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Dr. Riitta Rautio, Head of the Department of Interventional Radiology, Tyks - VSSHP - Turku University Hospital, Finland
Discover Riitta Rautio's unique perspective and expertise as she shares her shart responses in this interview with Dr. Jildaz Caroff.
What is the Rist™ radial access system, and what benefits does it offer compared to other radial access systems?
The RIST™ radial access system is a groundbreaking innovation in medical technology, revolutionizing the approach to intracranial procedures. It incorporates a 5F diagnostic catheter, available in either Simmons or Berenstein configuration, along with a 7F guide catheter, featuring an inner diameter of 0.079 inches.
Distinguished as the pioneering device exclusively tailored for radial access, the RIST™ system boasts several notable features. Notably, the RIST™ guide catheter encompasses the longest distal hydrophilic portion currently available, i.e. 25 centimeters. This extended hydrophilic segment greatly facilitates smooth distal navigation during procedures. Additionally, the distal flexible end of the RIST™ guide catheter extends a substantial 29.5 centimeters, further augmenting its reach and versatility.
How does the radial approach impact patient comfort and satisfaction?
Radial access offers notable advantages in terms of post-procedure bed rest, patient comfort, and potential complications. Compared to femoral access, radial access significantly reduces the required bed rest time, enabling patients to resume normal activities sooner. Moreover, patients experience minimal access site pain during both sheath insertion and removal, leading to improved overall comfort.
Additionally, patients often experience a reduction in feelings of embarrassment and anxiety that may arise during femoral approaches, as the radial approach provides a more discreet option.
Furthermore, the use of radial access simplifies the detection and management of potential puncture site hemorrhage. The radial artery, being closer to the surface, allows for easier identification of any bleeding and facilitates timely compression if necessary, minimizing the risk of complications associated with bleeding.
What are some strategies for maintaining stability during radial access procedures using the Rist™ catheter?
To ensure optimal performance of the RIST™ radial access system, it is crucial to position it appropriately. Due to the considerable length of the distal flexible end, it is essential to place the RIST™ high enough within the vasculature to prevent the flexible segment from lingering at the aortic arch. Ideally, the RIST™ should be advanced into the petrous part of the internal carotid artery (ICA), as this location offers optimal positioning and stability during procedures.
To enhance support during intracranial interventions, a distal access catheter serves as a valuable addition. It provides additional stability and maneuverability. One notable advantage of the RIST™ system is its compatibility with all 5F intermediate catheters.
In situations where extra support is required, the option to use a buddy wire presents itself. Even a 035 Terumo wire can be employed as a buddy wire, providing the necessary additional support during intricate procedures.
In your experience with the RIST™ catheter, what has been the rate of delayed radial artery occlusion and how does this compare to other systems?
To minimize the risk of endothelial damage and subsequent radial artery occlusion, I consistently employ a hydrophilic sheath, such as the Terumo Slender™ (in conjunction with the RIST™) along with careful puncture of the radial artery under ultrasound guidance. By utilizing a hydrophilic sheath, the need for extensive manipulation of the radial artery is reduced, significantly lowering the potential for endothelial damage.
Another factor contributing to the reduced risk of complications is the disparity in outer diameter between the 8F catheters and the RIST™ (7F).
Although a systematic follow-up of the access site was not performed in our study, a majority of our patients underwent a control digital subtraction angiography (DSA) examination 3-6 months after their procedures. The findings from these examinations revealed a lower incidence of radial artery occlusions compared to previous reports. In fact, within our patient cohort, only one silent radial artery occlusion was discovered.
Which patient populations are the most appropriate candidates for radial access procedures, and are there any specific circumstances or conditions that would make this approach contraindicated?
In our department, we prioritize radial access as the primary approach for adult patients. However, I strongly recommend utilizing ultrasound to measure the diameter of the radial artery before the puncture, ensuring compatibility with appropriate device sizes and avoiding the use of overly large devices in smaller radial arteries. To maintain a safe threshold, we typically consider a lower limit of 1.7 mm for a 7 F sheath.
Older patients often present with iliofemoral atherosclerotic disease, which can make radial access comparatively easier. Having pre-imaging from the aortic arch aids in planning and assessing the feasibility of the radial approach.
Have you fully transitioned from femoral access to radial access in your current practice, and if so, what has been your experience with this change?
No, I have not. There are still limitations in the use of radial access for certain procedures, such as carotid stenting and other interventions where the guide needs to be placed at or below the carotid bifurcation. We need more variability regarding sizes, proximal support, distal part flexibility and hydrophilic length of the radial devices. Despite these limitations, the transition from femoral to radial access in my practice occurred relatively quickly. I made a conscious decision to embrace this new technique and actively sought out devices that would work best in my hands. Furthermore, my nursing staff also embraced the change and understood that it not only expedited post-procedure care but also provided better outcomes for our patients.
What is the learning curve like for switching to radial access procedures, and what resources, training or techniques can help facilitate this transition?
It took me a few months to gain confidence and comfort with radial access procedures. During that time, I utilized various resources to enhance my skills. Training videos proved to be valuable references, providing step-by-step guidance and visual demonstrations. Additionally, practicing with a simulator allowed me to refine my technique and become more proficient.
To ease into the transition, I initially focused on diagnostic (DSA) procedures. This approach allowed me to familiarize myself with manipulating catheters from a different perspective than what I was accustomed to. By approaching the procedures with an open mind, coupled with enthusiasm and a strong motivation to excel, I was able to overcome the learning curve associated with radial access in neurointerventions within a relatively short time frame.
The key to success lies in embracing continuous learning and actively seeking opportunities for improvement. With dedication and the right resources, one can swiftly develop the necessary skills and expertise to perform various neurointerventions using radial access.
For a deeper dive, check out this short video where Dr. Riitta Rautio provides a 3-minute summary of her article, "A summary of the first 100 neurointerventional procedures performed with the Rist™ radial access device in a Finnish neurovascular center."
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