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Transradial Access
TECHNIQUES FOR
DIAGNOSTIC ANGIOGRAPHY AND
PERCUTANEOUS INTERVENTION

Howard A. Cohen, MD, Editor

Transradial Access
TECHNIQUES FOR
DIAGNOSTIC ANGIOGRAPHY AND
PERCUTANEOUS INTERVENTION
Transradial Access
TECHNIQUES FOR
DIAGNOSTIC ANGIOGRAPHY AND
PERCUTANEOUS INTERVENTION

Howard A. Cohen, MD, FACC, FSCAI

Temple University Health System
Philadelphia, Pennsylvania

Minneapolis, Minnesota
© 2013 Howard A. Cohen

Cardiotext Publishing, LLC

3405 W. 44th Street
Minneapolis, Minnesota 55410
USA

www.cardiotextpublishing.com

Any updates to this book may be found at: www.cardiotextpublishing.com/titles/detail/

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This book is intended for educational purposes and to further general scientific and medical
knowledge, research, and understanding of the conditions and associated treatments discussed
herein. This book is not intended to serve as and should not be relied upon as recommending or
promoting any specific diagnosis or method of treatment for a particular condition or a particular
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proper course of treatment for any condition or patient, including suitable and appropriate tests,
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Due to ongoing research, discoveries, modifications to medicines, equipment and devices, and
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ISBN: 978-1-935395-41-6

Printed in the United States of America.

 Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 2: Rationale for Transradial Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Robert W. Harrison
Sunil V. Rao

Chapter 3: Vascular Anatomy of the Arm and Hand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Richard P. Abben
Gary Chaisson

Chapter 4: Preoperative Evaluation of the Potential Patient for Transradial Access . . . . . . 39

Pierre-Louis Nadeau
Jean-Pierre Déry
Gérald R. Barbeau

Chapter 5: Obtaining Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Howard A. Cohen

Chapter 6: Closure and Hemostasis after Transradial Access . . . . . . . . . . . . . . . . . . . . . . . . . 55

Samir B. Pancholy
Tejas Patel
Sanjay C. Shah
Chapter 7: Basic Catheter Techniques for Diagnostic Angiography and PCI . . . . . . . . . . . . . 61
Tift Mann

Chapter 8: Sheathless Transradial Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Rajiv Gulati
Aaron M. From
Charanjit S. Rihal

Chapter 9: Transradial Access and Outpatient PCI:

State-of-the-Art and Persisting Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Eltigani Abdelaal
Olivier F. Bertrand

v
vi ■ Contents

Chapter 10: Transradial Access for PCI in Acute Myocardial Infarction . . . . . . . . . . . . . . . . . 95

Sameer J. Khandhar
Oscar C. Marroquin
Suresh R. Mulukutla

Chapter 11: Transradial Approach to Peripheral Interventions . . . . . . . . . . . . . . . . . . . . . . . 121

John T. Coppola
Cezar Staniloae

Chapter 12: Right Heart Catheterization and Transradial Access. . . . . . . . . . . . . . . . . . . . . . 131

Ian C. Gilchrist

Chapter 13: The Learning Curve for Transradial Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Yves Louvard
Hakim Benamer
Thierry Lefèvre

Chapter 14: Transradial Arterial Access: Economic Considerations . . . . . . . . . . . . . . . . . . . . 155

Ronald P. Caputo

Chapter 15: Tips and Tricks for Transradial Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Tejas Patel
Sanjay C. Shah
Samir B. Pancholy

Chapter 16: Complications of Transradial Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

Kirk N. Garratt

Chapter 17: How to Start a Transradial Program at Your Hospital . . . . . . . . . . . . . . . . . . . . . 193

Ankitkumar K. Patel
Zoltan G. Turi

Appendix: Video Legends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
 Contributors
About the Editor
Howard A. Cohen, MD, FACC, FSCAI
Professor of Medicine; Director, Temple
Interventional Heart and Vascular Institute;
Director, Cardiac Catheterization Laboratories
and Cardiac Intervention, Temple University
Health System, Philadelphia, Pennsylvania

About the Contributors

Richard P. Abben, MD, FACC, FSCAI Olivier F. Bertrand, MD, PhD, FSCAI
Director, Cardiac Interventions, Interventional Cardiologist, Quebec Heart-
Cardiovascular Institute of the South, Houma, Lung Institute; Associate-Professor, Faculty of
Louisiana; Associate Clinical Professor of Medicine, Université Laval; Adjunct-Professor,
Medicine, Louisiana State University School Department of Mechanical Engineering,
of Medicine, New Orleans, Louisiana McGill University; Director, CAIC Transradial
Interventions Working Group; Scientific
Eltigani Abdelaal, MD, MBBS, MRCP (UK), CCST Director, Université Laval RADIAL Research &
Cardiology (UK) Education Fund, Quebec City, Quebec, Canada
Interventional Cardiology Fellow, Clinical
Research & Interventional Cardiology Ronald P. Caputo, MD, FACC, FSCAI
Laboratories, Quebec Heart-Lung Director of Cardiac Services, St. Joseph’s
Institute, Université Laval, Quebec City, Hospital, Clinical Associate Professor of
Quebec, Canada Medicine, SUNY Upstate Medical School,
Syracuse, New York
Gérald R. Barbeau, MD, CSPQ, FACC, FRCPC
Cardiologue d’intervention & Imagerie Gary Chaisson, RTR, RCSA
cardiovasculaire par résonance magnétique, Technical Director Cardiac Catheterization
Institut universitaire de cardiologie et de Lab, Cardiovascular Institute of the South,
pneumologie de Québec, Université Laval, Houma, Louisiana
Quebec City, Quebec, Canada
John T. Coppola, MD, FACC, FSCAI
Hakim Benamer, MD Assistant Clinical Professor of Cardiology,
Institut Cardiovasculaire Paris Sud, NYU Langone Medical Center, New York,
Massy, France New York

vii
viii ■ Contributors

Jean-Pierre Déry, MD, MSc, FACC, FRCPC Tift Mann, MD, FACC
Cardiologue d’intervention, Institut Wake Heart and Vascular Associates, Raleigh,
universitaire de cardiologie et de pneumologie North Carolina
de Québec, Université Laval, Quebec
City, Quebec, Canada Oscar C. Marroquin, MD, FACC, FSCAI
Assistant Professor of Medicine and
Aaron M. From, MD Epidemiology; Director, UPMC Provider
Iowa Heart Center of Mercy Hospital, Analytics, Heart and Vascular Institute,
Des Moines, Iowa University of Pittsburgh Medical Center,
Pittsburgh, Pennsylvania
Kirk N. Garratt, MD, MSc
Lenox Hill Heart and Vascular Institute Suresh R. Mulukutla, MD, FACC, FSCAI
of New York; Associate Chair, Quality and Assistant Professor of Medicine and
Research; Director, Cardiac Interventions, Epidemiology; Director, Center for Quality,
Northshore/LIJ Lenox Hill Hospital, Outcomes and Clinical Research, Heart and
New York, New York Vascular Institute, University of Pittsburgh
Medical Center, Pittsburgh, Pennsylvania
Ian C. Gilchrist, MD, FACC, FSCAI, FCCM
Professor of Medicine, Interventional Pierre-Louis Nadeau, MD, CSPQ, FRCPC
Cardiology, Pennsylvania State University, Interniste, Résident en cardiologie; Institut
Penn State Heart and Vascular Institute, universitaire de cardiologie et de pneumologie
Hershey, Pennsylvania de Québec, Université Laval, Quebec
City, Quebec, Canada
Rajiv Gulati, MD, PhD, FACC, FSCAI
Associate Professor of Medicine, College Samir B. Pancholy, MD, FACP, FACC, FSCAI
of Medicine: Consultant, Division of Program Director, Cardiology Fellowship,
Cardiovascular Diseases Mayo Clinic, The Wright Center for Graduate Medical
Rochester, Minnesota Education; Associate Professor of Medicine,
Cardiovascular Diseases, The Commonwealth
Robert W. Harrison, MD Medical College, Scranton, Pennsylvania
Fellow, Department of Internal Medicine,
Division of Cardiology, Duke University Ankitkumar K. Patel, MD, MPH
Medical Center, Durham, North Carolina Cardiology Fellow, Division of Cardiology,
Cooper University Hospital, Cooper Medical
Sameer J. Khandhar, MD School of Rowan University, Camden,
Assistant Professor of Medicine, Center for New Jersey
Quality, Outcomes and Clinical Research,
Heart and Vascular Institute, University Tejas Patel, MD, DM, FCSI, FACC, FESC, FSCAI
of Pittsburgh Medical Center, Pittsburgh, Chairman and Chief Interventional
Pennsylvania Cardiologist, Apex Heart Institute,
Ahmedabad, Gujarat, India
Thierry Lefèvre, MD, FESC, FSCAI
Institut Cardiovasculaire Paris Sud, Sunil V. Rao, MD, FACC, FSCAI
Massy, France Associate Professor of Medicine, Department
of Internal Medicine, Division of Cardiology,
Yves Louvard, MD, FSCAI Duke University Medical Center, The
Institut Cardiovasculaire Paris Sud, Duke Clinical Research Institute, Durham,
Massy, France North Carolina
 Contributors ■ ix

Charanjit S. Rihal, MD, MBA Cezar Staniloae, MD, FACC

Professor and Chair, Division of Clinical Assistant Professor, Leon Charney
Cardiovascular Diseases, Mayo Clinic, Division of Cardiology, NYU Langone Medical
Rochester, Minnesota Center, New York, New York

Sanjay C. Shah, MD, DM Zoltan G. Turi, MD

Director of Cardiology, APEX Heart Institute, Director, Cooper Vascular Center, Cooper
Ahmedabad, Gujarat, India University Hospital; Professor of Medicine,
Cooper Medical School of Rowan University,
Camden, New Jersey
 Foreword
Introduced nearly 25 years ago as an alternative to femoral or brachial artery puncture, transradial
cardiac catheterization and percutaneous coronary revascularization has emerged as the dominant
vascular access strategy in many clinical practices worldwide. The adoption of this method has been
advanced by both observational experience and clinical trials demonstrating reductions in bleeding
and vascular access complications, lower resource utilization, and improved patient satisfaction. In
particular, recent evidence indicates that the clinical advantages of a transradial approach may be
especially evident among patients representing the highest risk for bleeding events, for example,
those with acute myocardial infarction.
Despite these unequivocal benefits of a transradial approach, its prevalence relative to
femoral arterial access remains varied, in part challenged by uncertainties regarding technical
challenges specific to radial catheterization, misperceptions of incapabilities related to complex
coronary revascularization, and, until recently, a general lack of operator and staff training. The
greatest determinant of whether a patient is treated by femoral or radial artery access is not the
comparative evidence but instead the clinician’s skill set. At present, however, the learning curve
for adoption of transradial catheterization and revascularization has never been more abbreviated
due to increasing awareness of patient-oriented benefits, opportunities for practice differentiation,
implementation of didactic programs through proctoring, regional training and media, and, more
generally, increased attention to this method in interventional conferences and clinical trials.
More specifically, reports following institutional and even multicenter adoption of transradial
cardiac catheterization and revascularization have demonstrated that following only a modest case
volume, reductions in procedural time and resource utilization, increasing procedural success, and
even improved patient outcomes may be realized. Furthermore, increasing comparative study of
femoral- versus radial-directed percutaneous coronary intervention related to unprotected left
main disease, chronic total occlusions, and acute myocardial infarction affirms the capabilities of a
transradial approach, reporting similar procedural success and clinical outcome.
In one of the most progressive fields of medicine, the radial approach to cardiac catheterization
and coronary intervention is part of the natural evolution of interventional cardiology. As
attention to procedural safety, cost containment, and patient-reported satisfaction increases, radial
vascular access represents a solution. To this purpose, the chapters in this book were developed
to inform the technical, procedural, and evidence-based aspects of transradial catheterization and
intervention for both beginning and advanced practitioners.

