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Clinical Practice Supports: Nursing Skills and Procedures

Support material for competency maintenance, evidence-informed practice and professional education.

About Radial Access

Transradial access is the standard access used worldwide for Cardiac Catheterization Laboratory and Interventional Radiology procedures (Pitta & Prasad, 2020). Transulnar access may also be used as an alternative to transradial if the patient has a small radial artery, radial stenosis/calcification, tortuosity, or other issues (Pitta & Prasad, 2020).

There are several benefits to transradial versus femoral access. A benefit noted at Nova Scotia Health is more efficient use of nursing time and shortened time to patient discharge. Additionally, patients who have difficulty lying flat (e.g., heart failure or confused patients) do not have to remain lying flat for long, leading to faster mobilization, reduced risk of complications and a better experience overall.

Additional benefits cited in the literature are:

  • Reduced major bleeding and all-cause mortality in patients with acute coronary syndrome (Pitta & Prasad, 2020).
  • Reduced complications related to vascular access site. It is easier to maintain hemostasis by applying direct pressure to the access site because the radial artery is smaller and more superficial than the femoral artery (Pitta & Prasad, 2020 & Mason et al., 2018)
  • Reduced procedural complications because the radial artery is not located near major nerves or veins (Morton, K. 2011).
  • Immediate mobilization post-procedure because sheaths are removed in the procedural environment (Mason et al., 2018).
  • Increased patient satisfaction and comfort as a result of shortened procedure to ambulation times (Mason et al., 2018).

Anatomy - Blood Supply to the Hand

  • The hand has a dual blood supply due to both radial and ulnar blood flow. (Morton, K. 2011).
  • The anatomic snuffbox refers to a small triangular space along the radial, dorsal aspect of the wrist.
  • The distal radial artery passes through the anatomic snuffbox and continues as the deep palmar branch, merges with the distal ulnar artery, and contributes to forming the deep palmar arch of the hand (Pitta & Prasad, 2020).
Figure 1. The pathway of RA via anatomical snuffbox and left hand posture of patient for puncture. The common puncture site (arrow) and the subsidiary puncture site (arrowhead). by Roh JH, Lee JH/CC BY

Potential Complications after Percutaneous Transradial Access

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  • Radial site hematomas are usually small and managed by additional compression or having a prescriber competent with radial bands adjust/reposition the compression device. It is important to remain vigilant with site assessments as an unrecognized or uncontrolled hematoma may lead to compartment syndrome (Mason et al., 2018). Compartment syndrome will often require surgical intervention (Sandoval et al., 2019).

For more information on compartment syndrome:

  • Early detection of site hematomas is key for timely diagnosis, treatment, and to avoid progression to compartment syndrome (Sandoval et al., 2019).
  • Forearm discomfort can be an early indicator of hematoma development (Mason et al., 2018).

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  • Radial Artery Occlusion (RAO) is one of the most common complications of transradial access (Mason et al., 2018). Post-procedural RAO rates are between 1-10% (Kern, M. 2011).
  • To prevent RAO, most patients will receive anticoagulation while in the procedure room (Mason et al., 2018 & Pitta & Prasad, 2020).
  • Other methods used to prevent RAO include patent hemostasis, minimizing puncture attempts, avoiding radial artery spasm intra-procedurally and using smaller sheaths/catheters interprocedurally (Sandoval et al., 2019).
  • RAO often goes unnoticed because the hand has a dual blood supply (Mason et al., 2018).
  • Some patients may experience arm soreness (Kern, M. 2011). Supportive treatment may include warm compresses and analgesics (Kern, M. 2011). Other treatment options may be considered with more symptomatic individuals (Sandoval et al., 2019).
  • It is important to preserve radial artery function so the radial artery can be used again for future procedures, as a potential graft for Coronary Artery Bypass Grafts (CABG) and for arteriovenous (AV) fistula creation (Sandoval et al., 2019).

