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Distal Transradial ApproachA new way of puncture?
Dr. Giovanni Amoroso
OLVG Amsterdam
A new way of puncture!
(potentiële)
belangenverstrengelingGeen / Zie hieronder
Voor bijeenkomst mogelijk
relevante relaties met
bedrijven
Bedrijfsnamen
Sponsoring of
onderzoeksgeld
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Medikit
Cordis
Svelte
Abbott
Biotronik
Medtronic
Disclosure belangen spreker
3
Superficial palmarBranch
Radial ArteryUlnar Artery
Deep PalmarArch
Dorsal viewVolar view
SnuffBox
True DTRARadial Artery
Distal Right Radial
Sheathless 5F Medikit
Footage taken at OLVG with permission
https://www.slideshare.net/theradialist/11-aimradial2016-thu-babunashvili-a
Dr A Babunashvili – Moscow
First description of distal radial puncture
Dr F Kiemeneij – Blaricum
First publication on distal radial approach (Eurointervention 2017)
8Capodanno D EuroIntervention 2018
#radialfirst#ldtra
Rationale for DTRA
• Comfort for the patient
• Comfort for the operator
• Secondary clinical outcomes
Comfort for the patient
• No wrist immobilisation after procedure
• Shorter hemostasis (day-care!)
• Only for Left DTRA: dominant hand (mostly right) unaffected
Comfort for the operator(only for Left DTRA)
• Stand at the Right side of table
• Less anatomical abnormalities/easier coronary cannulation (?)
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
Pitfalls
• Low puncture
Radial Artery
Palmar Arch
Cannula
0.014” wire to Radial Artery
Pitfalls
• Arterial bends
Conventional Puncture Site
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knot in the Distal Radial Artery
Cannula
330.014” Wire in Radial Artery
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Echo-guided puncture
Kiemeneij, Eurointervention 2017
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
Cannula
Radial Artery Occlusion
Straight Terumo 0.021” through the cannula
Angiography once 5F Glidesheath Slender inserted
Advancement of 0.014” coronary wire up to upper arm
Advancement of 5F Guiding Catheter (BAT Technique)
Radial artery successfully recanalised
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
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?
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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