David E. Kandzari, MD, FACC, FSCAI

Director, Interventional Cardiology
and Chief Scientific Officer
Piedmont Heart Institute
Atlanta, Georgia

xi
 Abbreviations
ACC American College of Cardiology FARMI Five French Arterial access with
ACS acute coronary syndromes Reopro in Myocardial Infarction
ACT activated clotting time FDA Food and Drug Administration
ACUITY Acute Catheterization and Urgent Fr French
Intervention Strategy GI gastrointestinal bleeding
AHA American Heart Association GP glycoprotein
APR-DRG All Patient Refined Diagnosis GRACE Global Registry of Acute Coronary
Related Group Events
ASB access site bleeding GU genitourinary bleeding
A-V anterior-venous GUSTO Global Use of Strategies to Open
AVF arteriovenus fistulae Occluded Coronary Arteries
BA brachial artery Hgb hemoglobin g/dL
BARC Bleeding Academic Research HORIZONS-AMI Harmonizing Outcomes
Consortium with Revascularization and Stents in Acute
BMI body mass index Myocardial Infarction
CA coronary angiography ICH intracranial hemorrhage
CABG coronary artery bypass graft IIb/IIIa glycoprotein IIb/IIIa inhibitor
CAD coronary artery disease IMA internal mammary artery
CARAFE Coronary Angiography Through the INR international normalized ratio
Radial or Femoral Approach IQR interquartile range
CHF congestive heart failure IUCPQ Institut Universitaire de Cardiologie
CMS Centers for Medicare and Medicaid et de Pneumologie de Québec
Services IVUS intravascular ultrasound
COPD chronic obstructive pulmonary disease LAD left anterior descending coronary artery
CRUSADE Can Rapid Risk Stratification of LAO left anterior oblique
Unstable Angina Patients Suppress Adverse LCX left circumflex coronary artery
Outcomes with Early Implementation of the LMCA left main coronary artery
ACC/AHA Guidelines LMWH low-molecular-weight heparin
CTO chronic total occlusion LOS length of stay
CVA cerebrovascular accident LVEF left ventricular ejection fraction
DAP dose area product MACE major adverse cardiac events
DES drug-eluting stents MI myocardial infarction
DPA deep palmar arch M.O.R.T.A.L Mortality Benefit of Reduced
D2B door-to-balloon Transfusion after Percutaneous Coronary
EASY Early Discharge After Transradial Intervention via the Arm or Leg
Stenting of Coronary Arteries MRA magnetic resonance angiography
ECG electrocardiogram NCDR National Cardiovascular Data Registry
ECMO extra-corporeal membrane NHLBI National Heart, Lung, and Blood
oxygenation Institute
e-GFR estimated glomerular filtration rate NPO nothing by mouth
EPIC Evaluation of c7E3 for the Prevention NR not randomized
of Ischemic Complications
xiii
xiv ■ Abbreviations

NSTEMI non-ST-elevation myocardial RCT randomized clinic trial

infarction REPLACE-2 Randomized Evaluation in PCI
OASIS Organization to Assess Strategies for Linking Angiomax to Reduced Clinical
Ischemic Syndromes Events II
OCTOPLUS Comparison of Transradial RIVAL Radial vs. Femoral access for coronary
and Transfemoral Approaches for intervention
Coronary Angiography and Angioplasty in RIVIERA Registry on Intravenous
Octogenarians Anticoagulation In the Elective and Primary
OX pulse oximetry Real World of Angioplasty
PAF paroxysmal atrial fibrillation RP retroperitoneal bleed
PCI percutaneous coronary intervention SC single center
PL plethysmography SCAAR Swedish Coronary Angiography and
POBA plain old balloon angioplasty Angioplasty Register
PPC potentially preventable complications SCAI Society for Cardiovascular Angiography
PTCA percutaneous transluminal coronary and Interventions
angioplasty SPA superficial palmar arch
PURSUIT Platelet Glycoprotein IIb/IIIa in STEMI ST-elevation myocardial infarction
Unstable Angina: Receptor Suppression STRIDE Same-day Transradial Intervention
Using Integrilin Therapy and Discharge Evaluation
PVD peripheral vascular disease TEMPURA Test for Myocardial Infarction by
R retrospective data collection Prospective Unicenter Randomization for
RA radial artery, right atrium/atrial Access sites
RADIAL Radial vs. Femoral Access for TF transfemoral
Coronary Intervention TFA transfermoral approach
RADIAMI Radial vs. Femoral Approach for TIMI thrombolysis in myocardial infarction
Percutaneous Coronary Interventions in TR transradial
Patients with Acute Myocardial Infarction TRA transradial access, transradial approach
RAO radial artery occlusion UA ulnar artery
RAO right anterior oblique VCD vascular closure device
RCA right coronary artery
 chapter 1

Chapter title
Introduction

Lucien Campeau was the first to describe if one considers the “expert” high-volume
transradial access for diagnostic angiog- operator. This became particularly apparent in
raphy.1 Ferdinand Kiemeneij subsequently those patients with acute coronary syndromes
reported the use of transradial access requiring vigorous anticoagulation. In the
for percutaneous transluminal coronary most recently reported RIVAL trial, comparing
angioplasty (PTCA) and for stent implanta- transradial to transfemoral access, there was
tion.2,3 Early on, it became clear that one of a difference in access site complications in
the major advantages of transradial access those patients with acute coronary syndrome
was the elimination of access site complica- who required vigorous anticoagulation.
tions. Furthermore, patient preference and Furthermore, when stratified by radial
satisfaction has clearly favored the transradial percutaneous coronary intervention (PCI)
approach. volume per center, the high-volume centers
In 1997, Kiemeneij reported the results had significantly improved outcomes.5
of the ACCESS trial4 comparing the results Despite the apparent benefits of the
of transfemoral versus transbrachial versus transradial approach, the adoption of this
transradial access revealing the decreased technique has been slow, particularly in the
complications of the transradial approach United States. There are several reasons for
that have been replicated in virtually all this, not the least of which are the increased
subsequent trials comparing access site and technical aspects of this approach because
subsequent complication rates, especially of a smaller artery, a more difficult access

Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention

©2013 Howard A. Cohen (Editor). Cardiotext Publishing, ISBN 978-1-935395-41-6.
1
2 ■ Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention

to the central circulation, and a more diffi- As the editor, I have taken the liberty to
cult engagement of the coronary arteries add [Editor’s notes] in an effort to emphasize
compared to the transfemoral approach. In points or to give some additional perspective.
addition, most fellows receive good training in Chapter 2: Rationale for Transradial
the transfemoral approach with the transra- Access In this chapter, the authors describe
dial approach being taught in only a very few diagnostic angiography and percutaneous
training programs, although this appears to coronary interventions and why they play a
be changing rapidly. The “learning curve” for critical role in treating patients with ischemic
the transradial technique is steep, requiring heart disease. Over the past 2 decades,
approximately 200 cases for the operator advancements in pharmacotherapy, device
to feel completely comfortable with this therapy, and application of PCI have led to
approach for diagnostic as well as interven- significant improvements in outcomes. In
tional procedures. This will, of course, vary light of such advances in efficacy, maximizing
depending on the experience and the skill the safety of therapies and procedures has
of the individual operator. The majority of become a clinical priority. Bleeding and
operators in the United States do not perform vascular complications are a significant
200 cases per year, making it difficult for source of morbidity, mortality, and cost in the
them to attain and to maintain the necessary invasive treatment of coronary artery disease
skills to perform this technique. Conversely, and acute coronary syndromes in particular.
those operators who are performing multiple Studies indicate a significant reduction in
cases per day may find themselves “too access site bleeding and vascular complica-
busy” to master the skills necessary for this tions with the radial approach. These benefits
approach. are also associated with reduced mortality in
Any operator of reasonable talent, however, specific clinical settings and among patients
who is willing to spend the time required treated at experienced radial centers and
to learn the technique can acquire the skills by experienced operators. In addition, the
necessary to master the transradial approach. reduction in procedural complications is
The “learning curve” certainly can be flat- associated with decreased length of stay,
tened by spending time in a busy laboratory decreased hospital costs, decreased nursing
with experienced and dedicated transradial workload, and increased patient satisfaction.
operators. Wider adoption of transradial percutaneous
procedures has the potential to significantly
affect public health in a positive way.
Q HOW TO USE THIS BOOK Chapter 3: Vascular Anatomy of the Arm
and Hand This chapter recognizes that
The purpose of this textbook is to provide, radial access has emerged as an important
in one place, the necessary tools for the advance in vascular medicine and, when
already experienced transfemoral operator applied appropriately, it results in improved
and for the newly minted transradial operator outcomes and patient satisfaction. To safely,
to master this technique. In addition, the effectively perform this technique, under-
textbook is meant to be a resource to learn standing the vascular anatomy of the arm
new techniques for the already experienced and hand is essential. With this knowledge,
transradial operator. We have attempted to one can alertly identify and avoid potential
make this textbook rich in still frame images procedural pitfalls that may result from the
and video callouts that can be viewed at www. presence of vascular anomalies, variances
transradial.cardiotextpublishing.com in an in vascular supply and vessel diameter, and
effort to demonstrate the technical issues encroachments of tissue integrity. This broad
involved. In this regard, the textbook is avail- understanding will foster excellent success
able digitally so that the reader can readily while maintaining complication rates at a
access the links to the teaching videos. minimal level.
 chapter 1 Introduction ■ 3

