The revolution of transradial access in the United States has reduced vascular complications, improved patient satisfaction and the cost effectiveness of cardiac catheterization, and will soon make it the default approach for interventions as well. Currently, recent data from the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR) suggest that 37% of percutaneous coronary interventions (PCIs) are performed via the transradial approach, and many centers have adopted a “Radial First” attitude (not to pat myself on the back, but recall this column1 in the July 2010 CLD). The benefits of patent hemostasis (meaning to control bleeding from puncture while maintaining blood flow through the artery) over complete hemostasis (i.e., total occlusion to produce clotting) for radial artery occlusion are no longer debatable and patent hemostasis is the accepted method to significantly reduce radial artery occlusion (RAO). The use of adequate anticoagulation, minimal compression, and small sheaths are all advocated to reduce early and late RAO. Some operators now approach the patency issue by also including ulnar artery occlusion at the same time,2 while others are looking at shorter manual compression times with or without hemostatic patches,3-5 as we will discuss below.
The RAO Problem
Among the now well-understood complications of transradial access, hematoma and RAO are the most common. Others include radial artery spasm, pseudoaneurysm, arterial perforation, dissection, and rarely, inversion of the radial artery. Recall that the incidence of RAO is about 8 to 10%, and in some reports, may be in excess of 25%. The mechanism of RAO is thought to be diminished blood flow at the site of endothelial disruption, promoting clot formation and obstruction to flow. The consequence of RAOs are generally minimal, since the hand has a dual blood supply; however, a small percentage of patients have pain or paresthesia (a nerve irritation or weakness which a minority report also with decreased arm function). Perhaps a more troubling consequence of RAO is the loss of the use of the radial artery for future cardiac catheterization from the right side.
(Manual Radial Artery Compression)
With the continuous improvement goals of making the procedure better, simpler, safer, and faster, many clinicians are exploring ways to shorten time to hemostasis while maintaining or increasing radial artery patency, and reducing acute and late radial artery occlusion. For example, long sheaths have been replaced by short hydrophilic sheaths and with smaller sizes (<5 French [F]). Anti-spasm and anticoagulation protocols have become more standardized. For radial hemostasis, most labs use an air-bladder bracelet (Table 1), but there is no consensus on the duration of artery compression, which ranges from 60 minutes to 6 hours (as practiced in Japan, I’m told). In our lab, which uses the TR Band (Terumo), we reduce pressure at 1 hour and remove the band at 2 hours.
Recently, manual compression has emerged as a potentially viable alternative to shorter radial artery hemostasis times. The MEMORY multicenter, randomized trial6 examined 589 patients who were randomized to a one-to-one hemostasis treatment strategy of either manual or mechanical patent radial artery hemostasis. Five French (5F) sheaths were used. Radial artery patency, evaluated by a color duplex and ultrasonography at 24 hours, and early RAO at 24 hours, was the primary endpoint. Access site bleeding, complications, and time to hemostasis were also secondary endpoints. The results demonstrated that early RAO occurred in 12% and 8% of the manual and mechanical closure groups, respectively. There were no differences with regard to access site bleeding or complications (mostly hematomas). The duration of hemostasis was significantly shorter in the manual group (22 minutes ± 34 vs 119 minutes ± 72, by design of the trial), an obvious big difference. The Greek cardiologists of the MEMORY trial suggest that manual compression should be strongly considered as an alternative to prolonged band compression.6
One may argue that 15-20 minutes of manual compression with gauze alone would likely suffice for hemostasis of 4F or maybe 5F diagnostic transradial procedures, particularly when we see that this method remains a highly effective approach for transradial hemostasis in many developing countries. In the absence of hemostatic agents or ulnar compression, very short (<20 minutes) compression times may have higher rates of hematoma formation, an increased need for recompression, and perhaps increased rates of RAO compared with standard >60-minute compression. An adoption of manual compression alone will have to wait. Most labs have not yet begun working on adopting a manual strategy, because the perceived shorter time and potential cost reduction will not greatly impact the current workflow or patient outcomes.
The Other Hand (Ulnar Compression)
A less-appreciated addition to increasing radial hemostatic patency and reducing RAO is the supplemental application of ulnar artery occlusion. This approach has been examined by Pancholy et al2 and found that ipsilateral ulnar compression increases radial artery flow and impacts the incidence of RAO. They studied 3000 patients who were randomized to receive either a standard patent hemostasis protocol or prophylactic ipsilateral ulnar compression in addition to patent hemostasis. The primary study endpoint was 30-day RAO. At 30 days, the RAO rate was significantly reduced in those patients with prophylactic ulnar compression compared with standard patent hemostasis (0.9% vs 3.0%; P=.0001). In addition, RAO was significantly reduced by prophylactic ulnar compression at all time intervals (P<.0001, Figure 1). The study concluded that use of ulnar compression during radial artery hemostasis is an effective, simple, and inexpensive technique to lower the risk of RAO after transradial access. Perhaps, in part because of the practicality and additional time and development involved in a new workflow, this 2016 study has not yet widely impacted transradial practice.
