Day 3: TR Band

Question 1

True or False: radial caths can be performed regardless of perfusion test results.

Answer 1

True

Question 2

What is the Barbeau or Modified Allen’s Test and how is it performed?

Answer 2

A test that uses pulse oximetry and manual compression of the ulnar and radial arteries to assess flow to the palmar arches.

First, the finger pulse oximeter will be placed and reading is confirmed. Next, compress both the radial and ulnar arteries and visualize flatline on PO. Release pressure on ulnar and watch for return reading on PO.

Question 3

What steps can you take to locate the radial artery without ultrasound?

Answer 3

First, locate the flexor crease and the styloid process. Access should be 2-3cm (or 2 finger widths) proximal to the crease. It should be about 1cm (or 1 finger width) proximal to the styloid process.

Question 4

What could happen if too much lidocaine is administered subcutaneously for radial access?

Answer 4

The radial artery pulse can be obliterated.

Question 5

What is the primary difference between single and double wall access?

Answer 5

Single wall is typically associated with Ultrasound guided access, non-coated wires (SS/Nitinol) and does not pierce through the back side of the vessel (aka anterior wall puncture only).

Double wall access does not use Ultrasound guided access, pierces through and through (aka back wall puncture), typically done by ICs, utilizes coated wires and can be easier for new operators learning access.

Question 6

True or False: SCAI does not consider Ultrasound guided radial access for coronary procedures best practice.

Answer 6

False

Question 7

Spasm is a physiologic response to stress, pain, and anxiety. What is happening during spasm?

Answer 7

Alpha receptors stimulated by the “fight or flight” response lead to contraction of the smooth muscle within the artery wall and cause vasoconstriction.

Question 8

Walk through the mitigation steps of radial artery spasm.

Answer 8

1) STOP - time and patience (15 min intervals)
2) DO NOT push or pull if resistance is present
3) Relax the patient via room ambience (dim lights/ calm music) and gentle sedation (Valium, Versed, Fentanyl)
4) Consider patient’s clinical condition and then administer antispasmodic cocktail (Nitro, Verapamil and check Heparin)
5) Apply best practices in further attempts (decrease sheath:artery ratio, use hydrophilic sheath)
6) Apply warm compress
7) Perform Flow mediated dilation (BP Cuff)
8) Call for anesthesia bailout

Question 9

What are the 3 primary drug classifications or categories involved in a radial cocktail?

Answer 9

• Vasodilators to relax and dilate the vessels
• Calcium Channel Blockers to block Calcium from entering muscle cells in the arterial walls
• Anticoagulants to prevent blood cells from clotting (aka blood thinners)

Question 10

What is the most common Calcium Chanel Blocker given in a radial cocktail and what is the typical dosage given?

Answer 10

2.5 - 5.0mg (milligram) of Verapamil is given via the sheath side port (IA)

Question 11

What is the most common Vasodilator given in a radial cocktail and what is the typical dosage?

Answer 11

200 - 400mcg (micrograms) of Nitroglycerin or Nitro is given directly through the sheath side port (IA).

Question 12

What is the most common anticoagulant in a radial cocktail and what dosage is given?

Answer 12

50 u/kg (units/kilogram) of Heparin is given either via IV or IA.

Question 13

What is the primary objective during radial access that significantly decreases the incidence of radial artery occlusion?

Answer 13

Patent Hemostasis - patent refers to keeping the artery open, while hemostasis refers to closing or clotting the access site. Therefore, PH can be defined as the minimum pressure to inhibit bleeding through the puncture site, but not so much as to cause failure of the vessel under pressure.

Question 14

What are the 3 KEY FEATURES of the TR Band?

Answer 14

1) 2 balloons for targeted compression of radial artery
2) transparent band for visualization
3) rounded edges for patient comfort and protection of ulnar nerve/artery

Question 15

What is the indication for use of the TR Band?

Answer 15

It’s indicated for use in managing closure and assisting in hemostasis of the RADIAL artery and enables the titration of air.

Question 16

What are the components of the TR Band (this labeling a spec diagram)?

Answer 16

Adjustable fastener
Belt
1mm green puncture site marker
Pressure confirmation balloon
Air injection port w/ valve
Small pressure balloon
Large compression balloon
Support plate with logo

Question 17

Why is the Slip Tip Air Inflation inlet on our syringe important?

