Fig. 4.1
(a) Right arm position prior to draping for right radial access. A-Image receptor. B-Ceiling mounted upper body radiation shield. C-Arm board draped with fitting Lead cover (reusable and kept under the sterile drape, also see c). D-Lower body radiation shield. E-a board placed half way under the patient to provide stable working area for the procedure. (b): Right radial access site draped and ready for the procedure. A-Right radial access site. B-Right femoral access site. C: Supported working area for procedure. (c): A-Arm board and B-0.25 mm Lead cover that is stitched to properly fit over the curved portion of the arm board. This arm board is placed between the pts arm and body (as shown in a) and helps reduce radiation exposure to the radial operator (Courtesy of Ajay Bhatia, RT, UTMB Cath Lab, Galveston, TX, USA)
4.2 Two Puncture Techniques Can Be Used for Radial Artery Access
- 1.
Single wall puncture technique using Micropuncture Access Set (Cook Medical, Bloomington, IN, USA) (Fig. 4.2). This provides the front wall single arterial puncture to radial artery using small 21-gage needle that comes in Micropuncture access set. The Micropuncture access set we use for radial access has a 21-gage 7 cm long needle, 0.018 in. 40 cm long guidewire and four or five French 10 cm long outer catheter with inner dilator.
Fig. 4.2
Micropuncture Access set (Cook Medical, Bloomington, IN, USA). A-21 gage, 7 cm long needle. B-0.018 in., 40 cm long guidewire (Nitinol guidewire with Palladium tip). C-5 French 10 cm long outer catheter with inner dilator. cm centimeter
- 2.
Double wall puncture technique using Glidesheath Access Kit (Terumo Medical Corporation, Somerset, NJ, USA) (Fig. 4.3). The kit includes Glidesheath with dilator, Surflo IV catheter (1.25 in. long, 20 or 22 gage needle with plastic catheter) and a nitinol/plastic guidewire (0.021–0.025 in., 45 cm long).
Fig. 4.3
Glidesheath Access Kit (Terumo Medical Corporation, Somerset, NJ, USA). A: Surflo IV catheter (1.25 in. long, 22 gage needle with plastic catheter). B- Nitinol/plastic guidewire (0.021 in., 45 cm long). C-5Fr Glidesheath with dilator. cm centimeter
Palpate the radial artery a few centimeters above the radial styloid process with the tips of the left hand index and middle fingers, separating the two by one centimeter or so. Palpate the radial pulse with both fingers and try to move both fingers side to side (medial to lateral or vice versa) over the radial artery so that you can correctly identify the location (site of the strongest pulse) and course of the radial artery under the fingers (avoid excess pressure as radial artery can be easily occluded by finger pressure). Once the location of the radial artery has been felt by both fingers of left hand, then you can place the artery at the tips of both fingers (radial artery coursing in straight line in-between the two points) (Fig. 4.4). Using the right hand, give small amount of local anesthetic to the skin in-between the fingers feeling the artery. Then for the single wall puncture technique, using the right hand hold micropuncture needle (Cook Medical, Bloomington, IN, USA) between the thumb and index finger at about 45–60° to the skin (Fig. 4.5) and advance the needle under the skin slowly until you have punctured the anterior wall of the artery and the blood is seen coming out from the hub. Due to smaller size of the micropuncture needle the pulsatile nature of the blood may be less prominent. At this point using your left hand thumb and index finger hold and stabilize the needle (thus freeing your right hand) (Fig. 4.6). With your right hand hold the micropuncture guide wire and slowly advance the wire into the radial artery (Fig. 4.7). Do not advance the guide wire against resistance into the artery. If resistance is met then take these steps, (1) lower the needle hub slowly (thus changing the angle of entry of the needle into the artery) and try to advance the wire, (2) may turn the needle hub clock wise or counter clockwise (thus changing the bevel and direction of the wire entry into artery) and try advance the wire again,(3) slowly pull the needle back (thus making the position of the needle inside artery more central) while keeping the guide wire inside the needle and try to advance the wire into artery (using right hand) each time you pull the needle back a little (using left hand). This is a slow and controlled maneuver and if done properly, in author’s opinion, will significantly increase the success rate of your radial artery access. Left hand palm could rest on the patient’s arm to give stability and control in adjusting the needle position. If at any point you are not sure that needle is still inside the artery, then remove the guide wire and see if there is blood flow through the hub. If no blood is coming through the hub, you may still be able to salvage the access if the needle is through the back wall of the artery (double puncture) by pulling the needle back until you see blood again. After arterial puncture and placement of 0.018 in. guidewire the outer catheter is placed over the guidewire in the artery. Then inner dilator and guide wire is removed and 0.035 in. guidewire is introduced into the artery for placing the final sheath/catheter for the procedure. One can also directly place the final five or six French radial sheath over the 0.018 in. guidewire as long as the sheath has a narrow tip (0.018–0.021in.) dilator providing smooth transition for skin entry (Figs. 4.8, 4.9, 4.10, and 4.11).
