distal transradial approach - nvhvv carvasz 2018/presentatie... · access-site complications:...
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Distal Transradial ApproachA new way of puncture?
Dr. Giovanni Amoroso
OLVG Amsterdam
A new way of puncture!
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(potentiële)
belangenverstrengelingGeen / Zie hieronder
Voor bijeenkomst mogelijk
relevante relaties met
bedrijven
Bedrijfsnamen
Sponsoring of
onderzoeksgeld
…
Medikit
Cordis
Svelte
Abbott
Biotronik
Medtronic
Disclosure belangen spreker
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Superficial palmarBranch
Radial ArteryUlnar Artery
Deep PalmarArch
Dorsal viewVolar view
SnuffBox
True DTRARadial Artery
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Distal Right Radial
Sheathless 5F Medikit
Footage taken at OLVG with permission
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https://www.slideshare.net/theradialist/11-aimradial2016-thu-babunashvili-a
Dr A Babunashvili – Moscow
First description of distal radial puncture
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Dr F Kiemeneij – Blaricum
First publication on distal radial approach (Eurointervention 2017)
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8Capodanno D EuroIntervention 2018
#radialfirst#ldtra
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Rationale for DTRA
• Comfort for the patient
• Comfort for the operator
• Secondary clinical outcomes
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Comfort for the patient
• No wrist immobilisation after procedure
• Shorter hemostasis (day-care!)
• Only for Left DTRA: dominant hand (mostly right) unaffected
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Comfort for the operator(only for Left DTRA)
• Stand at the Right side of table
• Less anatomical abnormalities/easier coronary cannulation (?)
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Secondary Clinical Outcomes
• Preservation of RA in case of distal occlusion
– A-V Shunts (dialysis)
– arterial Grafts (CABG)
–Repeated Interventions
• Lower rates of occlusions
• Less complaints/incidence of Upper Extremity Dysfunction (UED)?
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In case of right approach put the arm on its sideIn case of left approach put the hand palm down on the crotch
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My first case – May 29th 2017
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Keep it simple!
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1. a. Position left hand on the crotchb. Position right hand on the side
2. Hyperextend the wrist3. Give Lidocaine (3-5 cc)4. Use needle-cannula (transfixion kit)
and hydrophilic wire5. Extend the elbow before crossing6. Be gentle and patient!
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Thumb
Pink
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Pitfalls
• Low puncture
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Radial Artery
Palmar Arch
Cannula
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0.014” wire to Radial Artery
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Pitfalls
• Arterial bends
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Conventional Puncture Site
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knot in the Distal Radial Artery
Cannula
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330.014” Wire in Radial Artery
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Echo-guided puncture
Kiemeneij, Eurointervention 2017
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Advantages
• Bail out in case of failed conventional approach
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Dissection after conventional TRA
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Advantages
• Recanalisation of RAO
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Cannula
Radial Artery Occlusion
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Straight Terumo 0.021” through the cannula
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Angiography once 5F Glidesheath Slender inserted
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Advancement of 0.014” coronary wire up to upper arm
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Advancement of 5F Guiding Catheter (BAT Technique)
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Radial artery successfully recanalised
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Risks?
Avascular Necrosis of the Scaphoid Bone
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SafeGuard Radial 5-6 cc
+/- StatSeal DIsc
Remove after one hour
My Hemostatic Technique (1)
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5F Sheathless PCI Medikit
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Compression with SafeGuard Radial
6 cc, one hour
Footage taken at OLVG with permission
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TR Band XL 10 cc
Remove the hard support
Remove after one hour
My Hemostatic Technique (2)
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5F Sheathless PCI
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• 70 patients• 61% Angio 39% PCI/FFR
• 11% failure• 0% major bleedings• 1.5% dRAO
Kiemeneij F, EuroIntervention 2017
Are there scientific evidences?
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59Jun-Won Lee et al, EuroIntervention 2018
Access-Site Complications: Postprocedural and 1-month Follow-Up
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Learning Curve with Distal Transradial Access
Jun-Won Lee et al, EuroIntervention 2018
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Conclusions• Distal TRA seems a valid alternative to
conventional transradial approach, with the additional advantages of:• Increased comfort for both patient and
operator (in case of left distal approach)• Reduced incidence/impact of RAO
• Distal TRA seems a feasible approach for treating RAO
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Back – up slides
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