**6. Preprocedural assessment**

The choice of right radial vs. left radial is decided by the transradial operator and patient‐ related factors. Transradial operator may choose the left radial in special conditions as in requiring cannulation of the LIMA or in a presence of a contraindication for using the right radial access. The left radial approach may be preferred in specific patients who have a higher risk for right radial artery (RRA) touristy like in female gender, short stature, low body weights, and elderly.

#### **6.1. Right radial access**

The patient is positioned supine on the table in the same manner as the transfemoral route. An arm board extension is attached to the right‐hand side of the table. Arm boards are available in different shapes and designs. Perhaps best suited for this purpose may be the trapezoid‐ shaped fiberglass board, with the narrow end tucked under the mattress at shoulder level and the broad area at the wrist.

The patient should be prepared with the wrist exposed, the forearm placed in the supine position and the hand gently taped in position, with the wrist hyper extended and supinated. A pulse oximetry probe is placed on the right index finger or thumb to allow for continuous monitoring of the circulation to the hand throughout the procedure. After the wrist has been appropriately prepared, it will be examined for the radial artery. Infiltrate local anesthetic subcutaneously at least 2 cm proximal to the radial styloid process (in the region where the radial artery pulse is best appreciated) to form a small wheal. The skin is sterilized with an alcohol‐based skin preparation. The groin should also be prepared for access in the event of a failed radial artery insertion. The angiography drape is applied so as to expose the wrist in an area where the radial artery pulse will be palpable.

Radial artery puncture can be done using open needle technique (anterior wall puncture) or trans‐fixation technique (posterior wall puncture). After the artery has been successfully punctured, introduce the guide wire through the cannula. Once the guide wire has been smoothly advanced through the device, remove the cannula while leaving the guide wire in place. Introduce the sheath (with the dilator inserted) over the guide wire into the radial artery. A small superficial skin incision may be made where the guide wire enters through the skin to facilitate smooth passage of the sheath and to prevent radial artery spasm.

After the sheath is fully advanced, the guide wire and the dilator assembly may be removed. After the removal of the dilator, the sidearm may be used for administration of compatible medications as antispasmodic agents (e.g., verapamil 2.5–5 mg diluted in blood, nitrates 100– 200 mic) through the sheath via the sidearm. And anticoagulants (e.g., heparin 5000 U) may be administered either via the sheath or IV, depending on the procedure performed.

#### **6.2. Left radial access**

left radial artery access has advantages over the right radial approach in lower incidence of vascular anomalies less than right radial and using the left radial approach mimetic the femoral approach regarding the manipulation of the catheters and support of guiding cath‐ eters. **Table 2** summarizes the differences and similarities between right and left transradial

**Right radial access Left radial access**

Preparation and setup More standardized Less standardized (disrupt traditional setup)

Acceptability More popular Less popular (if indicated only)

Radiation dose Similar (longer with trainees) Similar (shorter with trainees)

Comfort for the operator More comfortable Less comfortable

Learning curve Longer Shorter Catheter manipulation More challenging (similar with experts) Better control

Efficacy and safety Similar Similar

**Table 2.** Comparison between right and left radial access [28].

The choice of right radial vs. left radial is decided by the transradial operator and patient‐ related factors. Transradial operator may choose the left radial in special conditions as in requiring cannulation of the LIMA or in a presence of a contraindication for using the right radial access. The left radial approach may be preferred in specific patients who have a higher risk for right radial artery (RRA) touristy like in female gender, short stature, low body

The patient is positioned supine on the table in the same manner as the transfemoral route. An arm board extension is attached to the right‐hand side of the table. Arm boards are available in different shapes and designs. Perhaps best suited for this purpose may be the trapezoid‐ shaped fiberglass board, with the narrow end tucked under the mattress at shoulder level and

The patient should be prepared with the wrist exposed, the forearm placed in the supine position and the hand gently taped in position, with the wrist hyper extended and supinated. A pulse oximetry probe is placed on the right index finger or thumb to allow for continuous monitoring of the circulation to the hand throughout the procedure. After the wrist has been appropriately prepared, it will be examined for the radial artery. Infiltrate local anesthetic subcutaneously at least 2 cm proximal to the radial styloid process (in the region where the

accesses based on the most recent studies [28].

8 Interventional Cardiology

**6. Preprocedural assessment**

weights, and elderly.

**6.1. Right radial access**

the broad area at the wrist.

There are more variations in catheterization laboratory setup, patient preparation, and equip‐ ment setup with the left radial compared to the right radial approach. Some operators prefer to perform the left radial procedure from the left side of the patient. In this case, the patient is positioned, prepped, and draped in a similar fashion as that of right radial access, only the arm board is attached to the left side of the table, and the equipment is arranged as a mirror image of the right‐sided approach.

The patient is positioned supine on the table in the typical manner as the transfemoral route. A pulse oximeter probe is placed on the left index finger or thumb to allow continuous moni‐ toring throughout the procedure. The operator achieves vascular access either from left side of the patient or from the right side of the patient, as if performing a left femoral artery punc‐ ture. After needle puncture and sheath insertion in a typical manner as right radial approach, the left forearm is pronated and adducted, such that the left wrist rests close to the right inguinal area. The operator then performs the catheterization procedure on the right side of the patient with a general setup that closely resembles the transfemoral approach.
