Читать книгу Interventional Cardiology - Группа авторов - Страница 76

Data suggests that over half of failed TRAs relate to inadequate radial artery puncture (57% due to failure to cannulate)[21]. Careful vessel palpation and puncture remain key to successful transradial procedure – particularly given the inherent risk of spasm with multiple punctures. The Society for Coronary Angiography and Interventions (SCAI) consensus document highlights the role for ultrasound stating that operators should develop “proficiency with ultrasound guidance to facilitate forearm vascular access”[22]. Contemporary evidence is emerging in support of this approach. A recent Australian factorial 2x2 randomized trial of traditional puncture versus ultrasound‐guided and radial versus femoral access showed that ultrasound reduced time to vascular access (93 vs 111s; p = 0.009), number of punctures and improved first‐pass success [23]. Bleeding and vascular complications were similar between approaches. As such operators should aim to utilise ultrasound guided vascular access whenever feasible.

We use conscious sedation with intravenous benzodiazepine and opioids for enhanced patient comfort. Subcutaneous 2% lignocaine (lidocaine) is useful for anesthetic and can be mixed with a small amount of subcutaneous nitroglycerin to facilitate a bigger target for puncture in small calibre radial arteries. Larger volumes of subcutaneous lignocaine can aid needle identification by increasing subcutaneous tissue depth on ultrasound. There are two main techniques with which to perform arterial puncture: a traditional Seldinger technique (“through‐and‐through” puncture) and a modified Seldinger technique (“anterior only” puncture). In the former, a needle with overlying Teflon coated cannula sheath is used to puncture the artery at approximately 30°. A flash of blood indicates anterior arterial wall puncture, and the needle is advanced through the posterior radial artery wall. After removal of the needle, a 0.021" guidewire is placed in the hub of the Teflon cannula and the entire system is withdrawn backwards until pulsatile flow occurs into the hub of the Teflon cannula (indicating luminal cannula sheath position). The guidewire can be advanced and subsequently the hydrophilic introducer sheath inserted over the guidewire. Alternatively, the modified Seldinger technique uses a short 21‐gauge bare needle with anterior‐only puncture technique. After puncture of the anterior wall of the radial artery, a 0.021" guidewire is advanced into the artery allowing removal of the needle and sheathing over the guidewire. A randomized trial showed the traditional Seldinger technique (through‐and‐through) to be a more reliable way to obtain radial artery access with greater success rates, shorter procedure time, and shorter time to gain access. Procedure related complications such as radial hematoma or radial artery obstruction were similar between the two approaches [24]. In the event of failed access, repeat procedures or attempts can be performed more proximally if required.

Table 3.1 Common diagnostic and guide catheter shapes for TRA.

Universal diagnostic	Diagnostic	Universal guide	Guide (left)	Guide (right)
Tiger II (Tig)	Judkins left 3.5	IKARI left	EBU/XB 3.5	Judkins right 4.0
Kimny	Judkins right 4.0	MAC 30/30	Judkins left	Amplatz right
Jacky		Kimny	Amplatz left	Amplatz left
			IKARI left	IKARI right