Cardiac Cath is now safer, faster & more comfortable for patients

Transradial Cardiac Catheterization

Dr. Van Crisco

Dr. Van Crisco, MD, FACC, FSCAI

Interventional Cardiologist and Peripheral Vascular Medicine Specialist, First Coast Heart and Vascular Center, Jacksonville, FL

 

What is cardiac catheterization, and when is it used?

In general, cardiac catheterization is a minimally invasive procedure done to get information about the heart muscle and its blood supply or to provide treatments such as intracoronary stents in certain types of heart conditions. It may also be used to determine the need for heart surgery or other procedures.

Your doctor may perform cardiac catheterization to:

  • Diagnose or evaluate coronary artery disease
  • Diagnose or evaluate congenital heart disease
  • Diagnose or evaluate problems with heart valves
  • Diagnose causes of heart failure or cardiomyopathy

In addition to its use as a diagnostic tool, cardiac catheterization can also be used as an interventional procedure to treat heart attacks, to open blocked arteries with balloons and stents, and/or repair stenotic, or narrowed heart valves.

In the United States, a majority of cardiac catheterizations (90-95%) are performed through the femoral artery, the large artery supplying blood to your leg, which is accessed through the groin. Although generally considered safe, this approach presents a slightly higher risk of bleeding compared to cardiac catheterization through the radial artery in the wrist.

What is transradial cardiac catheterization?

Transradial cardiac catheterization offers a less invasive, lower-risk option compared to traditional femoral artery access for cardiac catheterization because the procedure is performed through a small artery in the wrist rather than the groin. This allows for a quicker recovery time and a shorter hospital stay. Immediately after the procedure, patients should be able to sit up, eat, and walk. In contrast, after a traditional cardiac catheterization through the femoral artery in the groin, patients must lie flat for two to six hours, in order to ensure that bleeding will not occur from the site. Furthermore, the femoral artery is adjacent to the abdominal cavity.  Inadvertent puncture through the femoral artery can lead to blood loss into a very large space, the retroperitoneal cavity that is behind the abdomen.  Every year someone in every large city in America dies of a large bleed into this space that is either not stopped or not appreciated.  Transradial access for heart catheterization is without this risk, 100%. Blood loss from the radial artery is simply compressed with a finger.

The physicians of First Coast Heart and Vascular Center are some of the only cardiologists in North Florida who routinely offer transradial cardiac catheterization and transradial coronary intervention procedures, such as angioplasty and stenting procedures.

How is the procedure performed?

A determination is made to confirm that the patient is eligible and safe for radial artery catheterization. The patient is sterilely prepped, and minimally sedated. The wrist area is anesthetized and accessed with a small needle. Catheters are then inserted and advanced to the heart arteries. The rest of the procedure is identical as if it were performed from the traditional femoral approach. The catheter is then inserted through the wrist (radial artery) and is threaded through to the heart and its chambers. A wristband is used to compress the artery when the procedure is finished, and the patient is able to ambulate almost immediately after the procedure.

What are the benefits/advantages of transradial versus traditional cardiac catheterization?

  • Reduced risk of bleeding and damage to blood vessels
  • Patients can sit up, walk, and eat immediately after the procedure, rather than the typical two to six hours lying flat after femoral access
  • Shorter hospital stay
  • Quicker recovery time
  • Increased patient comfort
  • Potential discharge to home the same day even after stenting procedures

Who is eligible for transradial cardiac catheterization?

Despite the advantages to this approach, the procedure may not be appropriate for a very small number of patients:

  • Patients with inadequate blood supply to the hand due to prior surgeries on arteries or other injuries or causes of vascular insufficiency to the hand or wrist

We evaluate each patient’s case carefully to determine the best type of procedure to perform.  We encourage patients to ask our team about this form of diagnostic testing to see if it is appropriate for them.

Why doesn’t every cardiologist perform transradial cardiac catheterization procedures?

