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New Devices and Techniques
Case series
Feasibility and safety of transradial access for pediatric neurointerventions
  1. Visish M Srinivasan1,
  2. Caroline C Hadley1,
  3. Marc Prablek1,
  4. Melissa LoPresti2,
  5. Stephanie H Chen3,
  6. Eric C Peterson4,
  7. Ahmad Sweid5,
  8. Pascal Jabbour5,
  9. Christopher Young6,
  10. Michael Levitt6,
  11. Joshua W Osbun7,
  12. Jan-Karl Burkhardt2,8,
  13. Jeremiah Johnson2,
  14. Peter Kan2
  1. 1 Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
  2. 2 Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
  3. 3 Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
  4. 4 Neurological Surgery, University of Miami, Miami, Florida, USA
  5. 5 Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
  6. 6 Neurological Surgery, University of Washington, Seattle, Washington, USA
  7. 7 Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
  8. 8 Department of Neurosurgery, Texas Children's Hospital, Houston, Texas, USA
  1. Correspondence to Dr Peter Kan, Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA; peter.kan{at}bcm.edu

Abstract

Background Diagnostic cerebral angiograms are increasingly being performed by transradial access (TRA) in adults, following data from the coronary literature supporting fewer access-site complications. Despite this ongoing trend in neuroangiography, there has been no discussion of its use in the pediatric population. Pediatric TRA has scarcely been described even for coronary or other applications. This is the first dedicated large study of transradial access for neuroangiography in pediatric patients.

Methods A multi-institutional series of consecutively performed pediatric transradial angiograms and interventions was collected. This included demographic, procedural, outcomes, and safety data. Data was prospectively recorded and retrospectively analyzed.

Results Thirty-seven diagnostic angiograms and 24 interventions were performed in 47 pediatric patients. Mean age, height, and weight was 14.1 years, 158.6 cm, and 57.1 kg, respectively. The radial artery measured 2.09+/-0.54 mm distally, and 2.09+/-0.44 mm proximally. Proximal and distal angiography were performed for both diagnostic and interventional application (17 distal angiograms, two distal interventions). Clinically significant vasospasm occurred in eight patients (13.1%). Re-access was successfully performed 11 times in seven patients. Conversion to femoral access occurred in five cases (8.2%). The only access-related complication was a small asymptomatic wrist hematoma after TR band removal.

Conclusions Transradial access in pediatric patients is safe and feasible. It can be performed successfully in many cases but carries some unique challenges compared with the adult population. Despite the challenge of higher rates of vasospasm and conversion to femoral access, it is worth exploring further, given the potential benefits.

  • angiography
  • catheter
  • technique
  • ultrasound

https://doi.org/10.1136/neurintsurg-2020-015835

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    Introduction

    Neuroendovascular procedures, both diagnostic cerebral angiography and neuroendovascular treatments, are being performed with increasing frequency.1 Pediatric patients commonly require diagnostic angiography for workup of intracerebral hemorrhage, as they have a higher incidence of arteriovenous malformations, fistulae, or complex aneurysms.2 Until recently, modern cerebral angiography in adults and children has been performed via the common femoral artery (transfemoral access, TFA). In the past several years, following changes in practice in coronary angiography, there has been a growing trend toward radial artery access (transradial access, TRA) for cerebral angiography.3 Some authors have even described access via the distal radial artery in the anatomic snuffbox (distal TRA, dTRA).4 Although randomized data for neuroangiography is lacking, the purported benefits of reduced access-site complications and patient comfort found in the coronary studies are thought to apply.3 5–7

    Despite this ongoing trend on TRA in neuroangiography, there has been almost no discussion of its use in the pediatric population. In fact, TRA for other endovascular interventions in the pediatric population has scarcely been described, with contributions in small reports in the coronary literature,7–9 one brief dedicated series,10 and a recent series of four neurointerventional patients.11

    Methods

    Study design

    We performed a retrospective review of prospective maintained cerebrovascular databases at five academic institutions within the United States to identify all eligible cases. All patients 18 years or under who underwent either a diagnostic cerebral angiogram or a neurointervention through a transradial approach (either proximal or distal) were included. Data collected include basic demographics, height, weight, indication, procedure type, access site, arterial size at access, devices used (sheath, catheters), medications given, fluoroscopy time, radiation exposure, contrast dose, closure, complications, number of vessels selectively catheterized, and conversion to a femoral approach.