Chapter 4: Preoperative Evaluation is an extremely successful technique that

of the Potential Patient for Transradial preserves the radial artery as an access site.
Access This chapter describes some of the Chapter 7: Basic Catheter Techniques
issues to be addressed before performing a for Diagnostic Angiography and PCI This
transradial procedure. Careful evaluation of chapter recognizes that patient selection,
the patency of hand collateral arteries via the appropriate use of right as opposed to left
ulnopalmar arch is a fundamental step before radial access, and thoughtful catheter selec-
radial artery cannulation. Using combined tion are crucial to easing the transition to the
plethysmography (PL) and oximetry (OX) for radial approach. The benefits of transradial
the evaluation of the hand collateral circula- access are well documented but are fully expe-
tion has the advantage of being fast, simple, rienced only with its routine use. A commit-
and objective while avoiding many of the ment to transradial access is essential.
pitfalls of the modified Allen’s test. Although Chapter 8: Sheathless Transradial
the modified Allen’s test could identify a large Intervention Sheathless guides are
proportion of patients suitable for transradial currently available outside the United States
approach in the authors’ series, PL and OX but not yet approved in the United States.
had a higher sensitivity. Using this method This chapter explains how the sheathless
during the last 15 years, including Type A, technique can be utilized with currently
B, and C patterns, the authors have seen no available technology. As the guide’s outer
ischemic hand complications in case of radial diameter is 2-Fr sizes smaller than the sheath,
artery occlusion after a transradial procedure. a 7-Fr guide used without a sheath can be
Chapter 5: Obtaining Access Transradial exchanged, for example, for a 5-Fr sheath over
access is technically more difficult than a long guidewire without upsizing the access
transfemoral access because of the size of site. The advantages and disadvantages of this
the artery, the increased incidence of severe approach are discussed.
spasm, and anatomic variation such as loops Chapter 9: Transradial Access and
and tortuosity. Nevertheless, the technique Outpatient PCI: State-of-the-Art and
can be easily learned and mastered if the Persisting Challenges This chapter explains
operator is committed. This chapter describes that same-day-discharge practice after
the techniques that can be used to successfully uncomplicated PCI is both safe and extremely
obtain radial access as well as access to the effective in selected patients. In this regard,
central circulation, particularly when there is the transradial approach offers a tremendous
difficult anatomy. advantage over the standard femoral approach
Chapter 6: Closure and Hemostasis after as hemostasis can be obtained while the
Transradial Access This chapter explains patient is already ambulatory. As hemostasis
why hemostasis after radial artery access is usually completed within 2 hours of
is a simple, highly successful, cheap, and radial access, it remains prudent to have an
extremely effective portion of the transradial observation period of 4 to 6 hours to detect
procedure. Its effect on subsequent radial any severe complications prior to hospital
artery occlusion is frequently unrecognized discharge. Because a recent survey revealed
and needs to be underscored, with special that fewer than 50% of radial operators in
attention paid to maintenance of radial artery the world discharge patients the same day of
flow throughout hemostatic compression in the procedure, several nonmedical issues and
order to prevent radial artery occlusion. Radial obstacles remain to be resolved in order to
artery occlusion, although asymptomatic from promote outpatient practice.
an ischemia standpoint, eliminates the use of Chapter 10: Transradial Access for PCI
that radial artery in the future. Radial artery in Acute Myocardial Infarction This
occlusion deprives the patient of a low-risk chapter discusses how treating acute coronary
vascular access site for future percutaneous patients with the combination of medical
coronary intervention. Patent hemostasis therapy and revascularization has improved
4 ■ Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention

mortality in the ACS setting. However, despite on how central venous access can actually be
these remarkable advances, these patients readily obtained using forearm veins. Whether
are among those at highest risk for bleeding needed for catheter-based hemodynamic
complications following interventional monitoring or diagnosis, for temporary pacing
procedures. Furthermore, considerable during periods of iatrogenic bradycardia from
recent evidence suggests that bleeding in interventional techniques, or for a trans-
the ACS setting increases MACE and death, venous interventional procedure, forearm
and reducing bleeding should now be made venous access can provide a reliable and safe
a priority. As such, the authors recommend entry site to complement or complete the
that the approach to care of patients with ACS transradial procedure. Venous access from the
further evolve with efforts to reduce bleeding. forearm can be accomplished efficiently and
The authors’ approach to revascularization without compromise by avoiding otherwise
in the ACS setting is to consider all patients riskier anatomical approaches. Understanding
eligible for TRA and have a thoughtful process venous techniques and recognizing this
behind choosing radial access. Transradial PCI important adjunct to transradial interventions
has been shown in multiple trials to achieve completes the operator’s radial skills and
equal success rates without prolonging door- further advances the potential of transradial
to-balloon times in the setting of ST-elevation interventions.
myocardial infarction. Despite trends toward Chapter 13: The Learning Curve for
lower rates of mortality by radial access Transradial Access Use of the transradial
utilization, further trials are still necessary route in interventional cardiology procedures
to precisely define the benefit. Nonetheless, may practically eradicate the occurrence
improved patient satisfaction and the poten- of arterial access complications with their
tial for decreased bleeding complications are subsequent effects on mortality, morbidity,
compelling reasons to increase utilization of disability, and health care costs. Such improve-
transradial PCI in this clinical population. ments may be achieved with a modest increase
Certainly, several studies have shown that in x-ray exposure for coronary angiography
there is a learning curve with TRA, and the (decreased with increasing experience), but
authors recommend that operators be profi- without any increase in procedural time,
cient with TRA in the elective setting prior to patient or operator irradiation for coronary
attempting in ACS patients. In addition, the angioplasty, or any differences in terms of
authors advocate for identifying patients at efficiency in almost all patients and all clinical
risk of bleeding using the predictive models and technical settings.
discussed in this chapter. This will help to However, these results can only be
identify those patients who are at highest risk achieved after completion of a long learning
for bleeding and those who may benefit the curve. Thanks to the multiple training oppor-
most from bleeding-avoidance strategies such tunities available and after appropriate patient
as TRA. selection, a good command of clinical and
Chapter 11: Transradial Approach to technical predictors of failure allows trans-
Peripheral Interventions In this chapter, radial operators to obtain rapidly acceptable
the authors explain how peripheral vascular success rates, procedural durations, and x-ray
interventions can be safely performed using exposure. This may encourage colleagues,
the radial artery as an access point. This coworkers, paramedics, patients, and hospital
approach is particularly beneficial because the managers to support widespread use of this
patients with severe peripheral arterial disease vascular approach.
are at higher risk for access site complications. Chapter 14: Transradial Arterial Access:
The main limitation to this approach is the Economic Considerations Transradial
lack of equipment that could easily access arterial access for coronary and peripheral
every vascular bed, particularly at the level of arterial procedures provides economic
superficial femoral artery and tibial vessels. advantages compared to transfemoral arterial
Chapter 12: Right Heart Catheterization access. Significant benefit is realized through
and Transradial Access This chapter focuses decreased vascular and bleeding complications
 chapter 1 Introduction ■ 5

that are associated with added expenses Chapter 17: How to Start a Transradial
related to diagnosis, treatment, and prolonged Program at Your Hospital As the
length of stay. Decreasing vascular complica- chapter title indicates, the authors offer
tions is especially relevant in today’s health advice on how to start a transradial program
care environment, given the emergence of at your hospital. Transradial catheterization is
value-related reimbursement. Early and safe increasingly being used throughout the world.
mobility following TRA also confers economic Patient satisfaction and lower complication
advantage by decreasing nursing require- rates have driven the transition for many
ments, improving patient flow efficiency, and femoral access laboratories to primarily radial
facilitating safe outpatient PCI. operations. With adequate preparation and
Chapter 15: Tips and Tricks for Transradial perseverance through the learning curve,
Access In this chapter, the authors try to the radial approach can become the primary
resolve practically all important issues related means of catheterization for all except large
to TRA. The tips and tricks discussed here sheath and some limited peripheral access
shall help both beginners and experienced procedures. As newer technologies specifically
operators. To become a “committed radialist,” designed for the transradial approach come
a person needs to go through a process known to market, radialists will have an even greater
as “a new learning curve” and understand range of procedures that they can perform.
normal vascular anatomy of the region, Careful introduction of the radial technique
acquired variations, and congenital anomalies. should make the transition relatively
Chapter 16: Complications of Transradial seamless.
Access As with other aspects of medical We have attempted to present a compre-
practice, awareness of complication possibili- hensive approach and perspective, and I am
ties, knowledge of appropriate preventive and certain that those who are committed to and
corrective actions, and recognition of actual have an abiding interest in this technique
adverse events are the keys to a transradial will continue to learn along the way. We all
interventional practice characterized by a hope that this textbook will be a valuable
minimum of complications. resource for the transradial operator, whether
The principal benefit of radial artery access a neophyte or an expert.
for angioplasty is the added safety it offers.
This chapter describes how the complications
are less frequent than with femoral artery Q REFERENCES
access, but they can still occur and can be very
1. Campeau L. Percutaneous radial artery approach
serious. Common complications include radial for coronary angiography. Cathet Cardiovasc Diagn.
artery spasm, sterile granuloma develop- 1989;16:3–7.
ment, and radial artery occlusion (transient 2. Kiemeneij F, Laarman GJ. Percutaneous transradial
or persistent), which are generally benign in artery approach for coronary stent implantation.
Cathet Cardiovasc Diagn. 1993;2:173–178.
nature; the risk of all these complications can
3. Kiemeneij F, Laarman GJ, et al. Transradial artery
be readily diminished with simple measures coronary angioplasty. Am H J. 1995;129(1):1–7.
easily incorporated into routine practice. More 4. Kiemeneij F, Laarman GJ, et al. A randomized
serious vascular complications include the comparison of percutaneous transluminal coronary
development of a forearm hematoma with angioplasty by the radial, brachial and femoral
approaches: the ACCESS study. J Am Coll of Cardiol.
compartment syndrome, which stands as
1997;29(6):1269–1275.
the most important to recognize quickly and 5. Jolly SS, Yusuf S, et al. Radial vs. femoral access for
manage correctly because it can lead quickly coronary angiography and intervention in patients
to permanent neurologic injury. Surgical with acute coronary syndromes (RIVAL): a random-
decompression of the forearm compartment ized, parallel group, multicentre trial. The Lancet.
2011;377(9775):1409–1420.
is the mainstay of therapy for this problem.
Radial artery pseudoaneurysms and arterio-
venous fistulae are rare but can cause forearm
perfusion problems and discomfort and often
require surgical intervention for repair.
 chapter 2

Rationale for
Chapter title
Transradial Access

Robert W. Harrison, MD
Sunil V. Rao, MD

Q INTRODUCTION infarction has highlighted concerns about

safety, particularly with regard to peripro-
Diagnostic angiography and percutaneous cedural bleeding. Post-PCI bleeding has
coronary interventions (PCIs) are the most emerged in recent years as a significant
commonly performed invasive cardiac proce- clinical concern due to its strong and consis-
dures and have an integral role in diagnosing tent association with death, (re)infarction,
and treating the entire spectrum of coronary stroke, and stent thrombosis.3–5 Bleeding
artery disease—from stable refractory angina complications after PCI can occur both at
to acute myocardial infarction. Since the the vascular access site and remote from the
1950s, there have been significant advances access site. Implementing specific therapeutic
in catheter design, interventional devices, strategies can reduce the risk for both types
and adjunctive pharmacotherapy such that of bleeding. The focus of this chapter is to
procedures are routinely performed on outline the role of radial artery access for PCI
higher-risk patients with low rates of compli- in reducing bleeding risk. By virtually elimi-
cations.1,2 Evolution in the use of potent nating access site bleeding, transradial PCI is
adjunctive antiplatelet and antithrombotic associated with markedly reduced procedural
therapies has played an important role in complications and, in some clinical settings,
improving outcomes after PCI. However, the reduced mortality.
widespread application of PCI to high-risk
patients such as those with acute myocardial

Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention

©2013 Howard A. Cohen (Editor). Cardiotext Publishing, ISBN 978-1-935395-41-6.
7
8 ■ Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention

Q DEFINING BLEEDING AND incidence of these events. Vascular complica-

tions are obviously related directly to the
VASCULAR COMPLICATIONS access site, whereas bleeding complications can
A discussion of bleeding and vascular compli- be either access site related or non-access site
cations is not complete without summarizing related. Based on the available data, bleeding
how these events are defined. Definitions have complications are more common than vascular
a significant effect on the measured incidence complications, but they are not mutually
of complications. For example, an extremely exclusive events and often occur together.
conservative definition of bleeding—one that Access site bleeding accounts for a
includes data elements that reflect severe significant proportion of the bleeding events
blood loss—can lead to very low rates of associated with elective PCI (Figure 2.1).
reported bleeding because severe blood loss Kinnaird et al performed a retrospective
is relatively rare in current clinical practice. analysis of 10,974 patients who underwent
On the other hand, a liberal definition of elective or urgent PCI at a single center
bleeding—one that includes data elements between 1991 and 2000. In this analysis,
reflecting mild or modest blood loss—can major bleeding was based on the thrombolysis
result in higher rates of reported bleeding. in myocardial infarction (TIMI) criteria. They
Table 2.1 lists the definitions of bleeding used found that 588 (5.4%) patients had major
in several clinical trials. Therefore, standard- bleeding, and 1,394 (12.7%) had minor
izing bleeding definitions has become a bleeding. Four hundred (68%) of the major
priority.6 Standardization efforts have focused bleeds (370 hematomas and 30 retroperi-
on the fact that bleeding occurs in several toneal bleeds) and 834 (60%) of the minor
different settings—access site, non-access bleeds (823 hematomas and 11 retroperito-
site, coronary artery bypass graft (CABG)- neal bleeds) were related to the arterial access
related, and so on. site.7 Verheugt et al8 performed a pooled
Although the definition of a vascular analysis of 17,393 patients enrolled in the
complication is likely to have a similar effect REPLACE-2, ACUITY, and HORIZONS-AMI
on the reported incidence, this area has trials. All of these trials assessed bleeding
not been the subject of as much scrutiny. using the TIMI major and minor criteria (in
Although most operators are likely to agree addition to other criteria). Overall, there were
that arteriovenous fistulae or pseudoaneu- 357 episodes (2.1%) of access site bleeding
rysms are clinically important vascular compli- and another 145 episodes of combined access
cations, whether an access site hematoma is and non-access site bleeding (0.8%). Results
considered a “clinically significant” vascular from similar pooled analyses from PCI trials
complication would likely be debatable. As will are shown graphically in Figure 2.1. This
be detailed later in this chapter, specific types demonstrates that the proportion of access
of vascular complications are associated with site-related and non-access site-related bleeds
an increased risk for short- and long-term are dependent on the baseline risk of the
adverse outcomes. patient population. That is, in the elective
PCI setting where upstream antithrombotic
therapy is rarely used, access site bleeds are
Q INCIDENCE OF ACCESS SITE predominant; in contrast, in the setting of
BLEEDING AND VASCULAR acute coronary syndrome, non-access site
bleeding accounts for a greater proportion of
COMPLICATIONS overall bleeding events (see Table 2.1).
Despite the influence of definition on the Data on vascular complications are
reported rates of bleeding and vascular compli- more difficult to come by because they are
cations, one can look to both clinical trials not systematically captured in clinical trial
and observational studies to determine the databases. However, some clinical trials and
 chapter 2 Rationale for Transradial Access ■ 9

Table 2.1 Bleeding Definitions Used in Acute Coronary Syndrome Clinical Trials.

TIMI34
Major Intracranial hemorrhage
Bleeding resulting in a t 5 g/dL decrease in the hemoglobin concentration or in a t 15%
absolute decrease in the hematocrit
Minor Observed blood loss: t 3 g/dL decrease in the hemoglobin concentration or t 10% decrease
in the hematocrit
No observed blood loss: t 4 g/dL decrease in the hemoglobin concentration or a t 12%
decrease in the hematocrit
Minimal Any clinical overt sign of hemorrhage (including imaging) associated with a  3 g/dL
decrease in the hemoglobin concentration or a  9% decrease in the hematocrit

GUSTO34
Severe or Life-Threatening Intracranial hemorrhage
Bleeding that causes hemodynamic compromise and requires intervention
Moderate Bleeding that requires blood transfusion but does not result in hemodynamic compromise
Mild Bleeding that does not meet criteria for either severe or moderate bleeding

ACUITY and HORIZONS-AMI6

Major Intracranial or intraocular hemorrhage
Access site hemorrhage requiring intervention
Hematoma t 5 cm in size
Retroperitoneal hemorrhage
Reduction in hemoglobin concentration t 4 g/dL without overt source
Reduction in hemoglobin concentration t 3 g/dL with overt source
Reoperation for bleeding
Use of any blood product transfusion

OASIS-235
Major Fatal bleeding
Intracranial hemorrhage
Bleeding requiring surgical intervention
Bleeding that requires t 4 units of blood or plasma expanders
Bleeding judged to be disabling or requiring 2 or 3 units of blood
Minor All other bleeding events

CURRENT-OASIS 76,36
Severe Requiring transfusion t 4 units of PRBC or equivalent whole blood
Resulting in hemoglobin decrease t 5 g/dL
Leading to hypotension requiring inotropes
Requiring surgery
Symptomatic intracranial hemorrhage
Fatal bleeding
Other Major Requiring transfusion of 2–3 units of blood
Minor Other bleeding that leads to modification of drug regimen
Other Bleeding not meeting criteria for major or minor

Continued
10 ■ Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention

Table 2.1 Continued

RIVAL10
Major Fatal bleeding
Intracranial and symptomatic or intraocular with significant vision loss
Resulting in transfusion of t 2 units of PRBC or whole blood
Causing substantial hypotension requiring inotropes
Requiring surgical intervention (surgical access site repair qualifies if associated with
substantial hypotension or transfusion of t 2 units of blood)
Resulting in severely disabling sequelae
Resulting in t 5 g/dL decrease in hemoglobin concentration
ACUITY N on-CABG Major RIVAL major bleeding
Large hematoma (per investigator’s clinical judgment)
Pseudoaneurysm requiring intervention
Minor Bleeding not meeting definition for major bleeding and requiring transfusion of 1 unit of
blood or modification of drug regimen

several large regional and national quality is not without serious consequence and is
improvement registries do capture PCI-related predictive of adverse procedural outcome and
vascular complications. For example, Rao et al mortality.13
reported on the incidence of vascular compli-
cations (defined as arterial occlusion, periph-
eral embolization, arterial dissection, arterial Q NON-ACCESS SITE-RELATED
pseudoaneurysm, or arteriovenous fistula
formation) from the National Cardiovascular
BLEEDING
Data Registry (NCDR), which collects Bleeding that is unrelated to arteriotomy
outcomes in PCI procedures from more than occurs primarily due to the use of adjunctive
600 sites across the United States. In their antithrombotic and antiplatelet agents in a
analysis of 585,290 transfemoral cases, the population at risk for bleeding, such as the
combined incidence of vascular complications elderly, females, and those with ACS. Verheugt
with a transfemoral approach was 0.7%. The et al, in their analysis of the REPLACE-2,
incidence of complications was highest in ACUITY, and HORIZONS-AMI clinical trials,
the elderly (! 74 years old, 1.0%), women report that 61% of bleeding events were
(1.1%), and ST-elevation myocardial infarction not related to the access site—an overall
(STEMI) patients (0.8%).9 The RIVAL study incidence of 3.3%.8 Approximately half of the
comparing the radial and femoral approaches non-access site bleeding could not be local-
to angiography and intervention among acute ized to a specific site. Of those events that
coronary syndrome (ACS) patients captured could be localized, genitourinary bleeding
vascular complications in detail.10 In this trial, occurred in 18%, followed by gastrointestinal
3.7% of patients had major vascular complica- in 15%, head and neck in 10%, and pulmonary
tions—defined as a large hematoma, develop- in 1%.8 The RIVAL trial showed a similar
ment of a pseudoaneurysm or atreriovenous proportion of access site to non-access site
fistula, or an ischemic limb requiring surgery. major bleeding. Non-CABG major bleeding
However, the majority of these complications was defined as per Table 2.1. Overall, the non-
were hematomas. Excluding these, there was a CABG major bleeding rate was 0.8%, with 70%
vascular complication rate of 0.7%—similar to of these occurring distant from the access site.
the results described in the NCDR. It should Specifically, gastrointestinal bleeds accounted
be noted, however, that a large hematoma, for 27%, followed by intracranial and pericar-
particularly one that requires transfusion, dial bleeding.10
chapter 2 Rationale for Transradial Access ■ 11

Figure 2.1 Rates of

access site and non-
access site bleeding
in PCI and ACS clinical
trials. Rates of overall
and access site-related
bleeding in a sample of
PCI trials (REPLACE-2 and
ESPRIT) (A); non-ST-
segment elevation acute
coronary syndrome trials
(PARAGON A, PARAGON
B, GUSTO IIb non-ST-
segment elevation
cohort, PURSUIT, and
SYNERGY) (B); and
ST-segment elevation
myocardial infarction
clinical trials (GUSTO I,
GUSTO IIb ST-segment
elevation cohort, GUSTO
3, HERO-2, and ASSENT-2)
(C). Source: Rao SV,
Cohen MG, Kandzari DE,
Bertrand OF, Gilchrist IC.
The transradial approach
to percutaneous
coronary intervention:
historical perspective,
current concepts, and
future directions. J Am
Coll Cardiol. May 18
2010;55(20):2187–2195.
12 ■ Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention

Q ASSOCIATION BETWEEN BLEEDING included in these trials. At least one bleeding

event occurred in 27.6% of the patients. Mild
AND OUTCOMES bleeding occurred in 16.6%, with moderate
and severe bleeding occurring in 9.8% and
Mortality 1.2%, respectively. After multivariate analysis,
Multiple registry and clinical trial analyses bleeding was associated with increased risk
have demonstrated bleeding to be associated of death at 30 days, death or myocardial
with short- and long-term morbidity and infarction (MI) at 30 days, and 6-month
mortality. In a retrospective “real world” mortality with a “dose response” increase
sample of 10,974 patients undergoing PCI, in the risk from mild to severe bleeding.
Kinnaird and colleagues found that major Figure 2.2 shows the relationship between
bleeding was associated with increased mortality and the various levels of GUSTO
in-hospital mortality (odds ratio 3.5), and bleeding. Bleeding is not only associated
blood transfusion was associated with with increased risk of death after MI, but the
increased 1-year mortality (odds ratio level of risk has been shown to be equivalent
1.9).7 Rao et al demonstrated similar associa- to that associated with having a recurrent
tions in a clinical trial population consisting MI.12 Furthermore, the risk associated with
of ACS patients.11 In this study, patients were bleeding appears persistent beyond 30 days
pooled from 4 large acute coronary syndrome after the event, unlike the risk associated with
trials—GUSTO IIb, PARAGON A and B, and MI, which is manifest only within the 30 days
PURSUIT. A total of 26,452 patients were after the event.12

