The radial artery access with ultrasound trial (RAUST)

1. The Radial Artery access
with Ultrasound Trial
(RAUST)
Arnold Seto, MD, MPA
Jonathan S. Roberts MD, Mazen Abu-Fadel MD
Zoran Lasic MD
AIM-RADIAL Late-Breaking Clinical Trial
September 26, 2013
Disclosures: None

2. How hard is it to hit the radial artery?
Femoral Artery
ID 7 mm
2mm
Radial Artery
ID 2.6 mm
2mm
2mm
Area 38 mm2
Area 5.3mm2
13% of transradial PCI failures are due to radial access failure. Deghani JACC Interv 2009
“Normal” two point discrimination is 2-4 mm at the fingertips. DeJong's neurologic examination

3. How hard is it to hit the radial artery?
Radial Artery
ID 2.6 mm

4. Ultrasound for Arterial Access

5. FAUST: Procedural Outcomes
First Pass Success Rate
Number of Attempts
100%
5
p < 0.000001
90%
p < 0.000001
82.7%
80%
3
70%
60%
3
46.4%
50%
2
1.3
40%
30%
1
20%
10%
0
0%
Fluoroscopy
Ultrasound
Fluoroscopy
Risk of Venipuncture
20%
300
15.8%
10%
2.4%
5%
0%
p = 0.016
213
p < 0.000001
15%
Ultrasound
Time to Sheath Insertion
185
Seconds
Attempts
4
200
100
0
Fluoroscopy
Ultrasound
Fluoroscopy
Seto, JACC Cardiovasc Interv. 2010 Jul;3(7):751-8
Ultrasound

6. Radial Access
US Tips:
• Keep probe near/over
needle
• Mark the center of the
probe and line up artery
with centerline
• Short jabs on the skin or
tissue to identify needle tip
• Compress the skin to
close the veins

7. Longitudinal approach
Adashi, J Clin Monit Comput 2013 epub

8. Radial Artery Sizing

9. Radial Access
Radial tortuosity
Ulnar tortuosity
Yan ZX et al, Circ J 2010, 74:686-692
Radial stenosis

10. Radial Artery Access
Metaanalysis of First Pass Success
Shiloh, AL et al, Chest 2011 139(3):524-9

11. RAUST Study
• Inclusion Criteria

Adults with planned radial catheterization

Functional ultrasound equipment and trained operator
• Training: > 15 ultrasound radial procedures and > 100 radial cath
• Attending physicians (13) and advanced interventional fellows (3)
• Exclusion Criteria

Abnormal Barbeau’s (Class D) or Allen’s (>10sec) test

Emergency procedure (STEMI, shock)

ESRD on dialysis

Prior ipsilateral radial puncture within 1 week

12. RAUST Study
Primary Endpoints
• First-pass success rate
• Number of attempts to access

Forward motions separated by withdrawal of needle

Short “wiggle” to visualize path of needle on skin/tissue
above plane of artery allowed

Announced by operator / confirmed by observer/tech
• Time to access

From first application of US or needle for puncture to
successful sheath insertion

13. RAUST Study
Secondary endpoints
• Difficult access procedures
1.
≥ 5 minutes
2.
≥ 5 attempts
• Crossover to ultrasound guidance
• Crossover to another access site
• Wrist pain (VAS 0-10) 1-4 hours after
procedure
• Radial spasm
• Vascular complications

Hematoma >2cm, clinically evident RAO

14. RAUST Study
Procedural details
•
•
•
•
•
•
5F or 6F hydrophillic sheaths
Single wall or double wall technique
Patent hemostasis
Lidocaine IA
Heparin 2000-5000 units, or bivalirudin
Verapamil 2.5 mg or NTG 100 mcg IA