    Radial artery catheterization techniques

    Procedures were performed under general anesthesia or conscious sedation. Slight variations in the standard technique were performed by each individual neurointerventionalist.

    The right radial artery was used as the default point of access for all cases, either proximal or dTRA depending on patient factors (size of artery) and the preference of the interventionalist. However, in some cases left-sided access (if the left vertebral artery is the only target vessel) or ulnar artery (if its caliber is more favorable than the radial artery) access was used. Topical lidocaine/prilocaine cream was used at some centers. The radial artery was accessed with ultrasound guidance in all cases with a 20-gauge needle. Then, the introducer sheath is inserted over a 0.021- or 0.025-inch guidewire, followed by the administration of a “radial cocktail” that consists of some antispasmodic agents (verapamil, lidocaine, nitroglycerin) and heparin.

    Statistical analysis

    Analysis was performed using unpaired t-test and χ2 test as appropriate. Data are presented as mean and range for continuous variables, and as a frequency for categorical variables. All statistical analyses were performed using Microsoft Excel (Microsoft, Redmond, WA) and GraphPad Prism (GraphPad, La Jolla, CA).

    Results

    Retrospective review of the five institutional databases and personal series of the five neurointerventionalists yielded a total of 37 diagnostic angiograms and 24 interventions in 47 patients. Mean age was 14.1 (range 4–18 years) and 54.1% were female. Mean height and weight were 158.6 cm (102-194) and 57.1 kg (range 16.6–99.8). A demographic summary of the patients is listed in table 1.

    View this table:
    Table 1

    Summary of patient characteristics and procedural data across 61 pediatric transradial procedures

    For diagnostic angiography, 17/37 (45.9%) received dTRA, 19/37 (51.3%) received proximal access (TRA/ulnar). For interventions, 22/24 (91.7%) were TRA. The distal radial artery measured 2.09+/-0.54 mm, and the proximal radial artery measured 2.09+/-0.44 mm.

    Access was also performed for some very young patients for intra-arterial chemotherapy (four patients aged 4–14 years). Techniques included insertion of a 4Fr introducer from a micropuncture kit followed by a microcatheter and microwire directly inserted through this. For older patients, a 4Fr Merit Prelude sheath (Merit Medical) was used.

    Closure was performed by patent hemostasis technique with the Terumo TR band (Terumo Interventional Systems, Somerset, NJ) in 50/61 cases (81.9%). Other techniques including manual hemostasis and alternative compression devices (PreludeSync, Merit Medical, South Jordan, UT) were also used.

    In this series, seven patients received at least one subsequent angiographic procedure, for a total of 11 re-access events. Indications included repeat intra-arterial chemotherapy (three patients with two repeat procedures each), AVM embolization following a diagnostic (three patients with one repeat procedure each), and a patient who underwent a sequence of dTRA/TRA/dTRA for diagnostic angiogram, aneurysm embolization by Pipeline, and follow-up angiogram. At the time of repeat angiograms, no delayed radial artery occlusions were noted.

    For diagnostic angiograms, mean contrast usage was 74.97 mL, fluoroscopy time was 12.32 min, and radiation exposure was 774.91 mGy.

    Clinically significant vasospasm from the radial artery was noted in 13.1% of cases (8/61). Conversion rate to TFA was 8.2% (5/61). There was one case of a small asymptomatic wrist hematoma noted 30 min following removal of the TR band closure device. This resolved spontaneously. No other complications were seen.