Figure 2.2 Effect of bleeding severity on mortality. Kaplan-Meier estimates of 30-day survival
among patients enrolled in the GUSTO IIb, PURSUIT, PARAGON A, and PARAGON B clinical trials.
Survival curves are stratified by GUSTO bleeding category. Log-rank P values are < .0001 for all
4 categories, .20 for no bleeding versus mild bleeding, < .0001 for mild versus moderate bleeding,
and < .001 for moderate versus severe bleeding. Source: Rao SV, O’Grady K, Pieper KS, et al. Impact of
bleeding severity on clinical outcomes among patients with acute coronary syndromes. Am J Cardiol.
2005;96:1200–1206.
 chapter 2 Rationale for Transradial Access ■ 13

Access site and non-access site bleeding exsanguination, which is exceedingly rare
are both associated with increased mortality, after PCI, can lead to adverse outcomes simply
with the latter portending a worse prognosis. through blood loss. Similarly, bleeding in
Verheugt et al discriminated between the closed spaces such as the cranium or peri-
outcomes associated with access and non- cardial space can lead directly to mortality
access site bleeding. As mentioned previously, through either neurological compromise or
61% of the bleeding events in this study were hemodynamic embarrassment. Other, more
not related to the access site. The adjusted common types of bleeding are associated with
mortality risk was elevated with both access worse outcomes likely through secondary
site-only bleeding (hazard ratio 1.8) and non- mechanisms. As such, they may not be
access site bleeding (hazard ratio 3.9), although directly causing the outcome. For example,
the risk attributable to non-access site evidence-based antiplatelet and antithrom-
bleeding was significantly higher.8 Similarly, botic therapies are commonly discontinued
data from the National Heart, Lung, and in the setting of bleeding, and patients are
Blood Institute (NHLBI) Dynamic Registry less likely to leave the hospital on guideline-
supports the association between access site based antiplatelet therapy if they experienced
complications and mortality.13 After adjusting in-hospital bleeding.15 Patients with bleeding,
for multiple variables, hematomas requiring depending on the definition used, are also
transfusion emerged as an independent more likely to receive blood transfusions.
predictor of death at 30 days (odds ratio 3.6) There is mounting evidence of the harm
and 1 year (odds ratio 1.7). Retroperitoneal associated with transfused blood, which may
hematomas resulting from transfemoral access be related to impaired nitric oxide bioactivity
have also been implicated in worsened clinical and oxygen delivery in banked blood.16
outcomes.14

Q EFFECT OF TRANSRADIAL
Nonmortal Clinical Outcomes
Aside from mortality, hemorrhagic complica-
ACCESS ON BLEEDING AND
tions are also associated with myocardial CARDIOVASCULAR OUTCOMES
infarction, stroke, and stent thrombosis.
Eikelboom et al evaluated 34,416 patients Radial Access and Bleeding
with acute coronary syndromes from the Utilizing the radial artery for PCI is associ-
OASIS registry, OASIS-2 trial, and CURE trial. ated with a marked reduction in access site
Major bleeding occurred in 2% of patients. bleeding due to its superficial location, lack
Similar to other studies, mortality was higher of adjacent vascular structures, and ease
in the group who had major bleeding both of compressibility. A significant amount of
at 30 days and at 6 months. However, they evidence has accumulated from observational
also showed an increase in the rates of stroke and randomized clinical trials to support
and myocardial infarction at 30 days (hazard a decrease in bleeding with the transradial
ratios 6.5 and 4.5, respectively).4 Manoukian approach. Rao et al analyzed the NCDR and
et al, in an analysis of the ACUITY trial, compared rates of procedural success and
demonstrated that bleeding is also associated bleeding events between 7,804 transradial and
with an approximate 5-fold increase in stent 585,290 transfemoral cases.9 After adjusting
thrombosis in patients undergoing an invasive for NCDR risk score, gender, antithrombotic
strategy for acute coronary syndromes.5 use, and glycoprotein IIb/IIIa use, they found
that the transradial approach was associ-
ated with a 62% reduction in the risk for
Putative Mechanisms postprocedural bleeding compared with the
The mechanism by which bleeding may transfemoral approach. Procedural success
contribute to these adverse outcomes was similar between the 2 cohorts. The
is complex and multifactorial. Frank association between the transradial approach
14 ■ Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention

and decreased bleeding was more pronounced was 1.7% and 1.0% for transfemoral and
in younger (age  75) patients, women, and transradial cases, respectively. Similarly, 1-year
patients with non-ST-elevation myocardial mortality was 3.9% and 2.8%, respectively.
infarction (NSTEMI). Interestingly, among After adjustment for potential confounders,
the 241 STEMI cases who had transradial transradial access was associated with a
catheterizations, there were no bleeding significant 17% reduction in 1-year mortality.
events or vascular complications, compared Interestingly, blood transfusion emerged as
with rates of 3% and 0.8%, respectively, in the most powerful predictor of mortality at
the transfemoral cohort. A meta-analysis 1 year.18 After accounting for transfusion,
of 23 randomized clinical trials comparing the association between radial approach
the radial and femoral approaches to PCI and mortality was significantly attenuated,
showed similar findings with a 73% decrease suggesting that the reduction in transfu-
in bleeding among patients assigned to the sion was the mechanism that explained the
radial approach.17 In addition, the absolute mortality reduction. The RIVIERA (Registry
risk reduction in bleeding with transradial on IntraVenous anticoagulation In the Elective
access was highest for primary or rescue PCI and primary Real world of Angioplasty) study
for STEMI (3.1% absolute risk reduction). The evaluated patients enrolled in a multinational
rates of vascular complications in the RIVAL registry of PCI, with a focus on the effect of
trial, which randomized more than 7,000 ACS anticoagulant use on outcomes. The study
patients undergoing angiography or inter- enrolled 7,962 patients, and 11% of the
vention to transradial versus transfemoral procedures were performed via the radial
access, were significantly lower in transradial approach. Independent variables associated
patients (1.4% vs. 3.7%)—one major vascular with a decrease in the primary endpoint of
complication was prevented for every 43 tran- in-hospital death or myocardial infarction
sradial cases performed.10 Together, these included the use of enoxaparin, PCI of the
analyses suggest that procedural success rates left anterior descending artery (LAD), use of
are similar for transradial and transfemoral nitrates, pretreatment with thienopyridines,
cases, but the radial approach is associated and radial access. Of these, radial access was
with significantly lower access site bleeds associated with the most significant reduction
and vascular complications, and this benefit with an adjusted 84% reduction in in-hospital
increases as the risk for bleeding increases. death or MI. Notably, radial access was also
the only variable independently associated
with a reduction in bleeding events.19 The
Radial Access and Nonbleeding consistency of these analyses strongly
Clinical Outcomes suggests that, in certain populations, radial
Given the well-established association access is associated with a significant reduc-
between bleeding and adverse clinical tion in mortality, primarily driven by a reduc-
events, it is reasonable to hypothesize that tion in periprocedural bleeding. However,
the transradial approach may be associ- given the observational nature of the studies,
ated with reduction in nonbleeding clinical causality should not be inferred.
outcomes. Two large contemporary registry Prior to 2009, there were approximately
analyses have supported this hypothesis. The 23 small, randomized controlled trials investi-
M.O.R.T.A.L (Mortality benefit Of Reduced gating the benefits of transradial access, with
Transfusion after percutaneous coronary 12 of these reporting mortality, stroke, or MI
intervention via the Arm or Leg) study linked as a clinical endpoint. Jolly et al performed
a prospective PCI registry with transfusion a meta-analysis of these trials and showed
records and outcomes including 30-day a trend toward reduction in the combined
and 1-year mortality. Of the 38,872 cases endpoint of death, MI, or stroke with the
identified, 20% were performed via the radial radial approach compared with the femoral
approach. Approximately three-quarters were approach, but this did not reach statistical
urgent or emergent cases. Mortality at 30 days significance.17 The overall odds ratio was
Exploring the Variety of Random
Documents with Different Content
 152 A VISIT TO CEYLON. be desired, whether by water or
by land. A railway is projected between Kandy and Trincomalie, but
is not yet begun. As Kandy is, as nearly as may be, half-way
between the eastern and western coasts, and has long been
connected with the western side by the Colombo railway, the
extension of the line to the east coast seems indispensable,
particularly when we consider the great strategical importance of
Trincomalie and the superiority of its harbour, which is but little used
by the mercantile marine. Tn spite of all this, Trincomalie can still
only be reached from Kandy by a very difficult and fatiguing road,
passing day after day through dense and uninhabited forests. At the
beginning of December, too, when I wanted to make the journey,
this road was in a particularly bad state. The heavy rain-fall
accompanying the south-west monsoon had swept away many of
the bridges, and made large tracts impassable; I could not but fear
that the bullock- carts, which would have to carry my sixteen cases
of instruments, etc., would stick on the way, or only arrive after
much delay and with much damage. Nor was the sea-voyage more
promising. The Government despatches a small steamship, the
Serendih, every month to make the circuit of the island, taking the
northern half and the southern half first, alternately. This little
coasting vessel is the only means of regular and direct
communication between the principal places on the coast, otherwise
there is no intercourse, but by very uncertain and infrequent sailing
boats. As ill-luck would have it, at the very time when I wanted to
go to Trincomalie by the Serendib, it had suffered serious damage in
a storm, and had gone to Bombay for repairs. Thus, in the first
place, I
 THE ROAD FROM COLOMBO TO GALLL. 153 had to
postpone my visit to Trincomalie till a later date, and then, to my
great regret, in consequence of other hinderances, the plan could
not be carried out at alL For the moment, then, I had no choice but
to set out for the south coast, and set up my zoological laboratory
either at Galle, or at BeHigam. Galle, or Point de Galle, the most
important seaport in the island, having been till within a few years
the stopping station for all Indian travellers, and the place where
European voyagers landed and embarked, offered the advantages of
European civilization in procuring the necessaries of life and
intercourse with cultivated English society. I might count on being
able to fish in the fine large harbour in European boats, on finding
an abundance of interesting marine creatures on its celebrated coral
reefs, and on studying and preserving them with comparative ease
and convenience. Tliere would also be the advantage that other
naturalists had worked there before me, and I should have the
benefit of their experience of the locality and of its animal life.
Ransonnet's fine work especially contains much valuable information
as to the coral reefs of Galle. The prospects offered by Belligam
were widely different. Its beautiful and sheltered bay — fifteen miles
further south than Galle, and half-way between this and Matura, the
southernmost point of the island — might be expected to resemble
Galle as regards its coral banks and other topographical and
zoological conditions; it had also, as being rarely visited and little
studied, all the additional charm of the new and unknown. The
tropical vegetation and the scenery generally were, from all I had
read and heard, richer and more beautiful even than at Galle. To me.
tho
 154 A VISIT TO CEYLON. greatest temptation of all was
that after some months of the restraint of our artificial social life I
should there escape it entirely ; I could look forward to giving myself
up in perfect liberty to the delights of the lavish nature of the
tropics, to living in the midst of the simple children of nature, and
forming some conception of that visionary primaeval paradise into
which the human race was bom. For Belligam is nothing more than a
large, purely Cinghalese village, inhabited by fishermen, herdsmen,
and tillers of the soil. But few of these four thousand swarthy
natives, among whom there are no Europeans, inhabit the village
itself on the shore of the bay ; most of them live in scattered huts,
dotted here and there on a broad level, covered with a magnificent
wood of cocoa-nut trees. I should be able to pursue my
investigations more steadily and with less interruption in the quiet
and secluded rest-house of Belligam, than in the busy town of Galle
among a crowd of kind friends and inquisitive acquaintances. Of
course, I was prepared to meet with greater difficulties in arranging
my laboratory and in carrying on my work ; in fact, it was not
impossible that unforeseen and insuperable obstacles might more
easily occur there than in Galle to put a stop to it. After much
hesitation, and long debating the pros and cons, I finally decided for
Belligam, and I had no reason to egret the choice. The six weeks I
spent there were full to overflowing of wonderful experiences, and
never to be forgotten as forming the crowning " bouquet " of my
Indian journey, the sweetest and brightest flowers in a garland of
delightful memories. Though I might perhaps have carried on my
zoological studies better and more conveniently in Galle, I gained
infinitely more on the side of general know 
 THE EOAD FROM COLOMBO TO GALLE. 155 ledge of nature
and humanity in the charming seclusion of Belhgam. I had, of
course, to make considerable preparations for so long a stay in a
remote fishing village. As the only possible residence for a European
was the Government resthouse, and as no one is ever allowed to
stay in these hostelries for more than three days, I had, in the first
place, to obtain leave to reside there for several weeks. Sir James
Longden, the governor of the island, to whom I had been
\)articularly recommended by the English Government — and to
whom I here beg to record my gratitude for his kind reception —
gave me a letter of introduction to the president of the southern
district, which not only secured me this permission, but enjoined
each and every government official to be in all respects civil and
serviceable to me. Under the pattern regularity and discipline which
prevails in all the machinery of government throughout the English
colonies, as well as in the mother country, such a letter of
recommendation is not only an invaluable, but in many cases an
indispensable talisman. This is especially the case in Ceylon, since
the government of the island is independent of that of India, and
under the direct authority of the Colonial Office in London; the
governor is pretty nearly an unlimited monarch, and troubles himself
but little with the decisions of his parliament of councillors. Most of
the defects in the administration of afi'airs under which this fine
island suffers are attributed to this absolute power of an individual,
and it is certainly not at all to the taste of the constitutional English.
One of the worst faults in the system, however, is that the governor
never remains in office for more than four years — much too short a
period ;
 156 A VISIT TO CEYLON. hardly enough, indeed, to enable
him to know the island thoroughly. Still, under the peculiar
conditions of -a population consisting of two and a half millions, of
which only three thousand are Europeans, the concentration of
power in one person has many advantages. On the whole, a closer
intimacy with the state of affairs in Ceylon confirmed me in the
feeling that here, as in their other colonies, the practical instinct of
the English hits on the right method, and manages the
administration with greater diso'etion and insight than would be
possible to most other civilized nations. After providing myself with
some letters of introduction to Galle and making numerous
purchases for fitting up my lodgings at Belligam, I stowed my
sixteen boxes in a large two- wheeled bullock cart, which was to
transport them to Galle within a week. These bullock-carts are the
universal conveyance wherever there are roads on which they can
travel ; the largest can carry as much as two tons on their two huge
wheels, and are pulled by four strong humped oxen, or zebus, of the
largest breed. The yoke is not fixed across the front of the head but
across the neck, just in front of the hump which bears the weight.
The cart is covered with an arched tilt of plaited leaves of the cocoa-
nut, and this thick double matting protects the freight within against
the heaviest rain. Mats of the same material are hung in front and
behind to close the awning. The cargo must be so skilfully packed
and balanced that the centre of gravity rests in the middle over the
axle of the single pair of wheels. The driver sits on the shaft close
behind the beasts, or somotimes between them ; he never ceases
urging them by
 THE ROAD FROM COLOMBO TO GALLE. 157 shouts, or by
rubbing their tails between their legs. Hundreds of these bullock-
carts, some drawn by two and some by four zebus, are the living
accessories of every road scene in Ceylon. Among these, at a
quicker pace and sometimes even at a brisk trot, run the lighter
bullock-carts — " bullockbandys," or " hackeries." These are smaller
vehicles of the same shape, and drawn by a pretty and fairly swift
bullock of a smaller breed. On the 9th of December I left the
hospitable roof of " Whist Bungalow," followed by the good wishes
and not less good advice of my kind friends. The journey from
Colombo to Galle is a favourite theme for a chapter in every account
of a stay in Ceylon Until a few years since all the mail steamers went
first to Galle direct, and as the first excursion made by the
passengers was always to Kandy, they first made acquaintance with
the beauties of the island on that road. They are no doubt lavishly
displayed there. The park-like cocoa-nut groves, which I first saw on
my expedition to Kaduvella, with their endless variety of lovely
pictures, here extend over a wide tract along the southwest coast.
The road winds among them, coming out to skirt the rocky or sandy
sea-shore or plunging into their thickest depths, and crossing
bridges over the numerous small rivers which here fiow into the
sea^ Formerly, the whole distance from Colombo to Galle had to be
travelled in a cart or carriage, but now the railway goes for about a
third of the way. The line runs near the coast, cutting through the
palm forest in an almost straight line, and running as far as Caltura.
The extension of the line to Galle, which would be immensely
advantageous to this port, is not allowed by the Government, from a
fear
 158 A VISIT TO CEYLON. lest Galle should thereby gain a
pre-eminence above Colombo. As the traffic between the two towns
is very considerable and constantly increasing, there can be no
doubts as to its paying the shareholders. Unfortunately the ruling
determination to keep Colombo ahead of Galle at any cost impels
the Government to refuse even to grant their charter to a perfectly
sound company, who are prepared with capital to construct and
work the line. This is a standing grievance and discussed on every
opportunity. The traveller is consequently compelled either to hire a
conveyance at a great expense, or to trust himself in the mail
omnibus which runs daily between Galle and Caltura ; but this, too,
is dear and remarkably uncomfortable. This omnibus boasts, it is
