Best practices for transradial angiography and intervention: SCAI Updated Guideline

Ultrasound Guidance for Arterial access

• Operators should develop proficiency with ultrasound guidance to facilitate forearm vascular access.
• Real‐time ultrasound guidance should be available and used when difficulty with radial access is encountered or expected.

Ulnar Artery Access

• Radial artery access is preferred over ulnar artery access in most situations.
• The ulnar artery may be a reasonable alternate access site when the risks of radial access failure or complication are high (e.g., small radial diameter, calcification, tortuosity, or anatomic anomaly).
• The ipsilateral ulnar artery may be a reasonable secondary access site after failed radial access; however, the data are limited.
• In cases of radial artery occlusion, there are insufficient data to provide a recommendation on the use of the ipsilateral ulnar artery over alternate access sites such as the contralateral radial or femoral arteries.

Utility of Noninvasive Assessment of Collateral Flow or Palmar Arch Patency

• Transradial catheterization can be performed regardless of results of noninvasive collateral testing. Routine collateral testing should not be used as a triage tool for access site selection.
• Collateral testing may be useful in screening for postprocedural radial artery occlusion and in assessing the adequacy of hemostasis techniques.

Prevention of Radial Artery Occlusion

• Administration of intravenous or intra‐arterial unfractionated heparin 5,000 U or 50 U/kg or a higher dose as a bolus is recommended following placement of radial artery introducer sheath.
• Concomitant ipsilateral ulnar artery compression is recommended to further maximize radial artery patency.
• Use of lowest profile sheath and/or catheter system required for procedural success, with attention to sheath/catheter‐to‐artery ratio.
• Patent hemostasis should be the default strategy, regardless of the method or device used for compression of the arteriotomy.

Radial Access for Primary PCI for STEMI 

• Transradial access (TRA) can be used for primary PCI to reduce vascular complications and bleeding in cardiac catheterization laboratories with appropriate training and expertise in radial access procedures.
• Operators should become experienced with nonemergent TRA PCI prior to performing STEMI TRA PCI.
• Appropriately defined strategies for arterial access site crossover (contralateral radial or femoral) should be in place to facilitate the decision process during emergencies in order to avoid delays in revascularization and ensure optimal outcomes.