    The majority (84.2%) of procedures were performed under GA. The conscious sedation cases were two 18-year-olds undergoing diagnostic angiography and one 14-year-old undergoing balloon test occlusion.

    Case illustration

    A teenage patient presented with acute onset headache, photophobia, nausea, and emesis. Physical examination was notable for lethargy and disorientation. CT head demonstrated diffuse subarachnoid hemorrhage with intraventricular hemorrhage, and CT angiography demonstrated a ruptured 5 mm right anterior choroidal artery aneurysm (figure 1). An emergent external ventricular drain was placed for developing hydrocephalus. The patient was then taken to the angiography suite for coil embolization of the ruptured right anterior choroidal aneurysm performed via right transradial arterial puncture. In this case, the proximal radial artery measured 2.2×2.9 mm. Using coaxial technique, the aneurysm was embolized with two nano coils (figure 2). Post-neurointervention angiogram demonstrated complete occlusion.

    Figure 1
    Figure 1

    Axial sections of a CT and CT angiogram of the brain. CT demonstrates subarachnoid hemorrhage and intraventricular hemorrhage associated with a ruptured right anterior choroidal artery (AChA) aneurysm.

    Figure 2
    Figure 2

    Cerebral angiogram, AP view of the right internal carotid artery injection (A) demonstrates the AChA aneurysm. right (proximal) transradial access was used for coil embolization, resulting in complete occlusion on 3D rotational angiogram (B).

    Discussion

    Transfemoral access for neuroangiography is the current standard in pediatric patients. In this series, we sought to assess the application of an alternative technique of distal or proximal TRA, recently applied in our adult patients, to the pediatric population.

    Reasons to explore radial access in children

    There are several compelling reasons to explore TRA for pediatric neuroangiography. Transradial access has been associated with lower access morbidity than TFA,12 without additional risk. The overall rates of femoral access complications in pediatric patients is not well reported. However, for those that have been studied, such as loss of arterial pulse13 or closure device usage,14 rates are comparatively higher than adults.

    With TFA in adults, closure devices are frequently used as an alternative to manual pressure for hemostasis. In pediatrics, due to femoral vessel sizes, arterial closure devices are often not feasible and are rarely used. Thus, manual pressure and longer immobilization periods are required. This can be challenging to manage, especially in younger patients or in children with neurological disorders. Avoiding sedation in the post-procedural period and allowing early mobilization could be especially beneficial in this population.

    In addition, given the comfort and ease of radial access for adult patients, our expectation based on this early experience is that patient, nursing staff, and parental satisfaction will also be higher.15

    Technical nuances – access and vasospasm management

    One of the main differences between TRA in adults and children is the higher potential for focal vasospasm in the pediatric radial artery. Thus, much of the technique involved in TRA in pediatric neuroangiography involves reducing the occurrence of vasospasm.

    The sheaths used for typical radial angiography in adults are radial-specific 4Fr or 5Fr sheath or a 4-5Fr (2.13 mm outer diameter (OD), 1.78–1.9 mm inner diameter (ID)) slender sheath. So-called “slender” sheaths are associated with a lower rate of procedural failure and radial artery occlusion,16 as they are smaller in OD than standard femoral sheaths while maintaining a comparable ID, and contain a hydrophilic coating. While these are adequate in older children, these are often too large in children younger than the age of 10 years in our observation. One alternative is the Merit 3-4Fr (1.78 mm OD and 1.57 mm ID) sheath (Merit Medical, South Jordan, UT), used in several of our cases. This smaller sheath allows the use of a 4Fr catheter and is atraumatic even to small radial arteries. For closure, smaller compression devices are available that are suitable for the pediatric population (PreludeSync or Prelude Sync distal, Merit Medical). The use of a long sheath (either 16 cm or 23 cm) may also be beneficial in both adult and pediatric TRA, as the sheath spans the entirety of the radial artery, exposing only the larger-diameter brachial artery to catheter movement. Appropriate sheath selection and the use of antispasmodics (verapamil, nitroglycerin, and lidocaine) reduce the likelihood of catheter manipulation-related radial artery spasm.4

    A variety of catheters were used in arterial selection. However, the 4Fr or 5Fr Simmons 2 catheters were the most common (32/61, 52.5%) as they are the most versatile in our experience, including in the completion of six-vessel cerebral angiograms. We have found that catheterization of the left vertebral artery is possible and may be easier than with TRAs in adults, due to lack of tortuosity in the aortic arch and great vessels.