Answer 17

It is the tip on our inflation syringe that connects to the TR Band air port. It is important because it is not a leurlock and therefore will not allow air to enter the vessel. If it is lost or misplaced, they are not sold separately and a regular syringe is not compatible, so a new TRB would need to be opened. Suggested to tape or fasten the syringe to the table, patient’s upper arm or to the wall.

Question 18

Where do you line the green puncture site location marker and the Terumo logo on the TRB?

Answer 18

Align the green puncture site marker 2mm proximal from the insertion site.
Align the Terumo logo on the opposite side of the puncture site.

Question 19

What is a clinical consideration to be aware of when considering administering Nitro to a patient?

Answer 19

It can decrease blood pressure so the patient will need to be able to tolerate it.

Question 20

True or False: there is no significant difference between Intranet-arterial and systemic Heparin administration in regard to radial access.

Answer 20

True.

Question 21

The radial artery is more prone to spasms which can lead to complications like RAO. What are the 2 biggest factors that differentiate radial sheaths from femoral?

Answer 21

Hydrophilic coating and smaller ODs

Question 22

What are the differences between Glidesheath and Glidesheath Slender?

Answer 22

GS has a suture eye and is indicated for radial, brachial and ulnar.
GSS has slender technology for the smaller OD magic and only indicated for radial artery.

Question 23

Industry standard has OD two French sizes larger than the ID. Glidesheath Slender utilizes ___________ technology to achieve an OD _______Fr smaller than the ID.

Answer 23

Thin wall technology
1Fr

Question 24

What is the primary benefit of Slender technology?

Answer 24

Using a smaller French size reduces the risk of vessel trauma/spasm while still allowing the operator to use devices they’re accustomed to.

Question 25

What are the available TR Band sizes?

Answer 25

Standard = 24cm
Long = 29cm

Question 26

Why is Terumo’s hydrophilic coating so renowned?

Answer 26

It is a proprietary recipe made in Japan that was not patented, so no other companies have access to it. Therefore, it cannot be recreated. It has demonstrated best in class lubricity and durability. It adheres to the product differently than other hydrophilic coating, which allows it to stay on longer and stay slippery longer.

Question 27

What GSS and GS kits to we offer?

Answer 27

GSS: Access, SS & Nitinol
GS: Access, SS, Nitinol, Basic and 0.035”

Question 28

What are the main benefits of thin wall technology?

Answer 28

A reduced sheath to artery ratio (OD) leads to reduced complication risks
No need to upsize

Question 29

What is nominal pressure for the TR BAND?

Answer 29

13 mL

Question 30

List the first 2 steps in the TRB Application guidelines.

Answer 30

1) Withdraw sheath 2-3cm so band is not placed over.
2) Apply TRB by aligning green marker 1-2mm proximal to the puncture site. Fix strap on wrist (watch band tightness) and ensure the Terumo logo is opposite of the puncture site.

Question 31

List steps 3 & 4 of the TRB Application Guidelines.

Answer 31

3) Slowly inject 15-18mL air while simultaneously removing sheath ensuring bleeding stops once sheath is fully removed.
4) Begin titration of air by removing 1 mL x/sec . When bleeding occurs at access site, inject 1-2mL air or until bleeding stops.

Question 32

What is the final (5th) step of TRB Application?

Answer 32

5) Confirm radial pulse and radial artery patency via reverse Barbeau. If interruption of radial artery is evidenced, lower hemostatic compression pressure until waveform returns and patent hemostasis is achieved.

Question 33

What are the heparin considerations relating to TRB removal?

Answer 33

50 u/kg or less of Heparin = 60 min band time
50 u/kg or more of Heparin = 120 min band time

Question 34

What are the first 3 steps of TRB Removal?

Answer 34

1) Place pulse oximeter and confirm patent hemostasis
2) Remove 3-5mL air every 10-15 mins.
3) If bleeding occurs during removal, re-inflate enough air to achieve patent hemostasis and confirm. Wait 15-30mins and then repeat step 2

Question 35

What are steps 4-5 of TRB Removal?

Answer 35

4) Once air is completely removed, confirm hemostasis. Unfasten Band while stabilizing access site with gentle pressure. Remove band by lifting slowly towards palm on one side or gently wiggling.
5) Apply sterile dressing.