Insertion Site Dilemma: Rethinking Radial Arterial Catheter Placement for Device Resilience

The study by Marie et al (2023) discusses their outcomes regarding the distance of radial arterial catheters from the radiocarpal joint and its association to device failure, although authors found no significant difference in failure rates between catheters inserted proximally or distally to the radiocarpal joint. However, other recent studies have reported that catheters inserted more distally are more likely to fail, with rates high as 25%. Factors that contribute to failure include poor site selection, infection, device occlusion, or dislodgement. With reliance on accurate hemodynamics from arterial catheters, providers should be aware of the risks and take steps to minimize them, as catheter failure is more than just associated infection, the inability to aspirate blood or a useable arterial waveform. Optimal insertion location, use of ultrasound-guided techniques, appropriate securement, and close monitoring of the catheter, along with accurate reporting of failure reasons, will help clarify future research outcomes.

Evaluation of distal radial artery cross-sectional internal diameter in neonates and infants by ultrasound and adequate selection of an intra-arterial catheter size

BACKGROUND

Radial artery catheterization in neonates, infants, and young children is a common and useful invasive procedure that brings technical placement challenges and potential complications due to the small diameter size of the radial artery in these patients. The aim of this study is to determine appropriate catheter sizes in infants up to 6 months of age.

MATERIALS AND METHODS

A total of fifty infants undergoing general anesthesia or hospitalized in the neonatal intensive care unit were included. Images of the radial artery diameter were obtained from the infant's wrist using Philips EPIQ Diagnostic Ultrasound System CVX Release 4.0. All images obtained were distal in the forearm, medial to the border of the styloid process of the radius, at the point of maximal impulse of the radial artery, and with the wrist at a 45-degree angle position. We recorded postmenstrual age, chronological age, gender, weight, location, comorbidities, medications, weight, and vital signs of each individual.

RESULTS

In this single cohort study of 50 children whose ages ranged from 0 to 6 months chronological age, their radial artery diameters were averaged proportionally to their weight and age. Use of a 22G catheter would result in 100% occlusion of the diameter of the artery in most study subjects. Use of a 24G catheter would result in a range of 75%-99% occlusion depending on weight, postmenstrual age, and chronological age of the infants.

CONCLUSIONS

In view of these findings, we recommend using US to measure the diameter of the radial artery and choose the most appropriate catheter size before proceeding with US-guidance for radial artery cannulation in infants. This will prevent inappropriate sizing of the catheter and the thrombotic complications this can incur.

Evaluation of the factors related to difficult ultrasound-guided radial artery catheterization in small children: A prospective observational study

BACKGROUND

Although ultrasound guidance has significantly improved the success rate of radial artery catheterization, the failure rate in children is still high. For the further improvement of success rate, we prospectively evaluated the factors that make ultrasound-guided radial artery catheterization difficult in children under two years old.

METHODS

From October 2018 to September 2019, patients who required radial artery catheterization for surgery were enrolled. After collecting the anatomical characteristics of the radial artery using ultrasound at the puncture site, ultrasound-guided radial artery catheterization was performed by one experienced anaesthesiologist. The primary outcome was to identify the factors related to the first attempt failure. The factors associated with the total duration of the procedure until success were also evaluated.

RESULTS

A total of 183 children were included in the analysis. A radial artery cross-sectional area of ≤1 mm² (odds ratio [OR] = 5.26; 95% confidence interval [CI], 2.48-11.18; P < .0001) and the presence of an anomalous radial artery branch (OR = 3.37; 95% CI, 1.43-7.95; P = .005) were independent predictors of first-attempt failure during ultrasound-guided radial artery catheterization. The total procedure time was also negatively associated with the small cross-sectional area (P < .001).

CONCLUSIONS

A cross-sectional area of ≤ 1 mm² and the presence of an anomalous branch of radial artery significantly increased the difficulty of ultrasound-guided radial artery catheterization in children under two years old. In patients of these ages, pre-procedural ultrasound scanning to find an optimal site for catheterization may increase the first-attempt success rate although further studies are needed to verify our results.

TRIAL REGISTRATION

Clinical Research Information Service (https://crits.nih.go.kr, October 6, 2018 [KCT0003239]; Principle investigator: Jong-Hwan Lee).