On a side note, the use of the ulnar artery after a failed radial approach has been evaluated and while highly successful, the hemostasis for this dual puncture setting is evolving. One can use a StatSeal (Biolife) on one artery with a band on the other puncture, but using two pressure bands was found to be not very functional.3 So for dual artery hemostasis, manual compression, especially with the adjunct of hemostatic patches, may be a highly effective approach.
The “Button” (Hemostatic Patches)
Among the novel approaches and adjuncts to manual compression, some operators are finding success with hemostatic patches.4,5 There are a variety of hemostatic patches, including the potassium ferrate StatSeal (Biolife), kaolin QuikClot (Z-Medica), the chitosan derivatives, including SoftSeal-STF (Chitogen Inc.), Clo-Sur PAD (Merit Medical), ChitoSeal (Abbott), and ExcelArrest (Hemostasis, LLC), the thrombin D-Stat (Teleflex), and the poly-n-acetyl-glucosamine SyvekExcel XL (Marine Polymer Technologies) (Tables 1-2). These topical hemostatic patches use different agents including thrombin, kaolin-impregnated gauze, chitosan derivatives, and potassium ferrate, to accelerate physiologic coagulation and clot formation by various pharmacologic, desiccant, and chemical actions. While not identical, these patches are thought to promote coagulation through bio adhesion between the positively charged chitosan and the negatively charged blood and tissue components. The patches appear to be most effective for punctures of shallow depths below the skin. These patches are not as appealing for femoral hemostasis over manual hemostasis alone, suggesting that some patches are less effective at the typical 3-4 cm depth of the femoral arteriotomy. Moreover, hemostatic patches must complete with femoral vascular closure devices, which enjoy an acceptably high success rate for hemostasis. For radial hemostasis, a recent multicenter study suggested that the potassium ferrate patch can consistently facilitate a 40-60 minute TR Band removal time.4
The Bottom Line
In my view, the biggest advance in cardiac catheterization since my entry into the field (not including the birth of PCI) is the change from femoral to radial access. While all cath lab operators will always need to be competent in both approaches, our radial revolution (in the USA) is moving forward with more operators recognizing and patients receiving the benefits. It is very gratifying to learn of new and better ways to do something that helps our patients and health care systems. Maybe manual compression (with or without a button) for radial puncture hemostasis will be one of them. What’ll it be for you? Hand, band, or “button”?
- Kern M. Lessons learned from implementing a “radial first” program. Cath Lab Digest. 2010 July;18(7): 6-9. Available online at https://www.cathlabdigest.com/article/What-We-Learned-After-Starting-%E2%80%98Radial-First%E2%80%99-Program.
- Pancholy S, Bernat I, Bertrand O, Patel T. Prevention of radial artery occlusion after transradial catheterization. The PROPHET-II randomized trial. JACC Cardiovasc Interv. 2016 Oct 10; 9(19): 1992-1999. doi: 10.1016/j.jcin.2016.07.020.
- Roberts JS, Niu J. A novel technique for simultaneous hemostasis of ipsilateral radial and ulnar artery access sites. Catheter Cardiovasc Interv. 2018 Apr 1; 91(5): 901-904.
- Seto AH, Rollefson W, Patel MP, et al. Radial hemostasis is facilitated with a potassium ferrate hemostatic patch: the Statseal with TR band assessment trial (STAT). EuroIntervention. 2018 May 15. pii: EIJ-D-18-00101.
- Rocco V, Narins CR. Use of the SafeSeal hemostasis patch following coronary intervention. Cath Lab Digest. 2008 Nov; 16(11). Available online at https://www.cathlabdigest.com/articles/Use-SafeSeal-Hemostasis-Patch-Following-Coronary-Intervention. Accessed June 21, 2018.
- Petroglou D, Didagelos M, Chalikias G, et al. Manual versus mechanical compression of the radial artery after transradial coronary angiography: the memory multicenter randomized trial. JACC Cardiovasc Interv. 2018 Jun 11; 11(11): 1050-1058.
Disclosure: Dr. Kern is a consultant for Abiomed, Merit Medical, Abbott Vascular, Philips Volcano, ACIST Medical, Opsens Inc., and Heartflow Inc.