late RAO (intimal proliferation) ?
Medication after RA and medical treatment in case of RAO (if any):
- UFH, ASA, LMWH, DAPT
Ústřední vojenská nemocnice Praha

27. Conclusion
-Asymptomatic loss of pulsation (RAO) represents a specific complication of TRA
-It has benign character as a rule. We have not noted any relevant case.
-Prevention of RAO is important for the possible repeated use of a given access site.
-This saves other eventual vascular access sites ( HD, arterial grafts etc..)
-To estimate vessel patency exactly, DUS is the most suitable. (x routine)
- Patent hemostasis + TR band = RAO incidence < 6% (24 h) and <3% (30d) respectively
-Further decrease is possible mainly due to size reduction of devices used
Ústřední vojenská nemocnice Praha