Hi, good morning, my name is Janet Friant, I'm joined by Dr. Rohan Kalathia and we're here to talk to you about radial hemostasis band management. Thank you for asking us to join you today and I hope you find this information educational. Our objectives today are to review anatomy, transradial bands, hemostasis protocols and complications that you might see post-radial access. So just a quick anatomic review, your radial artery runs on the lateral aspect of your forearm. It is a branch off of your brachial artery and it runs parallel to your ulnar artery. It feeds your thumb, your pointer finger and part of your middle finger, so that's important to remember when we're talking about post-radial management. Some available devices, we have a few vendors listed here, so there's Merit, Cherumo, certainly your institution will, you will learn that specific institution's radial management preference. But the important thing to remember is they all are a Velcro band, they all have, they're all adjustable. Some come in different sizes, some are regular and have an extra large, some are just an adjustable one size fits all. The thing that they all have in common is that they all have a clear see-through area that goes over the radial access point and a balloon and that balloon provides you the hemostasis and essentially I tell patients it's in lieu of me standing over you for two to four hours. Some of them, like the Cherumo, come with a specific tapered syringe that is the only way you can deflate the balloon. Some come with a syringe or are compatible with your normal syringes you can pull from the hospital, so you will learn that from your institution. So the important thing is if it's a specific syringe, make sure that's taped to the chart or travels with the patient. A lot of times we'll keep backup syringes on our units that get the TR bands most. The top upper right picture, I just want to point out that snuff box access, so that has an additional band that goes between the thumb and the pointer finger. The only difference there is that additional band. The management is the same. The inflation management complications are the same, but it does look a little different and so if you start doing snuff box, a little bit of education for your recovery areas and your units that those patients go to is very helpful. Just reassurance that their management post is not any different even though the band looks a little different. So just some thoughts on application removal and this is a lot of trial and error on my part. So application will be done in the cath lab. The question I often get is will the patient come out with a sheath and a TR band? No, a patient should never come out with a sheath and a TR band. The TR band is applied at the end of the case and as the sheath is being removed, the balloon is being inflated. So at the end of the case, you are sending out a patient to the recovery area with just a TR band in place plus minus a syringe like that's pictured in this. Some of them have a little dot over the radial artery site, so it makes it really easy. You just apply the dot over the access site and then start inflating as the sheath is being pulled back. One of the most important things that I learned by mistake is the middle picture here. So this is a pressurized system. You need to have your thumb on the plunger of this when you start connecting this to try and take out the air. I say that because I didn't the first time and all the air came out and the patient bled and it was not a great first experience. So I tell you this because we all learn from our mistakes. Always have your thumb on the plunger so you can manipulate how much air you want taken out each time. This is our protocol here at the University of Chicago. So the TR band is removed. We start removing it at the 2-hour mark if they didn't receive anticoagulation, 4-hour mark if it was an intervention. We use EPIC. I'm sure whatever hospital system you are in has an electronic medical record. I encourage you to incorporate standardized orders and I encourage you to add to the orders the time that the person is supposed to start removing the band. So if your case ended at 9 and you want them to start moving in at 1, I think that's important information that sometimes gets lost. So just a quick kind of checking your knowledge here, so if we're monitoring perfusion, where should the pulse ox be placed for patients wearing TR bands? Is it the index finger, the opposite hand, the thumb of the hand with the TR band on, or their ear? The correct answer is the thumb of the hand with the TR band, because if you think back to the anatomy that we showed you in that first slide, your radial artery feeds the thumb and the pointer finger. If you have occlusion of the radial artery and you have the pulse ox on their ring finger, that ring finger is being fed by the ulnar artery. So it is important and very different, again, I am a nurse, nurse practitioner, it is very different to send patients out with a pulse ox on their thumb, but it is truly the only way to know if they're getting good hemostasis without occlusion of the radial artery. And so that's a good teaching point if you're taking your patients out to recovery, you have new staff, hey, this is where we want it, we didn't make a mistake in the lab, here's why. So it's a great kind of teaching point when you're doing handoff. And now I'm going to hand it off to Dr. Galafia. Thank you, Janet. That was very helpful. And I think a lot of what you just mentioned will be tied into some of the complications that we're going to discuss. So