The pulseless radial artery in transradial catheterization: challenges and solutions

ABSTRACT

Introduction: An absent radial pulse prior to cardiac catheterization is an ominous finding as it portends the need for higher-risk arterial access. Solutions exist that can avoid the use of more hazardous access. Given the benefits of the radial artery access, it is essential to prevent radial artery occlusion, to diagnose acute occlusion at the time of hemostasis so it can be treated, and understand alternatives for access that exists in the lower forearms if the radial occlusion is recalcitrant. Ultrasound plays a significant role in safe access and procedural planning. It should be a skill embraced by all operators. Future devices will be improved for shallow vessel access. Better knowledge of access techniques and adjunctive therapies will work synergistically to improve outcomes in the years ahead.

Areas covered: Literature review on forearm access is composed of small case series and underpowered trials but does provide a framework for evaluating the problem.

Expert opinion: The objective of this paper is to give an approach to tackle forearm access when there appears to be no palpable radial pulse. Preservation of radial flow is paramount while alternative forearm means to vascular access may help avoid the need to access the femoral artery.

KEYWORDS:

• Vascular access
• arterial occlusion
• vascular ultrasound
• hemostasis
• thrombosis
• pharmacology
• ulnar artery
• dorsal radial artery
• brachial artery
• femoral artery

Article Highlights box

• The finding of an absent radial pulse does not necessarily preordain the use of the femoral artery for access but should challenge the operator to find a solution that preserves the benefits of distal forearm vascular access.

• The differential for an absent radial pulse is broad and understanding the etiology can drive a solution.

• An accurate medical history and ultrasound imaging can usually tease out the underlying problem.

• For acute radial occlusions after transradial access, several therapeutic optionsare available to restore flow although prevention is the best.

Solutions for chronic radial occlusion are less certain and alternative access in the forearm may need to be employed.

Declaration of interest

I Gilchrist has consulting interests with Teuromo Interventional Systems and Cardinal Health without connection to this manuscript. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The paper was not funded.