    Distal vs proximal radial access

    The dTRA, in which the radial artery is cannulated in the anatomic snuffbox, has been recently well described in neuroangiography in adults4 and has a variety of advantages over standard TRA, including better ergonomics for the patient and surgeon, reducing the danger of radial artery occlusion (since the deep palmar arch arises proximal to the site of access), as well as sparing of the proximal radial artery for future re-access (especially for intervention).

    In diagnostic angiograms performed in our cohort, there was relative balance of dTRA vs TRA. Two interventions were performed by dTRA, with 91.7% being performed via proximal access to accommodate larger catheters, similar to adult series.7 In this series, the choice of dTRA vs TRA was left up to each individual surgeon, but most approached with the intention of dTRA if possible for diagnostic angiograms. Thus, the 50% rate of dTRA for diagnostic angiograms confirms the difficulty of this approach in children. Comparatively, using a “distal first” approach in adults is almost always feasible, with a conversion rate to TRA in only 14.3% even in early experiences.4

    Vessel size

    Limited data are available regarding sizing of the proximal and distal radial artery for placement of vascular access sheaths. However, the pediatric anesthesiology and critical care experience regarding arterial line placement provides some insights. Varga et al measured sub-1-mm sizing for patients under 4- years-old, confirming that very young children are generally unsuitable for TRA.17 In evaluating patients for microsurgical graft donors, Babuccu et al found that the diameters of the radial artery in children aged 4–14-year-old ranged from 1.39 to 1.57 mm. They found that the artery size correlated with age and weight.18 In our series, ultrasonic measurements were performed by the interventionalist at the point of puncture. Cut-off for vessel size varied in our series based on the interventionalist, from 1.4 to 1.7 mm.

    Complications, failure, and conversion rate

    In this series of 61 angiograms and treatments, no permanent complications were noted (we had one wrist hematoma). This follows with the large body of safety data that has been shown in the adult TRA literature.19 While not considered a permanent complication, there was 13% rate of temporary radial artery vasospasm, which restricted catheter movements. In our series of diagnostic angiograms (which allow for more direct comparison with published safety metrics), contrast usage, fluoroscopy time, and radiation exposure were in accordance with typical values for adult TRA (4.3 mins/vessel)3 and in line with standard TFA.9 20 Further, TRA limits fluoroscopy of the viscera and groin, which is advantageous in the pediatric population. However, in comparison the adult literature in which failure of TRA is rare,3 we had five cases (8.3%) of failure of either TRA or dTRA. The reason for these conversions was uniformly due to vasospasm limiting access and subsequent catheter movements. These cases were converted to TFA. We found that once the vessel is greater than 1.4 mm, neither young age nor small radial artery size appeared to correlate with failure. We believe that the access is extremely difficult below this cut-off. In contrast, in one personal series of adult TRA (43 dTRA, 15 TRA), only one case required conversion from TRA/dTRA to TFA (1.8%) (unpublished data, P.K.). Another personal series had an adult dTRA/TRA to TFA conversion rate of 5.6% (15/265) (unpublished data, M.L.). There are several factors that explain this finding. First, in the pediatric population (especially pre-teens or younger), there tends to be a lack of soft tissue overlying the anatomic snuffbox or proximal radial artery that renders dTRA sheath entry challenging. While the artery itself is accessible, the low angle of sheath entry in flexible tissues can cause resistance. Second, children appear to have a propensity for more proximal radial artery or even brachial artery vasospasm, which can also cause difficulty in catheter movements and manipulations even after initial access has been achieved. Finally, initial radial arterial catheterization can be difficult. In one series with a mean patient age of 7.1 months, arterial catheterization was only 50% on the first try even with ultrasound guidance.21