A comparison of radial versus femoral artery access for acute stroke interventions

OBJECTIVE

In this study, the authors aimed to investigate procedural and clinical outcomes between radial and femoral artery access in patients undergoing thrombectomy for acute stroke.

METHODS

The authors conducted a single-institution retrospective analysis of 104 patients who underwent mechanical thrombectomy, 52 via transradial access and 52 via traditional transfemoral access. They analyzed various procedural and clinical metrics between the two patient cohorts.

RESULTS

There was no difference between patient demographics or presenting symptoms of stroke severity between patients treated via transradial or transfemoral access. The mean procedural time was similar between the two treatment cohorts: 60.35 ± 36.81 minutes for the transradial group versus 65.50 ± 29.92 minutes for the transfemoral group (p = 0.451). The mean total fluoroscopy time for the procedure was similar between the two patient cohorts (20.31 ± 11.68 for radial vs 18.49 ± 11.78 minutes for femoral, p = 0.898). The majority of patients underwent thrombolysis in cerebral infarction score 2b/3 revascularization, regardless of access site (92.3% for radial vs 94.2% for femoral, p = 0.696). There was no significant difference in the incidence of access site or periprocedural complications between the transradial and transfemoral cohorts.

CONCLUSIONS

Acute stroke intervention performed via transradial access is feasible and effective, with no significant difference in procedural and clinical outcomes compared with traditional transfemoral access. Larger studies are required to further validate the efficacy and limitations of transradial access for neurointerventional procedures.

Ipsilateral radial and ulnar artery cannulation during the same coronary catheterization procedure

BACKGROUND

Switching to femoral after a failed radial approach carries an increased risk of bleeding complications since the femoral artery puncture is performed in patients already anticoagulated. Moreover, dedicated radial operators find it more and more difficult to use the femoral approach, and ulnar artery cannulation provides them with the opportunity to further reduce its use. Our objective was to evaluate the feasibility and safety of ipsilateral radial and ulnar artery cannulation during the same coronary catheterization procedure.

METHODS

We performed a retrospective analysis of all cardiac catheterizations, from January 2015 until June 2016, with initial radial approach and conversion to ipsilateral ulnar approach. Patients with sheath insertion both in radial and ipsilateral ulnar arteries were further evaluated.

RESULTS

Four thousand one hundred and two procedures were performed during the study period, and 3,876 (94.5 %) of them were performed initially through a radial approach. Radial and ipsilateral ulnar catheterization was accomplished in nine patients, resulting in successful catheterization and procedure completion, without any serious complications recorded.

CONCLUSIONS

Ipsilateral radial and ulnar artery catheterization proved to be feasible and safe, without any serious complications. Hippokratia 2016, 20(3): 249-251.

Impact of Center Experience on Patient Radiation Exposure During Transradial Coronary Angiography and Percutaneous Intervention: A Patient-Level, International, Collaborative, Multi-Center Analysis

Background

The adoption of the transradial (TR) approach over the traditional transfemoral (TF) approach has been hampered by concerns of increased radiation exposure—a subject of considerable debate within the field. We performed a patient‐level, multi‐center analysis to definitively address the impact of TR access on radiation exposure.

Methods and Results

Overall, 10 centers were included from 6 countries—Canada (2 centers), United Kingdom (2), Germany (2), Sweden (2), Hungary (1), and The Netherlands (1). We compared the radiation exposure of TR versus TF access using measured dose‐area product (DAP). To account for local variations in equipment and exposure, standardized TR:TF DAP ratios were constructed per center with procedures separated by coronary angiography (CA) and percutaneous coronary intervention (PCI). Among 57 326 procedures, we demonstrated increased radiation exposure with the TR versus TF approach, particularly in the CA cohort across all centers (weighted‐average ratios: CA, 1.15; PCI, 1.05). However, this was mitigated by increasing TR experience in the PCI cohort across all centers (r=−0.8; P=0.005). Over time, as a center transitioned to increasing TR experience (r=0.9; P=0.001), a concomitant decrease in radiation exposure occurred (r=−0.8; P=0.006). Ultimately, when a center's balance of TR to TF procedures approaches 50%, the resultant radiation exposure was equivalent.

Conclusions

The TR approach is associated with a modest increase in patient radiation exposure. However, this increase is eliminated when the TR and TF approaches are used with equal frequency—a guiding principle for centers adopting the TR approach.