The Transradial technique is the true minimally invasive "Drive-through" approach to perform percutaneous coronary and peripheral angiograms and interventions.

1. Transradial approach
Tools and technique

2. 1948
Radner demonstrated the
feasibility of accessing thoracic
aorta from the radial artery (RA) in
1948
Radner S. Thoracal aortography by
catheterization from the radial
artery; preliminary report of a
new technique. Acta
Radiol. 1948;29:178-180.

3. 1992
Transradial access (TRA) was not
used for performing CAG until
1989 and the first coronary stent
was deployed in 1992
1. Campeau L. Percutaneous
radial artery approach for
coronary angiography. Cathet
Cardiovasc Diagn. 1989;16:3-
7.
2. Kiemeneij F, Laarman GJ.
Transradial artery Palmaz-
Schatz coronary stent
implantation: results of a
single-center feasibility
study. Am Heart
J. 1995;130:14-21.

4. Blood supply to hand
Arising from the brachial artery, the hand receives blood supply from
the radial and ulnar arteries, both giving rise to superficial and deep
palmar arches, from which digital branches perfuse the digits. Branches
of the common interosseous artery that originate from the ulnar artery
after the radial tuberosity play a crucial role in providing blood supply
to the hand. The ulno-palmar arches in the hand are perfused from
both the UA and RA, with a watershed point where flow from both
sources meets under equal pressure. This watershed point is not static,
implying that a dynamic flow volume and rate is required by the
different parts of the hand at rest and upon exertion.This suggests if
either the RA or UA are compromised, there is a rich network of vessels
that maintains hand perfusion.

5. Understand the aortic arch
The aortic arch can be characterized into
three types based on the vertical distance
from the origin of the innominate artery to
the top of the arch
Type A-
-1: Arch has a distance that is less than one
times the diameter of the left common
carotid artery (CCA)
-2: Arch originates from one to two CCA
diameters from the top of the arch
-3 :Arch originates more than 2 CA diameters
from the top of the arch
Type B and C -left common carotid artery from
innominate artery
Type D-True bovine arch
Type E-Arteria lusoria

6. Barbeau test
The above illustration demonstrates
the morphology of the
plethysmography tracing and the
ability of the oximeter to provide a
reading of the oxygen saturation
(positive oximetry) before,
immediately after, and two minutes
after radial artery occlusion. The
response can be categorized into 1 of
4 types. Patients with a type D
response should not undergo
transradial catheterization of that
wrist.

7. Allen test
• Instruct the patient to clench his or her fist; if the patient is unable to do this,
close the person's hand tightly.
• Using your fingers, apply occlusive pressure to both the ulnar and radial
arteries, to obstruct blood flow to the hand.
• While applying occlusive pressure to both arteries, have the patient relax his
or her hand, and check whether the palm and fingers have blanched. If this is
not the case, you have not completely occluded the arteries with your
fingers.
• Release the occlusive pressure on the ulnar artery only to determine
whether the modified Allen test is positive or negative.
• Positive modified Allen test – If the hand flushes within 5-15 seconds it
indicates that the ulnar artery has good blood flow; this normal flushing of
the hand is considered to be a positive test.
• Negative modified Allen test – If the hand does not flush within 5-15
seconds, it indicates that ulnar circulation is inadequate or nonexistent; in
this situation, the radial artery supplying arterial blood to that hand should
not be punctured.

8. the inner and outer diameters of
5F to 8F radial sheaths and guides.
Using a sheathless guide catheter
allows one to use a larger inner
lumen without compromising on
external diameter
Gulati R, Prasad A,Rihal CS. Sheathless transradial intervention using standard guide
catheters. Catheter Cardiovasc Interv. 2010; 76: 911– 916

9. Eaucath to cross lacerated or injured TRA
• Outer diameter of the
Sheathless EauCath in relation to
standard sheath introducer

10. Counterpuncture technique is best

11. Alpha angle supports femoral approach
When using a JL catheter from
femoral access, there is usually a
wider angle (a) between the second
segment of the catheter and the
contralateral aortic wall. The wider
this angle is, the stronger the
support, because it allows for more
coaxiality and pushability. With TR
access this angle is usually narrower
with a consequent loss of backup
support; therefore, more supportive
alternatives for JL catheters, such as
extra backup or Amplatz left shapes,
are preferred[Veterans only].

12. Guide catheter for PCI : Transradial approach

13. Sheath size for PCI
6 Fr is enough except for bifurcation stenting which needs 7 Fr sheath

14. Transradial cocktail
• Heparin 2500-5000 IU
• NTG 200 microgram
• Verapamil 2.5 mg
• Xylocaine 2ml of 2%

15. Judkin’s right
Most commonly used Easy
engagement similar to TF. Weak
backup support as it does not
contact the contralateral aortic
wall. Can be deep
seated(Amplatzerisation by deep
push).