    Choice of anesthesia

    At all institutions, the default is for pediatric diagnostic cerebral angiography to be performed under general anesthesia (GA), while most adult diagnostic angiograms are performed under local/monitored anesthesia care (MAC). In this TRA experience, the majority (84.2%) of procedures were performed under GA, which may additionally help issues of patient anxiety causing vasospasm and limiting radial access.22 However, it is indeed possible to perform TRA in pediatric patients under MAC as the child moves toward their teenage years.

    Repeat angiography

    The total of 11 re-access procedures in this series demonstrate that even multiple repeat angiograms via the same radial artery is feasible, and that the rate of radial artery occlusion is likely to be low, especially when meticulous attention is paid to patent hemostasis during closure.23 This is particularly important as pediatric patients frequently require follow-up angiography as they age, depending on their pathology. However, this is only a small cohort with a small number of repeat procedures, and our results will need to be corroborated in a larger series. As these same patients return for routine follow-up we plan to continue our protocol and will assess for delayed radial artery occlusion.

    Limitations

    As a cohort study, this study has several limitations. First, the cases described have a clear selection bias (radial artery with size of less than 1.4 mm was not attempted in general). Furthermore, these cases may not be widely generalizable. The neurointerventionalists in this series had extensive prior experience in radial angiography in adults. Despite these limitations, our report is intended as a “proof of concept” to demonstrate the feasibility and safety to TRA in the pediatric population. Prospective studies comparing risks and benefits of established and novel treatment modalities are necessary to determine the overall safety profile of this approach. This will include attention to long-term radial artery patency and assessment of patient and parental satisfaction. Future studies will aim to specify the patient-indication combinations most favorable for a “radial first” approach.9

    Conclusions

    Transradial access for neuroangiography and intervention in pediatric patients is both safe and feasible. Challenges can be minimized with anticipation and optimization of technique.