This is a common question and one that is difficult to answer.  Some doctors have either never trained to do the procedure, or are reluctant to change their established practice.  If transradial cardiac catheterization is safer for the patient and associated with fewer complications, the physicians of First Coast Heart and Vascular Center believe it should be an option for every patient if appropriate.

Why come to First Coast Heart and Vascular Center?

First Coast Heart and Vascular Center is one of the few cardiology groups in North Florida to routinely offer transradial cardiac catheterization procedures, and our physicians have been perfecting this procedure for over 13 years. Our physicians are involved in training new physicians and already accredited interventional cardiologists in this technique.

Patients at First Coast Heart and Vascular Center are cared for by a multi-disciplinary team of board certified general and interventional cardiologists along side an electrophysiologist who work together to formulate individualized treatment plans based on each patient’s specific needs and disease stage. Our doctors have a dedicated team to consult on simple to complex cases of hypertension, heart failure, Atrial fibrillation, coronary artery disease, heart valve disease, vascular diseases, leg ulcers, leg pain, vein diseases ( varicose veins), leg swelling, carotid disease, mesenteric and  renal artery diseases. Please call our main office number (904) 423-0010 for all of our 8 locations. We are active at most hospitals in Duval, Clay and St. Johns counties.

 

79 Comments

  1. I had a heart cath through my wrist a week ago. My arteries were clean, but now I am having so much pain in that arm. Is that normal a week out? My whole hand and wrist is aching most of the time and even my arm is painful. I thought it would subside by now, but it seems to be getting worse. Oxi and Tylenol are not touching it. Can you enlighten me some?

    • This response is by Dr. Van Crisco – “Discomfort after a radial artery access for heart catheterization may last for about 2 weeks, but it should get better Many times people have inflammation of the artery or sometimes inflammation around the outside of the artery if blood leaks from the access site into the soft tissue. Most the time this does respond to ice and elevation and anti inflammatory medical management with drugs like ibuprofen and pain management with extra-strength Tylenol. If discomfort lasts more than 2 weeks, we typical see our patients in office and make a diagnosis and treatment plan on examination.”

      • I had the cath thru my wrist. All was good just minimal blockage. Since then I am having trouble with the middle finger of the hand where cath was done. It is like my finger locks up and it takes awhile to get over it. Recently my middle finger pains me and wakes me up. Could this be caused by the cath. I didn’t have this problem until after I had it. I had in May of this year.

        • This response is provided by Dr. Van Crisco. “May be related. Hard to say. Needs evaluation and exam by the operator who performed the procedure.”

      • I had a cardiac cathertization through my wrist 2 days ago. SInce then my legs are aching and burning. They are not swollen. they are worse at night, so much that the pain wakes me up.

        • This response is from Dr. Van Crisco. “It’s very hard to imagine that this is related at all. I would see the physician who performed the procedure, but I cannot understand how these two could be related at all from a medical standpoint. I’m not saying I don’t believe the patient, I’m just saying it doesn’t make a lot of physiologic sense.”

    • This response is from Dr. Van Crisco.
      After such a procedure, many surgeons tell their patients not to have faster access in the same extremity on the side with the breast surgery. This is largely related to the risk for infections complications and lymphedema. We have perform faster access for a heart catheterization through the wrist in the same arm or in the other arm easily. I would favor the contralateral arm first, but I would not hesitate to go in the hips a lateral arm if needed. The overall risk is quite low as we are inside an artery, not inside of a vein, and the procedures done under sterile conditions.

      The bleeding risk is really the advantage going in the wrist compared to the groin, as vascular access complications are higher from a femoral approach in the either groin.

      I hope this answers your question and please feel free to come in for a consultation if you have further concerns.

  2. I am having a heart catherization procedure done but can’t do it on my right wrist due to breast removal and reconstructive surgery. If I get it done through my neck, how long will I have to lie flat before getting up? Is it less time than through my groin? I definitely will panic if I am awake or partially sedated. Can I be completely asleep?

    • This response is from Dr. Van Crisco.
      We would do it from your left wrist, no problem. Up and out in 1 hour.