true, of the hio^h-soundino title of "Royal Mail Coach," and displays
the arms of England on its door panel, with the motto, " Honi soit
qui mal y pense ; " but the hint is unqualified mockery in view of the
coach itself and the horses whose suffering lot it is to draw it. The
slightly built vehicle looks as if it had been " constructed to carry "
barely half a dozen passengers, but when opportunity serves double
the number are cranjmed into it. The two narrow seats in the small "
inside," and another stuck up behind, are then made to hold each
three persons, though there is hardly space for two. The best seats
are the box-seats by the driver, under the shade of a projecting roof.
Here the traveller has a free view of the glorious scenery on every
side, and at the same time escapes the strong and by no means
agreeable perfume that exhales from the perspiring Cinghalese, well
polished with cocoa-nut oil, who are packed into the inside places.
For this immunity, however, the white traveller pays fifteen rupees
for
 THE KOAD FROM COLOMBO 10 GALLE. 159 a five hours'
ride — about six shillings an hour — whilt the dusky native pays only
half. The most horrible concomitant of this omnibus journey, as of all
coach travelling in Ceylon, are the torments iniiicted on the
miserable horses. The " mild Cinghaiese " seem, from time
immemorial to the present day, never to have conceived the idea
that the management of horses is an art to be acquired, or that the
horse itself must be trained or broken to harness. On the contrary,
they seem to take it for granted that this comes as a matter of
course, and that horses have an inherited tendency to pull vehicles.
So, without any proper training, an unbroken colt is fastened in front
of some conveyance by a kind of tackle, which is as uncomfortable
to the beast as it is illadapted to its purpose, and then put to every
variety of torture till it takes to its heels in sheer desperation. As a
rule neither shouts nor flogging reduce it to this extremity, and every
kind of ill-treatment is resorted to : it is dragged by the nostrils,
which are particularly sensitive in the horse ; its ears are wrung
almost out of its head ; ropes are tied to its forelegs, and half a
dozen of howling and shrieking youngsters drag the poor beast
forward, while others hold on to his tail and belabour him behind,
sometimes even scorching the hapless brute with torches. In short,
he goes through every torment that the '* Holy Office " ever devised
for the conversion of heretics and infidels; and many a time, as I
have sat perched on the box-seat for a quarter of an hour at a time,
forced to look on at these and similar barbarities without being able
to prevent them, the question has irresistibly risen in my mind : For
whose sins had these wretched horses to suffer? Who knows
 160 A VISIT TO CEYLON. whether a similar fancy may not
be lurking in the minds of the black coachman and stable lads, who
are most of them worshippers of Siva, and believe in the
transmigration of the soul. Perhaps they imagine that by these
brutalities they are avenging their wrongs on the degraded souls of
those cruel princes and warriors who were the former tyrants of
their race. It must be either some such notion as this or a total
absence of humane feeling — or, perhaps, the extraordinary theory
which is occasionally found to exist, even in Europe, that the lower
animals are devoid of sensation — which explains the fact that the
Cinghalese consider these and similar tortures inflicted on beasts as
a delightful entertainment. The wretched oxen are always marked
with their owners' names in large letters, cut quite through the skin.
In the villages, through which the road passes and where the horses
are changed, the arrival of the coach is the great event of the day,
and all the inhabitants assemble with eager curiosity, partly to stare
at the travellers and criticize their appearance, partly to look on at
the ceremony of changing horses, and chiefly to play an active part
in tormenting the fresh team. The poor beasts are at last driven to
fly, and they usually start at a wild gallop, pursued by the yells of the
populace, and rush madly onward till they lose their breath and fall
into a slow trot Covered with sweat, foaming at the mouth, and
trembling in every limb, in about half an hour they reach the posting
station, where they are parted from their fellow-sufferers. This mode
of travelling, it need not be said, is not agreeable to the stranger
who has trusted his person to the ricketty stage coach, nor is it
devoid of danger. The con 
 THE ROAD FROM COLOMBO TO GALLE. 161 veyance is
often upset and damaged, the goaded horses not unfrequently run
away across country, or back the coach into the banana thickets or a
deep ditch, and I was always prepared to spring from my perch on
the box at a critical moment. In fact, it is difficult to conceive how
the English Government, which is generally so strict in its
arrangements and discipline, has not long since put an end to this
brutality to animals, and more particularly extended its protection to
the wretched horses that serve the "Royal Mail Coach." Great
Buddha ! you who strove so earnestly to diminish the miseries of this
miserable life and mitigate the torments of suffering creation, what
mistakes you made ! What a blessing you would have conferred on
men and beasts if, instead of the foolish prohibition to take the life
of any creature, you had laid down the merciful law : Thou shalt
torture no living thing. The prohibition is, on the whole, scrupulously
attended to by every Cinghalese Buddhist, though there are many
exceptions. For instance, they look on with frank satisfaction when a
naturalist fires at the monkeys and flying foxes that rob them of their
bananas, or when a planter shoots the elephants that tread down
their rice-fields, the leopards that carry oflf their goats, or the palm-
cats which devour their fowls. But, as a rule, they will give no
assistance or encouragement, and take the greatest care to avoid
killing anything themselves. For this reason, almost all who belong to
the fishermen's caste are Roman Catholics; they have renounced
Buddhism to avoid all difficulties in the way of catching fish. The
stubborn recalcitrancy displayed by the Indian horses to their
tormentors, and their universal propensity to
 162 A VISIT TO CEYLON. shy at unexpected moments,
together with the frenzied pace at which they start, demand no
small skill in he, driver. The coachman and his assistant, the stable
lad must be constantly on the alert. The endurance and staying
power of these horse-boys are quite amazing; naked, all but a loin-
cloth and a post-horn strung round him, with a white turban on his
head, a black Tamil will run a whole stage by the side of the horses,
pulling the traces first one way and then another, and swinging
himself up on to the step or coach pole when going at the utmost
pace. If the coach meets another vehicle, or if the road makes a
sudden bend, he seizes the horses' heads and gives them a violent
jerk in the right direction. In crossing the long wooden bridges which
span the wide torrents, he suddenly checks the steeds in their career
and leads them carefully over the shifting and clattering logs. If a
child runs into the road, as often happens, or an old woman does
not get out of the way, the horse-boy jumps forward with swift
promptitude and pushes the horses back with a strong hand. In
short, he must be ready for everything, here, there, and everywhere.
Although the seventy miles of road between Colombo and Galle
present no variety in the character of the landscape, the enchanted
eye of the traveller is never weary of it. The unflagging charm of the
cocoa-nut wood, and the inexhaustible variety of grouping and
combination in the accessories of the landscape, never fail to keep
him interested. The stinging heat of the tropical sim is not often
unbearable, for it is greatly mitigated, both by the cool sea breeze
and the shade of the woods. The elegant nlumes of the cocoa-nut
palm, as of most palm-trees, do not,
 THE ROAD FROM COLOMBO TO QALLE. 163 it is true,
afford the deep and refreshing shade of the denser foliage of our
forest trees, for the sunbeams filter through the divisions between
the leaflets in every direction in broken flecks of light. But their
slender stems are, in many cases, covered by graceful garlands of
climbing pepper-vines and other creepers; they hang in festoons
from one tree to another, like artificially woven wreaths, and hang
down in massive pendants, densely covered with leaves. Many of
them are gay with splendid flowers, as, for instance, the flame-
coloured Gloriosa, the blue Thunhergia, the rose-pink Bougainvillea,
and gold-coloured butterfly-orchids of various species. Between and
under the ubiquitous palms grow a host of other trees, particularly
the stately mango, and the towering breadfruit tree, with its dense
dark -green crown. The slender columnar trunk of the papaw (Carica
papaya) is elegantly marked and crowned with a regular diadem of
large palmate leaves. Many varieties of jasmine, orange, and lemon
trees are completely covered with fragrant white blossoms; and
among these nestle the pretty little white or brown huts of the
natives, with their idyllic surroundings— the traveller might fancy
himself riding through one long village in the midst of palm gardens,
but that now and again he passes through a more crowded tract of
forest trees, or finds himself among a colony of houses, standing in
closer rows round a country bazaar, and forming a real and more
populous village. Presently the road diverges towards the sea and
runs for some distance along the shore. Here wide levels of smooth
sand alternate with rocky hills, and these are picturesquely covered
with the Pandanus, or screw -pine.
 164 A VISIT TO CEYLON. The pandang (Fandanus
odoratissimus) is one of the most remarkable and characteristic
plants of the tropics. It is nearly related to the palm tribe, and is
known by the name of screw-pine, which should more properly be
screw- palm The elegant trunk is cylindrical, commonly from twenty
to forty feet high, and often bent; it is forked or branched, like a
candelabrum. Each branch bears at the end a thick sheaf of large
sword-shaped leaves, like those of a Draccena or Yucca. These
leaves are sometimes sea-green and sometimes dark, gracefully
drooping, and with their bases arranged in a close spiral, so that the
tuft looks as if it had been regularly screwed. From the bottom of
this spiral hang racemes of white and wonderfully fragrant flowers,
or large fruits, something like a pine-apple. The most singular part of
this tree is its slender aerial roots, which are thrown out from the
trunk at various places and fork below ; when they reach the soil
they take root in it, and serve as props to the feeble stem, looking
exactly as if the tree were mounted on stilts. These screw-pines
have a particularly grotesque appearance when they stand upon
these stilts, high above the surrounding brushwood, or straddle
down into the rifts between the stones, or creep like snakes along
the surface of the soil. The white stretch of sand which forms the
strand, frequently broken by dark jutting rock, is alive w^ith nimble
crabs, which vanish with great rapidity; indeed, their swiftness has
gained them the classic-sounding name of Ocypoda. Numbers of
hermit crabs (Faguriis) wander meditatively among their light-footed
relatives, dragging the shells in which they protect their soft and
sensitive bodies with great dignity. Here and there sandpipers are
 THE ROAD FROM COLOMBO TO GALLE. 165 to be seen,
graceful herons, plovers, and other shore-birds, busied in catching
fish in successful competition with the Cinghalese. These fishermen
ply their calling sometimes singly, sometimes in parties ; they then
commonly go out in several canoes with large seine nets, which they
combine to draw to the shore. The solitary fishers, on the contrary,
prefer to take their prey in the rolling surf; and it is very interesting
to watch the naked brown figure, with no protection against the
scorching sun but a broad-brimmed palm hat, leaping boldly into the
tumbling waves and bringing out the fish in a small hand-net. He
seems to enjoy his fresh salt bath as much as his children do, who
play by dozens on the sands, and are accomplished swimmers by
the time they are six or eight years old. The white or yellowish
margin of sand follows the coast often for miles, like a narrow
gleaming satin ribbon, bending with its multifarious curves and
beautiful open bays, and dividing the deep blue waters of the Indian
Ocean from the bright green cocoa-nut groves. This hem of sand is
all the prettier where the stooping heads of the crowded palms bend
far across it, as if leaning forward to breathe the fresh sea-breeze
more freely and enjoy the full blaze .of the sunlight. The soil at their
feet is strewn with beautiful shore plants, of which three are
particularly conspicuous — the goat s foot convolvulus, with its two-
lobed leaves and violet flowers — Ipomaea pes-capri ; an elegant
pink-blossomed Impatiens; and the noble funnel-shaped lily
Pancratium Zeylanicum. Its beautiful white flowers, which have
narrow pendant petals, grow in umbels on slender stems six to eight
feet high. Then by the roadside there are the huge arrowhead leaves
of the Calla, a handsome aroid. If the sun is
 106 A VISIT TO CEYLON. too hot, or a shower comes on
suddenly, the Cinghalese simply breaks off one of the great
Caladium leaves — it protects him better than a cotton or silk
umbrella, and is elegantly marked with transparent veining, often
painted with crimson spots. Thus, in this sunny paradise, parasols
grow by the wayside, or, more precisely, en-tout-cas, since they
serve the double purpose of an umbrella and a sunshade. A most
beautiful feature of the Galle and Colombo road are the numerous
river mouths, which intersect the cocoswood, and the wide lagoons
which stretch between them, particularly along the northern portion
from Colombo to Caltura. The former lords of the island, the Dutch,
were 30 delighted with these water-ways, which reminded them of
their native land, that they adapted them to a regular system of
canals and neglected the land roads. Under their rule numerous
barges and canal-boats, like the Trekschuit of the low countries,
travelled from town to town, and were the chief means of
communication. Since the English have made the capital high road,
the water-traffic has fallen into desuetude. But they still afford a
succession of pleasing pictures to the traveller as he is hurried by,
with their banks covered with dense thickets of bamboo and lofty
palms, and their pretty little islands and rocks; the tall ocoa-nut
palms tower above the undergrowth, "like a forest above the forest,"
as Humboldt aptly describes it. The undulating hills in the blue
distance supply an appropriate background where, here and there,
the high heads of the mountains are visible, and loftiest of all the
noble cone of Adam's Peak. At the mouths of the larger rivers,
several of which are
 THE ROAD FROM COLOMBO TO GALLE. 167 crossed on the
road, the smiling landscape assumes a gravelcharacter; the sombre
mangroves are a particularly conspicuous feature. The shore of
these estuaries is generally thickly covered with them, and their
aerial roots form an impenetrable tangle. Formerly they used to be
infested with crocodiles, but the progress of civilization and
agriculture has driven these reptiles up the rivers. The finest of the
rivers is the noble Kalu Ganga, or Black river, which I afterwards
explored for the greater part of its length. The lower reaches are as
wide as the Rhine at Cologne. At the mouth stands Caltura, a large