    References

    1. ↵
      2. Wolfe TJ ,
      3. Hussain SI ,
      4. Lynch JR , et al
      . Pediatric cerebral angiography: analysis of utilization and findings. Pediatr Neurol 2009;40:98–101.doi:10.1016/j.pediatrneurol.2008.10.006 pmid:http://www.ncbi.nlm.nih.gov/pubmed/19135622
      OpenUrlCrossRefPubMed
    2. ↵
      2. Srinivasan VM ,
      3. Gressot LV ,
      4. Daniels BS , et al
      . Management of intracerebral hemorrhage in pediatric neurosurgery. Surg Neurol Int 2016;7:S1121–6.doi:10.4103/2152-7806.196919 pmid:http://www.ncbi.nlm.nih.gov/pubmed/28194298
      OpenUrlPubMed
    3. ↵
      2. Snelling BM ,
      3. Sur S ,
      4. Shah SS , et al
      . Transradial cerebral angiography: techniques and outcomes. J Neurointerv Surg 2018;10:874–81.doi:10.1136/neurintsurg-2017-013584 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29311120
      OpenUrlAbstract/FREE Full Text
    4. ↵
      2. Brunet M-C ,
      3. Chen SH ,
      4. Sur S , et al
      . Distal transradial access in the anatomical snuffbox for diagnostic cerebral angiography. J Neurointerv Surg 2019;11:710–3.doi:10.1136/neurintsurg-2019-014718 pmid:30814329
      OpenUrlAbstract/FREE Full Text
    5. ↵
      2. Chen SH ,
      3. Snelling BM ,
      4. Shah SS , et al
      . Transradial approach for flow diversion treatment of cerebral aneurysms: a multicenter study. J Neurointerv Surg 2019;11:796–800.doi:10.1136/neurintsurg-2018-014620 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30670622
      OpenUrlAbstract/FREE Full Text
    6. ↵
      2. Chen SH ,
      3. Brunet M-C ,
      4. Sur S , et al
      . Feasibility of repeat transradial access for neuroendovascular procedures. J Neurointerv Surg 2020;12:431–4.doi:10.1136/neurintsurg-2019-015438 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31586940
      OpenUrlAbstract/FREE Full Text
    7. ↵
      2. Snelling BM ,
      3. Sur S ,
      4. Shah SS , et al
      . Transradial approach for complex anterior and posterior circulation interventions: technical nuances and feasibility of using current devices. Oper Neurosurg 2019;17:293–302.doi:10.1093/ons/opy352 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30496537
      OpenUrlPubMed
    8. ↵
      2. Cinteză EE ,
      3. Filip C ,
      4. Bogdan A , et al
      . Atretic aortic coarctation – transradial approach. case series and review of the literature. Rom J Morphol Embryol 2017;58:1029–33.pmid:29250685
      OpenUrlPubMed
    9. ↵
      2. Yee J ,
      3. Kumar V ,
      4. Li S , et al
      . Clinical factors associated with physician choice of femoral versus radial access: a real-world experience from a single academic center. J Interv Cardiol 2018;31:236–43.doi:10.1111/joic.12479 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29277921
      OpenUrlPubMed
    10. ↵
      2. Irving C ,
      3. Zaman A ,
      4. Kirk R
      . Transradial coronary angiography in children and adolescents. Pediatr Cardiol 2009;30:1089–93.doi:10.1007/s00246-009-9502-6 pmid:http://www.ncbi.nlm.nih.gov/pubmed/19669827
      OpenUrlCrossRefPubMed
    11. ↵
      2. Majmundar N ,
      3. Patel P ,
      4. Dodson V , et al
      . First case series of the transradial approach for neurointerventional procedures in pediatric patients. J Neurosurg 2020:1–5.doi:10.3171/2019.12.PEDS19448 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32005020
    12. ↵
      2. Chase AJ ,
      3. Fretz EB ,
      4. Warburton WP , et al
      . Association of the arterial access site at angioplasty with transfusion and mortality: the M.O.R.T.A.L study (mortality benefit of reduced transfusion after percutaneous coronary intervention via the arm or leg). Heart 2008;94:1019–25.doi:10.1136/hrt.2007.136390 pmid:http://www.ncbi.nlm.nih.gov/pubmed/18332059
      OpenUrlAbstract/FREE Full Text
    13. ↵
      2. Alexander J ,
      3. Yohannan T ,
      4. Abutineh I , et al
      . Ultrasound-guided femoral arterial access in pediatric cardiac catheterizations: a prospective evaluation of the prevalence, risk factors, and mechanism for acute loss of arterial pulse. Catheter Cardiovasc Interv 2016;88:1098–107.doi:10.1002/ccd.26702 pmid:27535615
      OpenUrlPubMed
    14. ↵
      2. Smith JC ,
      3. Monroe EJ ,
      4. Shivaram GM , et al
