**6. Radial access support**

Support for access in the wrist has advanced over the past decade, with a focus on left arm support, radiation protection and having a board to hold equipment.

#### *Interventional Treatment for Structural Heart Disease*

There has been a surge in the last several years to use the left wrist to circumvent challenges with access to the left internal mammary artery post coronary artery bypass surgery (CABG), those older than 75 years, short statue less than 5 foot five inches (1.65meters), and long term hypertension [5, 27]. Wrist access requires support for: access in the artery, management of equipment, radiation exposure along with comfort of the patient and the operator. Right arm support has advanced with arm extension boards to help with access, for example Radial Runway (TZ Medical), Rad Rest (Merit) or STAR system (Adept Medical) to help with access of the artery, especially useful if not using ultrasound **(Figure 1)**. Right boards include the Cardiotrap (Radial Solutions) (**Figure 2a**), EGGNEST from EGG medical (**Figure 2b)**, STARSYSTEM by Adept Medical, Rad Board from Merit provides both arm support and radiation protection. The left arm support for both access and arm support across the abdomen is the Left Arm Support System by LP Medical **(Figure 2c)** and Cardiotrap from Radial Solutions. Other options for arm support alone include STARSYSTEM by Adept Medical, Cobra Board by TZ medical (**Figure 2d**), left radial support sling by Academic Health Science Network and Tesslagra sterile sleeve by Tesslagra Design Solutions. Once access is made for the left wrist and arm is placed across the abdomen, use of sheath extension such as the StandTall by

**Figure 1.**

*Devices to hold the wrist out to assist in accessing the radial artery. a. Radial Runway©, TZ medical. b. Rad Board© and Rad Rest©, Merit Medical.*

**Figure 2.** *Arm support systems. Right arm: a. Cardiotrap® (Transradial solutions, SC) b. EGG Nest® (EGG Medical, MN) c. Left arm support system (LASS) (LP Medical, MN) d. Cobra Board® (TZ Medical, OR).*

**Figure 3.** *Sheath Extension Standtall® (Radux Devices, MN).*

Radux (**Figure 3**), distal radial approach or having a long sheath partly extended out (although risk for kinking of the sheath) will allow the physician to have an upright position on the right side of the patient while manipulating the catheter or guide.