15. RAUST Study
Design
698 patients with nonemergent radial
angiography enrolled and randomized
between December 2011 and March 2013
DESIGN: Prospective, multicenter
randomized study
OBJECTIVE: To evaluate the
accuracy of ultrasound vs. palpation
guidance for radial access.
SITE LEAD INVESTIGATORS:
Arnold Seto, Jonathan
Roberts, Mazen Abu-Fadel, Zoran
Lasic
Palpation
(n = 351)
Procedural / Clinical outcomes
114 Censored*
SITES:
Jamaica / Lenox Hill Hospital (357)
Long Beach VA / UC-Irvine (193)
Miami Baptist (98)
Oklahoma VA (50)
Ultrasound
(n=347)
Palpation #attempts
(n = 237)
111 Censored*
Ultrasound #attempts
(n=236)
* First 225 patients from Jamaica Hospital censored due to first-pass success (96.5% P and 97.3% US) counted by # punctures

16. Patient Population
Palpation
Ultrasound
N=351
N=347
62.3
61.5
0.80
Male
262 (75%)
254 (73%)
0.66
Outpatient
141 (40%)
139 (40%)
0.98
30.2
30.4
0.64
Obesity (BMI >30)
153 (44%)
149 (43%)
0.86
Hypertension
305 (87%)
292 (84%)
0.30
Hypercholesterolemia
265 (75%)
254 (73%)
0.49
Diabetes Mellitus
151 (43%)
149 (43%)
0.98
Tobacco
107 (30%)
128 (37%)
0.07
16 (5%)
14 (4%)
0.73
54 / 149 (36%)
56 / 149 (38%)
0.81
Characteristic
Age, years
Body mass index (BMI)
PVD
Barbeau’s Class B or C
P-value

17. Procedural Characteristics
Palpation
Ultrasound
N=351
N=347
Intervention
63 (18%)
73 (21%)
0.30
5F Sheath
193 (55%)
185 (53%)
0.66
Single wall technique
306 (87%)
295 (85%)
0.41
Right radial access
323 (92%)
328 (95%)
0.19
Verapamil (≥2.5mg)
340 (97%)
342 (99%)
0.20
Nitroglycerin (≥100mcg)
271 (77%)
278 (80%)
0.35
Lidocaine IA (5mg)
167 (48%)
170 (49%)
0.71
TR band Closure
225 (64%)
229 (66%)
0.60
D-stat band
114 (33%)
111 (32%)
0.89
Heparin
322 (92%)
321 (92%)
0.71
Heparin dose
3487 U
3700 U
0.16
GPIIb/IIIa
13 (4%)
14 (4%)
0.82
Bivalirudin
51 (15%)
50 (14%)
0.96
P2Y12 Inhibitor
193 (55%)
200 (58%)
0.48
Characteristic
P-value

18. Number of Attempts
4
p<0.0001
3.05
Attempts
3
1.65
2
1
0
N = 237
Palpation
N = 236
Ultrasound

20. Time to access
150
P=0.006
108
120
Seconds
88
90
60
30
0
N = 351
Palpation
N = 347
Ultrasound

21. Difficult Access
≥ 5 attempts
≥ 5 minutes
18.6% P<0.001
P=0.07
Percent
20
6.8%
10
3.7%
2.4%
0
237
236
Palpation Ultrasound
351
347
Palpation Ultrasound

22. Clinical Outcomes
Palpation
Ultrasound
N=351
N=347
12 (3%)
15 (4.3%)
0.56
0.71
0.69
0.85
4 (1.1%)
5 (1.4%)
0.75
10 (8 successful)
N.A.
N.A.
Crossover to other site after
successful sheath insertion
5
2
0.45
Crossover to other site before
sheath insertion / failed
access
7
3
0.34
Characteristic
Spasm
Pain score (0-10)
Bleeding
Crossover to ultrasound
rescue attempts after >5
minutes
P-value

23. Radial Artery access with Ultrasound Trial
Arnold Seto, MD MPA
Summary Conclusions
1. Routine ultrasound guidance increases accuracy
and reduces time for transradial access
2. Ultrasound guidance reduces the incidence of
difficult access procedures, and is a useful rescue
technique for palpation guided access
3. Ultrasound guidance does not reduce radial artery
spasm, vascular complications, or patient pain.

24. Results by Site