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  • Radial artery spasm may occur intra-procedurally or while the sheath is being removed (Kern, M. 2011).
  • Radial artery spasm is a sudden, temporary narrowing of the artery. Patients may feel forearm discomfort, and the physician performing the procedure may feel resistance to advancing equipment through the artery. The most common complication related to spasm is the inability to complete the procedure via this artery (Sandoval et al., 2019).
  • It is linked to higher rates of RAO (Sandoval et al., 2019).
  • During the procedure, the patient may receive a combination of calcium channel blockers (e.g. Verapamil), Nitroglycerin, Fentanyl, and Versed to reduce discomfort and radial artery spasm (Mason et al., 2018).

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  • Pseudoaneurysms can occur after an arterial puncture site bleeds into the surrounding tissue (Dynamic Health, 2024).
  • Pseudoaneurysms are a rare complication that should be suspected when a pulsatile mass is present at the access site (Sandoval et al., 2019).
  • Pseudoaneurysms are usually painless but may cause discomfort in some patients (Sandoval et al., 2019). Diagnosis can be confirmed by ultrasound (Sandoval et al., 2019).
  • Pseudoaneurysms are usually treated with manual compression and occasionally with thrombin injection or surgical repair. (Mason et al., 2018 & Sandoval et al, 2019).

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  • AV fistula formation is very rare but should be suspected if a patient develop discomfort with swelling and a palpable thrill at access site. Diagnosis can be confirmed by ultrasound (Sandoval et al., 2019).
  • Generally, these are managed conservatively (Mason et al., 2018). Interventions may include compression, percutaneous intervention, or surgery (Sandoval et al., 2019).

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  • Radial Artery Perforation is a rare complication that can occur intra-procedurally due to a wire perforating the vessel. It is often diagnosed immediately in the procedure room. Although rare, it can cause bleeding that can lead to compartment syndrome and the need for surgical intervention (Sandoval et al., 2019).

Caring for Patients with RAC Devices

  • Absence of radial artery flow while using a compression device is a strong predictor of radial artery occlusion (Pitta & Prasad, 2020). Prolonged application of a compression device may contribute to radial artery occlusion (Maqsood et al., 2023).
  • During post-procedure assessments, pulses distal to the compression device must be checked to ensure adequate blood flow to the hand. Refer to applicable order set for frequency of assessments.  
  • The snuffbox area may be palpated if you are unable to assess the radial and/or ulnar pulses due to the compression device location. 
  • The pulse oximeter should be placed on the thumb or index finger of the access site hand while assessing oxygen saturation to ensure an adequate pleth waveform (measure changes associated with pulsatile arterial blood flow) is present.
  • Post-procedure, the ambulation of patients with radial compression devices is not restricted (Mason et al., 2018). Refer to prescribed mobilization. Patients should be instructed not to use their hand to assist with body movement (e.g., push themselves up from a chair) x 24 hours. Patients may hold light objects (such as utensils and phones) after the band is off. 
  • If the radial compression device requires repositioning (e.g. hematoma or bleeding), contact the Authorized Prescriber. 
  • After removal of the band, keep it at the patient’s bedside overnight in case reapplication is required (inpatients only). 

Patient Education

Types of Radial Compression Devices

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Various styles of radial compression devices exist. As of 2024, radial bands currently used at the Halifax Infirmary site include Terumo’s TR Band and Zoom’s Hemostop.
Terumo TR band [picture by Nova Scotia Health Clinical Nurse Educators]
  1. Green dot indicates placement
  2. Pilot - when inflated, you know that the balloon has air in it. 
  3. Slip tip connector - unique connection for band 
  4. Air connector port - connect inflator 

Terumo’s TR bands use an air-filled balloon/pillow to maintain patent hemostasis. As per the relevant order set, the band is loosened by gradually removing air from the balloon using the TR band inflator syringe. Once the syringe is connected to the device, maintain pressure on the syringe plunger to avoid removing too much air.  Bands are transparent to allow for observation of the puncture site and are available in 2 sizes (Regular and Large).  

