Clinical Editor's Corner: Kern

Securing the Radial Sheath: An Update on a Pesky But Persistent Little Problem

Morton Kern and Peter J. Golden, RN, with contributions from John Bittl, Ocala, Florida; Emmanuel Brilakis, Minneapolis, Minnesota; David Cohen, Kansas City, Missouri; Mauricio G. Cohen, Miami, Florida; Larry Dean, Seattle, Washington; Kirk Garratt, Wilmington, Delaware; Neil Kleiman, Houston, Texas; Mitchell Krucoff, Raleigh-Durham, North Carolina; Jeff Marshall, Atlanta, Georgia; Joe Moore, Bolivar, Missouri; Jeff Moses, New York City, New York; Keith G. Oldroyd, Glasgow, United Kingdom; Gurpreet S. Sandhu, Rochester, Minnesota; Karen Smith, Winston-Salem, North Carolina. 

Morton Kern and Peter J. Golden, RN, with contributions from John Bittl, Ocala, Florida; Emmanuel Brilakis, Minneapolis, Minnesota; David Cohen, Kansas City, Missouri; Mauricio G. Cohen, Miami, Florida; Larry Dean, Seattle, Washington; Kirk Garratt, Wilmington, Delaware; Neil Kleiman, Houston, Texas; Mitchell Krucoff, Raleigh-Durham, North Carolina; Jeff Marshall, Atlanta, Georgia; Joe Moore, Bolivar, Missouri; Jeff Moses, New York City, New York; Keith G. Oldroyd, Glasgow, United Kingdom; Gurpreet S. Sandhu, Rochester, Minnesota; Karen Smith, Winston-Salem, North Carolina. 

My daughter, at age 6, said to me many years ago when I was struggling with some vexing problem, “Dad, it’s not rocket surgery”. She meant to say rocket science, but we talked a lot of medicine then. Okay, I agree that securing the radial sheath in place is not “rocket surgery”. I don’t stay up nights worrying about this, but now that I’m back in the lab routinely, it is troublesome to have your radial sheath threatening to be pulled out of the artery during catheter exchanges when you just want a quick and safe procedure. (Fellows, are you listening?) 

Like most other labs, we have been using a clear plastic film, Tegaderm, to cover and secure the radial artery sheath in place (Figure 1). In most routine cases, it suffices, but in some procedures, particularly those involving left arm access for patients with bypass grafts requiring several catheter exchanges, blood leaks from the sheath valve under the Tegaderm and fixation is lost. (NB: Sheath movement with distal left radial sheath seems to be much reduced despite more catheter exchanges for our patients with bypass grafts. Also see comments on long sheaths below.)  

Currently, our lab has been trying different methods to secure the radial sheath, but it is a tradeoff between too much tape or too little adhesion. We thought we found an answer with a specialized bandage for intravenous lines (Figure 2).1 Mr. PJ Golden, one of our super cath lab nurses, found another catheter securing tape system by Dale Medical Products (Figures 3-4). This system anchors the sheath with 2 crossover steri-strip arms. It is strong and secure, and better at keeping the blood from getting under the bandage when covered with the Tegaderm. As a worthwhile incremental advance, we thought we would share it and update our previous discussion on securing the radial sheath by asking our colleagues (again) to add their experience on how they secure their radial sheath in 2020. 

Best Method: Tegaderm With a Gauze?

David Cohen: I use Tegaderm, but have the same issue with loss of integrity. I haven’t really found anything better or more convenient. Some people say it’s all a waste and just leave the sheath bare so you can actively deal with it. What I really miss is the islet that was on the non-slender sheaths (when we used to use them) that you could suture securely. I assume there is some reason why Terumo didn’t put the islet on the Slender sheaths (saves a couple of cents?), but I wish they would put it back.

Mauricio G. Cohen: We have been using the large Tegaderm to hold the sheath in place. In addition, we place a folded gauze under the sheath hub, so it absorbs the blood that drips during catheter exchanges (Figure 5). One caveat is that we use the Merit radial sheath that is braided and doesn’t kink easily, and the hydrophilic coating is less slippery than the Terumo Glidesheath.

Larry Dean: We also use Tegaderm without the gauze and the issue of loss of Tegaderm integrity also occurs with that approach as well. We need a better solution.

Kirk Garratt: Good heme management helps a lot. I teach fellows to put generous gauze down between the hand holding the needle and the patient to catch spray when the artery is punctured — that is when the wrist and drape get bloody. If you start with a dry Tegaderm and you keep a bit of gauze under the valve during catheter exchanges, you’ll be good.

Jeff Marshall: We too use Tegaderm, but the method of application that we employ, I believe, helps with the security of the sheath. We make a tiny, “X-shaped” incision in the center of the Tegaderm, and then stretch and apply the incision over the opening of the sheath. This allows the Tegaderm to adhere proximal and distal to the radial sheath and promotes more adhesion even when heme leaks under the Tegaderm. 