      . An update on the use of an arterial closure device following femoral arterial puncture in children. Pediatr Radiol 2019;49:1217–21.doi:10.1007/s00247-019-04442-0 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31190109
      OpenUrlPubMed
    15. ↵
      2. Satti SR ,
      3. Vance AZ ,
      4. Golwala SN , et al
      . Patient preference for transradial access over transfemoral access for cerebrovascular procedures. J Vasc Interv Neurol 2017;9:1–5.pmid:28702112
      OpenUrlPubMed
    16. ↵
      2. Aminian A ,
      3. Dolatabadi D ,
      4. Lefebvre P , et al
      . Initial experience with the Glidesheath Slender for transradial coronary angiography and intervention: a feasibility study with prospective radial ultrasound follow-up. Catheter Cardiovasc Interv 2014;84:436–42.doi:10.1002/ccd.25232 pmid:24285594
      OpenUrlCrossRefPubMed
    17. ↵
      2. Varga EQS ,
      3. Candiotti KA ,
      4. Saltzman B , et al
      . Evaluation of distal radial artery cross-sectional internal diameter in pediatric patients using ultrasound. Paediatr Anaesth 2013;23:460–2.doi:10.1111/pan.12151 pmid:http://www.ncbi.nlm.nih.gov/pubmed/23577822
      OpenUrlPubMed
    18. ↵
      2. Babuccu O ,
      3. Ozdemir H ,
      4. Hosnuter M , et al
      . Cross-sectional internal diameters of radial, thoracodorsal, and dorsalis pedis arteries in children: relationship to subject sex, age, and body size. J Reconstr Microsurg 2006;22:049–52.doi:10.1055/s-2006-931907 pmid:16425122
      OpenUrlPubMed
    19. ↵
      2. Hamon M ,
      3. Pristipino C ,
      4. Di Mario C , et al
      . Consensus document on the radial approach in percutaneous cardiovascular interventions: position paper by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care** and Thrombosis of the European Society of Cardiology. EuroIntervention 2013;8:1242–51.doi:10.4244/EIJV8I11A192 pmid:23354100
      OpenUrlCrossRefPubMedWeb of Science
    20. ↵
      2. Acton H ,
      3. James K ,
      4. Kavanagh RG , et al
      . Monitoring neurointerventional radiation doses using dose-tracking software: implications for the establishment of local diagnostic reference levels. Eur Radiol 2018;28:3669–75.doi:10.1007/s00330-018-5405-3 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29651772
      OpenUrlPubMed
    21. ↵
      2. Schults JA ,
      3. Long D ,
      4. Pearson K , et al
      . Insertion, management, and complications associated with arterial catheters in paediatric intensive care: a clinical audit. Aust Crit Care 2019. doi:doi:10.1016/j.aucc.2019.05.003. [Epub ahead of print: 11 Jun 2019].pmid:http://www.ncbi.nlm.nih.gov/pubmed/31201037
    22. ↵
      2. Whitehead NJ ,
      3. Clark AL ,
      4. Williams TD , et al
      . Sedation and analgesia for cardiac catheterisation and coronary intervention. Heart Lung Circ 2020;29:169-177.doi:10.1016/j.hlc.2019.08.015 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31601511
      OpenUrlPubMed
    23. ↵
      2. Pancholy S ,
      3. Coppola J ,
      4. Patel T , et al
      . Prevention of radial artery occlusion-patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv 2008;72:335–40.doi:10.1002/ccd.21639 pmid:http://www.ncbi.nlm.nih.gov/pubmed/18726956
      OpenUrlCrossRefPubMedWeb of Science

    Footnotes

    • Twitter @PascalJabbourMD

    • Contributors Author contributions to the study and manuscript preparation include the following: conception and design: Srinivasan, Kan; acquisition of data: all; analysis and interpretation of data: all; drafting the article, critically revising the article, and reviewed submitted version of manuscript: all authors; approved the final version of the manuscript on behalf of all authors: Srinivasan; study supervision: Kan.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

    • Competing interests Dr Peterson is a consultant for Medtronic Neurovascular, Stryker Neurovascular, Penumbra, InNeuroCo, and Cerenovus, and is a stockholder in RIST Neurovascular. Dr. Kan is a consultant for Styker Neurovascular and Cerenovus.

    • Patient consent for publication Not required.

    • Ethics approval Institutional Review Board approval was provided by the organizing institution (Baylor College of Medicine, H-23688). Data collection was approved by other institutions and all information was de-identified. Informed consent was provided by patients’ guardians for this study of pediatric patients.

    • Provenance and peer review Not commissioned; externally peer reviewed.