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Zoom Hemostop band [picture by Nova Scotia Health Clinical Nurse Educators]
  1. Foam
  2. Retaining strip with notches
  3. Securement tool
  4. Non-adherent pad
  • The Hemostop band uses a piece of foam to compress the access site by tightening a zip-tie style bracelet. The bracelet is gradually loosened per physician orders by carefully pulling on the band’s retaining strip and allowing the tail to loosen. After loosening the prescribed number of notches, ensure the retaining strip is re-engaged and the securement tool is re-applied.
  • Follow written Authorized Prescriber post-procedure orders.
  1. Note the time the band was applied. 
  2. Use a permanent marker to indicate the initial tightness level of the band. This will be used as a reference during the gradual removal process. 
  3. 1.5 hours after application: release the band 2-3 notches. 
  4. 3 hours after application: remove band and apply a sterile transparent dressing. 

If bleeding occurs: 

  • In the first 1.5 hours after application, contact Authorized Prescriber for instructions. 

  • 1.5-3 hours after application, tighten band 2-3 notches and maintain for 1.5 hours.  

  • After 1.5 hours, loosen band 2-3 notches and maintain for 1.5 hours. 

  • If bleeding re0ccurs, contact Authorized Prescriber for instructions. 

  • After removal of band, maintain manual pressure and contact Authorized Prescriber to assess the patient. 

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  1. Note the time the band was applied. 
  2. Use a permanent marker to indicate the initial tightness level of the band.  This will be used as a reference during the gradual removal process. 
  3. 1.5 hours after application: release the band 2-3 notches. 
  4. 3 hours after application: remove band and apply a sterile transparent dressing. 

If bleeding occurs: 

  • In the first 1.5 hours after application, contact Authorized Prescriber for instructions. 

  • 1.5-3 hours after application, tighten band 2-3 notches and maintain for 1.5 hours.  

  • After 1.5 hours, loosen band 2-3 notches and maintain for 1.5 hours. 

  • If bleeding re0ccurs, contact Authorized Prescriber for instructions. 

  • After removal of band, maintain manual pressure and contact Authorized Prescriber to assess the patient. 

References

Costa, F. & Renato, S. (2019, July/August). Radial Compression Devices Used After Cardiovascular Interventions. Cardiac Interventions Today. https://citoday.com/articles/2019-july-aug/radial-compression-devices-used-after-cardiovascular-interventions.

Mason, P. J., Shah, B., Tamis-Holland, J. E., Bittl, J. A., Cohen, M. G., Safirstein, J., Drachman, D. E., Valle, J. A., Rhodes, D., Gilchrist, I. C. (2018). An Update on Radial Artery Access and Best Practices for Transradial Coronary Angiography and Intervention in Acute Coronary Syndrome: A Scientific Statement From the American Heart Association. Circulation: Cardiovascular Interventions, 11(9), e000035. https://doi.org/10.1161/HCV.0000000000000035.

Maqsood, M. H., Pancholy, S., Tuozzo, K. A., Moskowitz, N., Rao, S. V., & Bangalore, S. (2023). Optimal Hemostatic Band Duration After Transradial Angiography or Intervention: Insights From a Mixed Treatment Comparison Meta-Analysis of Randomized Trials. Circulation: Cardiovascular Interventions, 16(2), e012781. https://doi.org/10.1161/CIRCINTERVENTIONS.122.012781.

Morton J. Kern. Cardiac Catheterization Handbook E-Book : Expert Consult. Vol 5th ed. Mosby; 2011. Accessed September 16, 2024. https://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=445150&site=ehost-live.

Pitta, S. & Prasad, A. (2019). Accessing the Wrist: From Data to Tips and Tricks. Intervent Cardiol Clin 9 (2020) 1-19. https://doi.org/10.1016/j.iccl.2019.08.009.

Sandoval, Y., Bell, M. R., & Gulati, R. (2019). Transradial Artery Access Complications. Circulation: Cardiovascular Interventions, 12(11), e007386. https://doi.org/10.1161/CIRCINTERVENTIONS.119.007386.