village, and the terminus of the railway. At the southernmost end of
Caltura a magnificent banyan tree grows across the high road, like a
triumphal arch. The aerial roots of this huge tree have taken hold on
the soil on the opposite side of the road and grown to be large
trunks, and these and the main trunk form a lofty Gothic vault,
which is all the more striking because a number of parasitic ferns,
orchids, wild vines, and other parasitic plants have overgrown the
stems. Not far from the shore near Caltura I found, on a subsequent
visit, another wonderful tree — an indiarubber tree — of which the
snake-like roots, twisted and plaited till they look like a close lattice,
form a perfect labyrinth. Troops of merry children were playing in
the nooks between these root-trellices. Another delightful spot is the
rest-house of Bentotte, where the "Royal Mail" stops for an hour to
allow the passengers to rest, and recruit their powers of endurance
by breakfast. A particular delicacy here are the oysters, for which the
place is famous. They are served raw, or baked, or pickled in
vinegar. The rest-house is beautifully situated on a hill, among tall
tamarind trees, and has a
 168 A VISIT TO CEYLON. splendid view over the sunlit sea
and the bridge which spans the river-mouth. After breakfast I
watched the oyster-fishery below this bridge, and then spent a
quarter of an hour in lounging through the picturesque bazaar of the
straggling town. The wares and traffic in this bazaar are in perfect
keeping with the idyllic character of the surroundings, with the
primitive furniture of the native huts, and the elementary character
of their owners' dress. By far the most important articles of
commerce are rice and curry, the staples of food, and betel and
areca, the favourite luxury. Tliese and other matters for sale lie
temptingly spread on wide green banana leaves in simple booths,
with an open front, serving at once as door and window. Between
them are heaps of cocoa-nuts, monstrous bunches of bananas, and
piles of scented pine-apples; the starchy roots of the yam, the
Cohcasia, and other plants ; enormous breadfruit, weighing from
thirty to forty pounds each, and the nearly allied jack-fruit; and then,
as delicacies, the noble mango and the dainty anona, or
custardapple. While we are strongly attracted to these fruitstalls —
which the Cinghalese often decorate very prettily with flowers and
boughs — by their delicious perfume, we are equally repelled from
certain others by a pungent odour, which is anything rather than
tempting. This "ancient and fish-like smell " proceeds from heaps of
fresh and dried marine creatures, principally fish and Crustacea;
among these the prime favourites are shrimps or prawns, an
important ingredient in the preparation of the native spiced dish,
curry.* * Beis lourze, Herr Haeckel calls curry, regarding it — as it no
doubt was nrijrinally — as a spice to flavour the inevitable meal of
rice.
 THE ROAD FROM COLOMBO TO GALLE. 169 There can be
no greater mistake than to expect to find in these Cinghalese
markets the noise and clamour and confusion which are
characteristic of market scenes among most nations, and more
particularly in the southern countries of Europe. Any one who has
looked on, for instance, at the bustle and hurry on the pretty piazza
at Verona, or the vehement tumult of Santa Lucia at Naples, might
imagine that in a tropical bazaar in Ceylon the crowd and uproar
would rise to a still higher pitch. Nothing of the kind. The gentle
subdued nature of the Cinghalese affects even their way of trading;
buyers and sellers alike seem to take but a feeble interest in the
transaction, small in proportion to the trifling copper coin for which
the most splendid fruits may be purchased. These coins, I may
mention, are pieces of one cent and of five cents, and there are a
hundred cents to a rupee (worth two shillings) ; they are stamped
with a cocoa palm. The Cinghalese, however, are not indifferent to
the value of money, but they need less of the commodity, perhaps,
than any other people on earth ; for there are few spots, indeed,
where kindly mother Nature pours out so inexhaustible and
uninterrupted a supply of her richest and choicest gifts as on this
privileged isle. The poorest Cinghalese can with the greatest ease
earn as much as will buy the rice which is absolutely indispensable
to life ; ten to fifteen cents are ample for a day's food. The
abundance of vegetable produce on land, and the quantity of fish
obtained from the sea are so enormous that there is no lack of curry
with the rice and other variety in their diet. Why, then, should the
Cinghalese make life bitter by labour ? Nay, nay — they have far too
much of the easygoing nature, the true philosophy of life. So they
may be
 170 A VISIT TO CEYLON. seen stretched at full length and
reposing in their simple dwellings, or squatting in groups and
chatting to their hearts' content. The small amount of labour
required in their garden-plots is soon accomplished, and the rest of
the time is theirs to play in. But their very play is anything rather
than exciting or energetic. On the contrary, a spell of peace and
languor seems to have been cast over all the life and doings of these
happy children of nature, which is amazingly fascinating and
strange. Enviable Cinghalese ! you have no care either for the
morrow or for the more distant future. All that you and your children
need to keep you alive grows under your hand, and what more you
may desire by way of luxury you can procure with the very smallest
amount of exertion. You are, indeed, like " the lilies of the field "
which grow round your humble homes. "They toil not, neither do
they spin," and their mother, Nature, feeds them. You, like them,
have no warlike ambitions; no anxious reflections on the increasing
competition in trade, or the rise and fall of stock ever disturb your
slumbers. Titles and Orders, the highest aim of civilized men, are to
you unknown. And in spite of that you enjoy life ! Nay, I almost think
it has never occurred to you to envy us Europeans our thousand
superfluous requirements. You are quite content to be simple human
souls, children of nature, living in paradise, and enjoying it. There
you lie, at full length, under the palm roof of your huts,
contemplating the dancing lights and shadows among the plumes of
the cocoa-nuts ; perennially refreshed by the unequalled luxury of
chewing betel-nut, and playing at intervals with your sweet little
children, or taking a delicious bath in the river that flows by the
road, and devoting
 THE ROAD FROM COLOMBO TO GALLE. 171 your whole
attention to the subsequent toilet, so as to set the tortoiseshell comb
at the most bewitching angle in that elaborately twisted top-knot.
Where is the careworn "^on of culture who would not envy you your
harmless modb of existence and your Eden-like simplicity ! These
and similar reflections irresistibly rose in my mind as I stood gazing
at the groups of Cinghalese enjoying life in their blameless fashion in
the peaceful silence of their banana groves, while the coach changed
horses at the last stage before reaching Galle. Here the struggle for
existence seemed to have ceased; seemed, at any rate. I was first
roused from my reverie by being asked by the two horse-boys to
mount again to my box-seat. These worthy Malabars then informed
me, in broken English, that this was an appropriate moment for
presenting them with the usual " tip," or " bakhsheesh," for drink,
since, when we should arrive in Galle, they would be too busy and
the time would be too short for this important matter to meet with
due attention. As I had seen a highly respectable Cinghalese, who
had been set down some time previously, give each of these two
fellows a double anna, a little silver coin worth about threepence, I
thought I was doing ample credit to my higher dignity as a white
man by offering four times as much — half a rupee a-piece. But the
coachman and the conductor alike held up my donation with
indignant gestures, and gave me a lecture on the superiority of my
white skin, which was, no doubt, highly flattering. The upshot of it
was that every white gentleman must give at least double — a rupee
— to each of them as drink-money, and that a man as white as I
was and with such light hair, must certainly be very high caste, and
must expect to be
 172 A VISIT TO CEYLON. fleeced accordingly. Although to
be so highly taxed for my fair complexion could not be otherwise
than delightful, I was not to be persuaded to pay more on that
score, than a rupee to each as a " white man's " tax; and I finally
had the satisfaction of hearing myself pronounced to be a " perfect
gentleman." However, when I thought of the exquisite enjoyment of
nature I had derived from my five-hours' ride, I thought the fare well
laid out, and in spite of the heat and fatigue I was sorry when, at
about four in the afternoon, the lighthouse of Galle came in sight.
Soon after the " mail coach " rattled over the drawbridge of the old
moat, and then through a long dark barbican, pulling up finally in
front of the elegant " Oriental Hotel " of Panto Galla.
 CHAPTER IX. POINT DE GALLE. Galle, the most famous and
important town of Ceylon from a very remote antiquity, is proudly
situated on a rocky promontory, lying to the west of a bay which
opens to the south. The Cinghalese name Galla, means rocks, and
has no connection with the Latin word Gallus, as the Portuguese, the
first masters of the island, assumed; a memorial of this false
etymology still exists on the old walls in the form of a moss-grown
image of a cock, dated 1640. We infer from the concurrent evidence
of many writers of classic times, that Galle was an important trading
port more than two thousand years ago, and probably through a
long period was the largest and richest place in the whole island.
Here the Eastern and Western worlds met halt way; the Arabian
merchantmen, sailing eastwards from the Red Sea and the Persian
Gulf, here hekl commerce with the Malays of the Sunda Archipelago,
and the still more remote Chinese. The Tarshish of the ancient
Phoenicians and Hebrews can only have been Galle; the apes and
peacocks, ivory and gold, which those navigators brought from the
legendary Tarshish, were actually known to the old Hebrew writers
by the same names as they now bear among the Tamils of Ceylon,
and all the descrip 
 174 A VISIT TO CEYLON. * tions we derive from them of
the much-frequented port of Tarshish apply to rxone of the seapor.ts
of the island, but the Rock point — Punto Galla. The natural
advantages of the geographical situation of Galle, close to the
southern end of Ceylon, in latitude 6° N.; of its climate and
topographical position, and especially of its fine harbour, open only
to the south, are so great and self-evident, that they would seem to
give this beautiful town the pre-eminence above all the other
seaports in the island. But the unflagging efforts of the English
Government to maintain the supremacy of Colombo at any cost,
particularly by more efficient communication with the interior, have
of late years seriously damaged the prosperity of Galle, not to speak
of its greater nearness to the central cofleedistricts. I have before
observed that the greater part of the export traffic has been
transferred to Colombo, and the noble harbour of Galle is no longer
what it used to be. However, Galle cannot fail to keep its place as
only second in importance to Colombo, and particularly as the
natural depot for the export of the rich products of the southern
districts. Of these products the principal are the various materials
derived from the Cocoa-palm ; cocoa-nut oil, which is very valuable ;
Coir, the tough fibrous husk of the nut, which is used in a variety of
ways, as for mats and ropes ; palm sugar, from which arrak, a
fermented liquor, is distilled, etc. Formerly the traffic in gems was
also very considerable, and more recently the export of graphite or
plumbago. When the bill shall at last be passed for extending the
railway from Caltura to Galle, and when some of the rocks and coral-
reefs which render parts of the harbour unsafe shall have been
blown away by dynamite,
 POINT DE GALLE. 175 the vanished glories of Galle may be
restored and even enhanced. The situation of Point de Galle is truly
delightful, and as a matter of course this spot has been highly
lauded in almost all former accounts of travels in Ceylon, being the
place where Europeans used first to land. The whole of the point
which juts out towards the south is occupied by the European town,
or "Fort," consisting of store-houses one story high, surrounded by
pillared verandahs, and shaded by projecting tiled roofs. Pretty
gardens lie between them, and serve no less to decorate the town
than the wide avenues of shady Suriya trees (Thespesia populnea)
and Hibiscus (H. Tosa sinensis). These here take the place of roses ;
they are densely covered with bright green leaves and magnificent
red blossoms, but the tree is known among the English by the
prosaic name of the Shoe-flower, because its fruits, boiled down, are
used for blacking. Among other public buildings we remark the
Protestant church, a pretty Gothic structure, on one of the highest
points of the Fort-hill. Its thick stone walls keep the interior, which is
lofty, delightfully cool, and it is surrounded by fine trees, so that it
was deliciously refreshing when, one burning Sunday morning, tired
with a long walk, I could take refuge from the scorching sunbeams
in this shady retreat. Opposite to the church are the public offices of
Galle, in what is known as the Queen's House, which formerly was
the residence of the Dutch, and subsequently of the English,
governor. Travellers of rank, or if provided with particular
recommendations, were here hospitably entertained by the governor.
For this reason, the government
 176 A VISIT TO CEYLON. buildings of Galle and their
immediate neighbourhood were usually the first spot in Ceylon to be
described and admired in old books of travels. Among German
travellers, Hoffmann and Ransonnet both have been at home there.
Within the last few years, however, the Queen's House has become
private property, and is now the head-quarters of the chiet
merchant-house in Galle — Clark, Spence, & Co. I had Leen warmly
recommended to Mr. A. B. Scott, the present head of the house, by
my friend Stipperger, and was received by him with the most liberal
hospitality. He placed two of the best of the fine spacious rooms of
the Queen's House at my disposal, with a delightful, airy verandah,
and did everything in his power to render my visit to Galle as
agreeable and as profitable as possible. Not only did I soon feel
myself at home in Mr. Scott's amiable family circle, but in him I made
acquaintance with an English merchant whose many and various
accomplishments are worthy of his prominent social standing. He is
now consul for several Powers, and it is only to be lamented that he
should not also represent the interests of Germany. Mr. Scott lived in
Germany for many years, for a long time at the commercial school of
Bremen, and highly appreciates German literature and German
science. So, as I was so fortunate as to be regarded by him, for the
time beings as the representative in person of German science, I
enjoyed the benefit of his favour and help to the utmost. This led me
once more to doubt whether T should not do well to avail myself of
his kind offer, and to set up my zoological studio for several weeks in
Queen's House, instead of moving to Belligam. Here, at any rate, I
should live surrounded by every European comfort and pleasant and
family society, and be far better off than in the
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