PCI—troubleshooting radial access

Although the radial access route is becoming the preferred approach to femoral access in percutaneous coronary interventions (PCI), it does not come without its complications. In this video, Dr O'Brien will troubleshoot the radial access approach and offer his hard-won, expert advice to ensure that you learn how to perform a safe and effective procedure.

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[00:00:00] Radial spasm is common and can cause issues with PCI and even angiography. It's more common in small arteries and in smokers, and it's provoked by excessive catheter movement or manipulation so aim to keep these down to a minimum. I mentioned earlier the use of an intraarterial anti-spasm cocktail, and this can help especially for new or inexperienced operators.

[00:00:30] Verapamil and nitrate are commonly used. Use concentrated drug and dilute it into the patient's blood aspirated into the syringe from the sheath as this is less irritant to the artery and less uncomfortable for the patient. Long sheath may help reduce spasm, but I don't use them very often in my standard daily practice. Hydrophilic catheters and sheathless guides may also be of use as these have

[00:01:00] a very slippery coating once wet. Sometimes, while small catheters will pass over the radial artery, it's not possible to advance a larger guiding catheter as the end of this is often more blunt and less tapered. It's sensible to give more radial cocktail and to reduce the chance of any spasm and also some sedation or pain relief will improve things for the patient and make passage of equipment easier. If this fails, one way of improving

[00:01:30] passage is to make the leading edge of the guiding catheter smoother. This is achieved as shown in the video by passing an angioplasty wire through the catheter and up the artery and inflating a small angioplasty balloon just out of the catheter to essentially produce a smooth structure to allow the catheter to track. This technique is known as balloon tracking. Notice the distal balloon markers positioned just outside the catheter before it's inflated

[00:02:00] which then allows the catheter to pass easily up the artery. Inadvertently, small branches can be entered and may even be large enough to take small diagnostic catheters especially

[00:02:13] catheters with very little angulation. It may then be difficult to advance a guiding catheter as these are much larger and blunter ending. And if the vessel is a small branch, this may not respond to antispasmodic and may result in dissection or

[00:02:30] perforation if you continue to push. Sometimes the J-wire and catheter go from the arm straight into the descending aorta rather than the aortic route or ascending aorta. If this happens, as you can see on the video, it's best to change to a left anterior oblique or LAO view, pull back the wire and catheter and use the catheter to redirect the wire into the aortic route. Sometimes it also helps to get the patient to take a deep breath enjoying this maneuver

[00:03:00] to straighten out the vessels and facilitate the correct placement. Remember, if you've caused an issue in accessing the radial artery, the patient may only bleed into the arm after the procedure once the guiding catheter is removed. This is due to the relatively smaller diameter of the radial artery, meaning that a large guiding catheter may have been covering or sealing the perforation or dissection whilst in place. The patient's then anticoagulated for the PCI

[00:03:30] and when the sealing action of the guiding catheter is taken away, the bleeding may be prompt. Apply firm further pressure to tampen out the leak at the puncture site. Fortunately, this is usually very easy to achieve for the radial artery in contrast to the femoral artery. If concerned then apply a manual sphygmomanometer cuff proximally and inflate higher than the last recorded systolic blood pressure to prevent blood flow into the arm and allow repositioning of pressure hemostasis

[00:04:00] devices distally. Elevate the arm in a Bradford sling above the level of the heart. Following PCI, it's important to check the distal pulses, evaluate capillary refill and general perfusion of the tissues and to monitor arterial waveforms noninvasively using pulse oximetry to confirm a good collateral circulation to the hand whilst the hemostasis device is in place. Watch for any signs of compartment syndrome including

[00:04:30] pain and skin changes. This is a serious but rare complication post PCI. With appropriate and careful monitoring, it can be caught and managed early.