The pulseless radial artery in transradial catheterization: challenges and solutions.

Introduction: An absent radial pulse prior to cardiac catheterization is an ominous finding as it portends the need for higher-risk arterial access. Solutions exist that can avoid the use of more hazardous access. Given the benefits of the radial artery access, it is essential to prevent radial artery occlusion, to diagnose acute occlusion at the time of hemostasis so it can be treated, and understand alternatives for access that exists in the lower forearms if the radial occlusion is recalcitrant. Ultrasound plays a significant role in safe access and procedural planning. It should be a skill embraced by all operators. Future devices will be improved for shallow vessel access. Better knowledge of access techniques and adjunctive therapies will work synergistically to improve outcomes in the years ahead.Areas covered: Literature review on forearm access is composed of small case series and underpowered trials but does provide a framework for evaluating the problem.Expert opinion: The objective of this paper is to give an approach to tackle forearm access when there appears to be no palpable radial pulse. Preservation of radial flow is paramount while alternative forearm means to vascular access may help avoid the need to access the femoral artery.