three important complications that we need to be aware of are radial artery occlusion, hematoma formation, and pseudoaneurysms. So let's go to radial artery occlusion. The incidence of radial artery occlusion is rare in the contemporary area, and that's important because we've incorporated a lot of things that Janet just mentioned. Things such as a long compression time, occlusive versus patent hemostasis, this goes directly back to what Janet was just mentioning with putting the pulse ox at the thumb. If you don't have any flow at the thumb, you've actually occluded the artery and prolonged compression of an occluded radial artery has a high risk of occluding the radial artery. So you want to avoid that. Importantly, we've also incorporated using thin-walled sheets, so the slender sheets, because the bigger the sheet size, the higher the risk of radial artery occlusion. And another important point that we need to be aware of is we need to be dosing the anticoagulation appropriately. Underdosing of anticoagulation is also a risk factor for occluding the radial artery after the intervention. So at least 50, I would say my practice is usually 50 to 70, and usually I at least give 4,000 no matter what the patient size is, and my standard one is about 5,000 for most patients. If you do identify this, and usually this presents with some numbness and tingling, any neurological complication beyond that is highly, highly rare, very rare I should say. But when you do see some vague symptoms and you identify radial artery occlusion, you can consider conservative management for most with just some short course of DOAC and see if a radial artery pain C is restored. Again, if there are concerns regarding neurological deficits, they really need to be seen by vascular surgery or even consider further intervention, but this is very rare. We can move on to the next complication, which is hematoma formation. So hematomas are easily recognizable and that's one of the benefits of radial artery access point and usually are benign. They're localized, but if they're not identified or treated appropriately, they can have pretty detrimental effects when they are progressed to things such as compartment syndrome that can be very morbid for the patient. So majority of the time, these form when the band is placed too proximal, so you have retrograde propagation of blood, so you want to make sure that the band is placed at the arteriotomy or just proximal to the patient's body so that that's where the arteriotomy is and you want to make sure that adequate hemostasis is achieved with this band. If you do identify a hematoma, make sure that the band is placed appropriately, you can just reapply it and then you can always just put a compression band along the forearm to make sure that there's no further propagation. Again, you want to make sure that the band is something that gets taken off quickly and make sure that you're monitoring the hematoma for size and progression. We can go to the next complication, which is a pseudoaneurysm. This is even more rare, but something that does likely need intervention. So this is a pulsatile mass at the radial artery access site. Oftentimes you'll see these patients in clinic a few weeks or a month or two after the cath and it will present as a lump on the side of the arteriotomy and you can see a represented image here. That is a telltale sign of a pseudoaneurysm formation. The two biggest risk factors for pseudoaneurysm formation is inadequate hemostasis. So again, we're balancing the risks of radial artery occlusion with this risk, which is that we take the band off too early. The second risk is chronic anticoagulation use of patients on DOAC for a variety of reasons or Coumadin for a variety of reasons have a higher risk of forming a pseudoaneurysm. This happens when there's weakening of the radial artery wall and then there's blood that forms a cavity, as you can see on the ultrasound here, which is the treatment, sorry, which is a diagnostic modality of choice in identifying them. What you see here is the classic formation of a pseudoaneurysm with a neck that connects the radial artery to the pseudoaneurysm. You can see it here and you can see it on the longitudinal view here where at the top here is a pseudoaneurysm and there's flow from the radial artery into the pseudoaneurysm. These are treated best by surgical treatment, but can consider band compression and thrombin injection, although I will say that thrombin injection can be something that may make most operators nervous given the nerves and everything else that is important in that arm. Usually I have sent my patients a couple, two times actually I would say that this has happened to me. I've sent my patients to a vascular surgeon who just does a quick incision, primary repair of the radial artery enclosure and patients oftentimes have no long-term complications. This is important to identify and get them to surgery or whatever treatment you want to choose. Again, my preference has been surgery so that they get the primary repair of the artery. So those are the three main things that I wanted to make sure we discuss. In summary, as Janet mentioned, there are multiple devices for radial artery hemostasis and the goal is patent hemostasis and with an additional point of only providing hemostasis for as long as necessary. Now this is a variable goal, but you want to balance the risk of complications that I just discussed.

radial hemostasis band management

radial artery anatomy

adjustable bands with clear see-through area

post-procedure management

complications