Keith G. Oldroyd: We make the cut in the Tegaderm after we have stuck it down. I also use a small fenestrated drape under the full table drape to improve “stickiness” (Figure 5, middle). It lets me get on with the radial puncture as well, whilst the scrub nurse is getting everything else ready. 

Karen Smith: I put the sheath in and then cover the entire thing with the Tegaderm, so that the hub of the sheath is underneath the middle of the Tegaderm. Then make a little slit in the Tegaderm with a scalpel at the opening of the sheath. It works most of the time, if the sheath does not leak a lot and get blood underneath. Usually it is pretty good. Make sure your scalpel does not go into the sheath and cut the valve.

Mitchell W. Krucoff: We use Tegaderm. I would agree with you that many times it suffices, maybe about 60-70% of the time, and it becomes loosely wadded, bloody debris the rest of the time. But by the time the Tegaderm loses integrity, we usually have the guide catheter in or we are done with the case, so there is very little consequence. I don’t go to sleep at night dreaming about a better anchoring device. But I would go naked wrist [presumably no securing device – MK] before suturing eyelets in a wrist…worse may be that more likely your new fellows will suture the eyelet to the artery.

Neil Kleiman: We have the same problem [with Tegaderm] and are looking for something stickier. The obvious alternative — suturing the sheath —seems a bit drastic.

Jeff Moses: I just suture. Saves a ton of hassle. Too many close calls with Tegaderm.

Clip the Side Arm With a Hemostat?

Emmanuel Brilakis: We use a hemostat to secure the sheath to the drape (Figure 6).

John Bittl: Likewise, we use a clamp to secure the sidearm of the sheath to the fenestrated radial drape. It is safe, secure and foolproof (Figure 6).

Long Sheath?

Gurpreet S. Sandhu: The simplest and most effective solution is to use a long 6 French (F) (or 5F) sheath. This requires no Tegaderm or suture, never slips out, there is no drag on the catheters due to vasospasm in the forearm, and no vasodilators are ever required (simply use the usual heparin). Malcolm Bell and I use long sheaths almost exclusively. Hope this helps reduce the short sheath stresses for others!

Joe Moore: I have tried the short and long hydrophilic-coated sheaths (Terumo) and am not a big fan since they slip in and out with catheter exchanges. I have tried tape and Tegaderm, and agree they tend to be messy and after a while, fail to secure the sheath. When I started doing transradial cath in 1994, we used 23 cm Cordis sheaths and I still prefer the longer sheaths. These are not coated and stay put almost all the time, despite multiple catheter exchanges. Cordis still makes the kit (catalogue #504626Z). These sheaths have a little edge at the wire/dilator transition and can sometimes be a bit of challenge to insert. They can also be a little tough to advance in smaller folks, since they are not slippery. Sedation is the key. There are also occasions where I simply can’t get the sheath/dilator transition in the vessel and I switch to a Terumo sheath.

A comment on sheath removal. Occasionally the non-coated sheath will tug a bit, but after the beginning moving in the sheath, the vessel releases (we put the TR Band [Terumo] on after pulling the sheath back a couple cm and inflate part way). We inflate the TR syringe completely after the sheath comes out and we see a little flash. In the rare instance where the radial artery really grabs on to the sheath, I will insert the .035-inch guidewire into the radial artery up to the upper arm and then apply gentle, steady traction on the sheath (stop pulling if the sheath obviously deforms or turns white). I’ve never had one that didn’t come out smoothly using this technique. I’ll even leave the wire in the vessel until I’m happy with the TR Band compression and then simply remove it. I know the data suggests the hydrophilic sheaths result in fewer vascular complications, but in my experience the benefits don’t outweigh the frustrations.

I feel this non-coated sheath had made my life more efficient and less messy over the years. I think of it as the difference between a Toyota and a Ferrari. The Toyota works most of time, but every once in a while, you just need the Ferrari.

The Bottom Line

Tegaderm works, but good ‘heme’ management is key. A gauze under the sheath covered by Tegaderm seems to work very well. For a more secure bandage when anticipating numerous catheter exchanges, the Dale cross arm anchor is very effective, but harder to remove at the end of the procedure. Several operators like hemostats; a few like sutures. The use of a long sheath has advocates, as no dressings are required. Of course, at the end of the day, select the one method you like for your lab’s best efficiency.

I hope this review was helpful even though it wasn’t “rocket surgery”. 

Disclosures: Dr. Morton Kern reports he is a consultant for Abiomed, Abbott Vascular, Philips Volcano, ACIST Medical, and Opsens Inc. 

Dr. Kern can be contacted at mortonkern2007@gmail.com.

On Twitter @drmortkern

References
  1. Kern M. How do you secure your radial sheath? Cath Lab Digest. 2018 Jan; 26(1): 12. Available online at https://www.cathlabdigest.com/article/How-Do-You-Secure-Your-Radial-Sheath. Accessed October 20, 2020.
  2. Kern M. The Armen glove for radial access prep — a better way. Cath Lab Digest. 2010 May; 18(5): 4-6. Available online at https://www.cathlabdigest.com/content/armen-glove-radial-access-prep-better-way. Accessed October 20, 2020.