Transradial diagnostic cerebral angiography – from the wrist to subclavian

MICHAEL R. LEVITT, MD FAANS

NEUROLOGICAL SURGERY, RADIOLOGY & MECHANICAL ENGINEERING

STROKE AND APPLIED NEUROSCIENCE CENTER

UNIVERSITY OF WASHINGTON

SEATTLE, WA USA

Disclosures

• NIH: Grants (R01NS105692, R01NS088072, U24NS100654); reviewer

• American Heart Association: Grant (18CDA34110295)

• The Aneurysm and AVM Foundation: Grant

• Medtronic: Investigator-initiated unrestricted educational grant

• Stryker: Investigator-initiated unrestricted educational grant

• Philips Volcano: Investigator-initiated unrestricted educational grant

• eLoupes, Inc: Shareholder

• Cerebrotech: Shareholder

• Corindus Vascular Robotics: Shareholder

• Off-label usage will be discussed

Credits

• Eric Peterson

• Joshua Osbun

• Brian Snelling

• Pascal Jabbour

• Melanie Walker

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Before you start

• Ultrasound and measure radial in

holding area

• Access point ~2 fingers breadth above wrist crease

• EMLA cream

• Barbeau test?

5 Kotowycz et al, Circ Cardiovasc Interv 2012

Palmar arch patency testing

• No difference in short- and long-term hand complications

• Pre-procedure testing has poor sensitivity

6 Van Leeuwen et al, Circ Cardiovasc Interv 2017

Access

• “Standard” vs “distal” radial

• Ultrasound every time

• Flat or linear probe (not hockey stick)

• Local every time

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Puncture

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• Double-wall (“through-and-through”) technique

• 22G angiocath

• 0.021” Cope wire (comes with kit) or 0.014” Nitrix

Snelling et al, JNIS 2017

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Distal

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• Double-wall (“through-and-through”) or single-wall technique

• 22G angiocath

• 0.014” Nitrix

• Needle angle is important!

McCarthy et al, World Neurosurg 2019

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CONFIDENTIAL – DO NOT DISTRIBUTE

Sheath selection

• Radial-specific options are best

• Terumo GlideSheath Slender

• Merit Prelude Ideal

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Diagnostics Interventions

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Radial cocktail

• Nitroglycerin 200mcg

• Verapamil 2.5-5mg

• Heparin

• Buffer in patient’s blood

• Inject over 60-90s

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Diagnostic procedure

3 Phases

• Arm/subclavian

• Arch

• Great vessels

• Radial artery run every time!

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Spasm

Prevention:

• Longer sheath (16/25cm)

• Minimize catheter manipulation

• Conscious sedation

Treatment:

• Deepen sedation

• More spasmolytics/Nitroglcyerine (TD/SC/SL)

• Ulnar artery compression

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Radial artery loops

20 Sinha et al, Cardiol Res 2017; Patel et al, Catheter Cardiovasc Interv 2014

Closure

• Patent hemostasis is the goal

• Terumo TR band, Merit

• Post-procedure Barbeau testing

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Closure

22 Snelling et al, JNIS 2018

THANK YOU mlevitt@uw.edu