16. AR-1
Provides some passive, but no
active support.

17. Multipurpose
Universal catheter. Requires
extensive manipulation. Ideal for
right-sided bypass grafts and
anomalous circumflex originating
in the right coronary cusp.

18. Ikari left
Allows “single catheter”
technique.Similar manipulation as
JR, but contacts the contralateral
aortic wall for support. May
engage deeply at the power
position.

19. Amplatzer left
Deep engagement. Passive
support. Fits well in “shepherd’s
crook” configurations. Higher risk
for coronary dissection

20. Most commonly used catheter via TRA
1. Tiger and Jockey
2. Judkin’s left
3. Ikari (Universal)
4. Extra back up
5. Amplatzer left

21. Clockwise vs counterclock rotation

22. Success
• Guide catheter support

23. Failure
• Arterial spasm
• Anatomic limitations(Loops ,tortuosity and etc.)
• Failure to cannulate the target vessel
• Inadequate guide support

24. Hemostasis
• A:Apply TR Band on the puncture site and above
• B: Compress the access site by increasing the
pressure applied by the band. Once compression
of the subcutaneous tissue is evident, remove the
introducer sheath from under the band. Allow the
introducer sheath side port to bleed on its way out,
to purge the prothrombotic contents of the radial
artery lumen
• C: Once the introducer sheath is removed, if the
band is providing hemostasis, proceed to step D.If
bleeding is evident at the puncture site, increase
the compression pressure given by the band to
eliminate all visible bleeding
• D: Gradually decrease the compression pressure in
the band until minor bleeding (leakage) is seen at
the puncture site, and,once bleeding is seen,
increase the pressure just enough to completely
eliminate the bleeding
• E:

25. Reverse Barbeau test
assess for presence of antegrade flow in the radial artery. If antegrade
flow is present in radial artery (presence of plethysmographic
waveform on compression of ipsilateral ulnar artery), leave the band in
place. If antegrade flow in radial artery is not present, titrate the
pressure to the lowest needed pressure to achieve hemostasis.In the
first 10 to 15 minutes of initiating hemostatic compression, due to
changes in the dynamic balance of local nfluences, repeat attempts at
achieving the balance of patency and hemostasis frequently succeed,
even if the very initial attempt does not.

26. Once optimal hemostatic compression is achieved, continue to monitor
the presence of radial artery patency periodically (every 15 minutes) by
using reverse Barbeau test. The patient is instructed to report
immediately if any bleeding is observed at the site. If radial artery
patency is not achievable at the outset, despite continuous attempts,
reevaluation at 15 minutes and reattempting establishment of patent
hemostasis are advised.

27. ?Routine use of Allen test is flawed
Randomized trials of TRA-PCI have excluded
patients with abnormal Allen’s tests,
whereas routine practice includes a large
number of such patients. High-volume
transradial centers worldwide document
the extremely low, almost unheard of,
incidence of hand ischemia after TRA
without prior AT. Observations from the
congenital heart disease and vascular
surgery spheres lead us to conclude that AT
is a misleading and inaccurate test of
collateral blood supply to the hand. In our
opinion, the case for its.
1. Hildick-Smith D. Use of the Allen’s test
and transradial catheterization. J Am
Coll Cardiol.2006;48:1287; author reply
1288.
2. Gilchrist IC. Is the Allen’s test accurate
for patients considered for transradial
coronary angiography? J Am Coll
Cardiol. 2006;48:1287; author reply
1288.
3. Ghuran AV, Dixon G, Holmberg S, de
Belder A, Hildick-Smith D. Transradial
coronary intervention without pre-
screening for a dual palmar blood
supply. Int J Cardiol. 2007;121:320-322.

29. Overcoming radial artery injury

30. Maintain patency after TRA
Strategy Level of Evidence
Use of smaller sheaths,
eg, 5F vs 6F
A
Use of sheathless
guides
C
Patent hemostasis A
Anticoagulation B

31. 10 commandments of transradial access
1. Advancing guiding catheter to ascending aorta Perform catheter exchanges with the tip of a
260-cm long wire in the aortic root
2. Stiff wires can be used in severe cases of tortuosity for additional support
3. If needed, use hydrophilic wires to navigate tortuous subclavian anatomy
4. Have patient take deep inspiration to help navigate and straighten tortuosity
5. If not sure of wire position, perform a limited angiogram to understand anatomy
6. Engaging coronary artery
7. Advance catheter and start manipulation over the wire deep into aortic cusp of interest
8. To prevent knotting and kinking, keep wire within the guide catheter during manipulations
9. Once the catheter is engaged in the coronary ostium, pull back gently to improve coaxiality and
avoid dissections
10. Feel minute resistance and confirm by visualisation

32. Gift for coming so far

33. Your health is my health
• Eat healthy
• Drink water in place of soft drink
• Walk more
• No to sugar reach drink