  3. We were told my father in law would have a transradial heart cath. The risks were very low so we all agreed it was a good choice based on his symptoms. He has severe swelling in his right leg and the thought of going in through his groin was out of the question. We just learned that they did the procedure through his groin and he had severe complications including bleeding for over 30 minutes, extreme pain and blood clots. Our main concern is to get him well again, he is 81 years old and strong. With good lungs and now we also know a good heart. Just extreme swelling in his right leg and shortness of breath. Any advise on how to proceed would be greatly appreciated.

    • This response is from Dr. Van Crisco. “This patient needs to be seen in order to make a diagnosis so we can develop a treatment plan. It’s very difficult to make a diagnosis of what’s going on with a vague description like this without seeing and examining a patient. I’m sorry I cannot offer more, but a simple office visit to assess the problem should be able to make a diagnosis and treatment plan can be initiated to improve the condition.”

  4. I have to have a heart cath done and want it thru my wrist. I am worried that doctors don’t do it that often. Im just so worried about it

    • Dr. Van Crisco replied to this question.
      Radial (wrist access) is our default access strategy. We use radial access because its associated with the least amount of vascular access complications and allows for earlier ambulation. We certainly can approach the patient from the femoral position if the patient is concerned and would rather not have radial access.

    • This response is by Dr. Van Crisco. NO. It is not normal to have leg swelling after a heart catheterization from the radial artery access site.

      Suggest you are seen by the doctor performing the case or someone else about this.

  5. If its done in the wrist a week ago, is it safe for a person who drives a semi and has to shift gears and such. Is it safe for that person?

  6. I am having one done on the 15th in 5 days.

    I have a hard time breathing when lying on my back, also everything from my nose goes into my throat. Are they able to put me to sleep

    • Dr. Van Crisco responded to this:
      Typical heart catheterization is done without deep sedation. This improves safety. Mild or moderate conscious sedation is the level that is safe for this type of procedure. Accommodation can be made to possibly elevate the head during the procedure. Please discussed with the staff on arrival. The stenotic is in the way of a safe procedure being performed. General anesthesia a increases the risk and does not improve safety at all.

  7. I had a heart cath done thru my groin and they placed one stint, how long should I wait before returning to work, there is still a lot of bruising after one week

    • This response is from Dr. Van Crisco. “This should be discussed with you doctor. Typically, in the absence of any concerns most patients can return to work within 48hrs. If there is any concern about healing of the vascular access site, on going pain, or discomfort, or swelling or limb pain, we would recommend being seen by a healthcare provider prior to returning to work to evaluate the site.”

  8. I had this procedure through my wrist 4 days ago. I have pain from wrist to top of arm. I’m reading if not gone within two weeks to see my doctor…thanks for that answer. My question is how long before I can actually lift things. Like my grandkids….. I don’t want to damage anything or open an artery

    • This response is by Dr. Van Crisco. Symptom limited activity. If it hurts don’t use it. If it doesn’t hurt use it. Typically discomfort is from inflammation around the outside of the artery that was accessed and that gets better in about 2 weeks. A follow-up visit with the doctor should confirm no other problems, but without taking a look at the patient, it’s hard to comment further.

    • This response is from Dr. Van Crisco “Awareness of a patient’s predisposition to problems with anxiety for a procedure helps us with moderate Conscious Sedation techniques during the procedure to avoid any issues and to make the procedure as comfortable as possible for the patient. Letting the staff know about it on a arrival is probably the best strategy and we can help get the patient through the procedure without difficulty.”

  9. I’m having it a heart cathetder through wrist I’m 59 yrs old and scared about having it done afraid of having complications as I have copd asthma and chronic bronchitis

    • This response is by Dr. Van Crisco – “Lung disease is rarely if ever is an issue with a heart catherization from any access procedure other than the potential for complications related to sedation. Sedation can depress respiratory drive and this should be discussed with your provider prior to the procedure at length.

      Also, lung disease should be optimized before any elective procedure and the access does not really make a difference. Radial access through the wrist clearly has been shown to have fewer vascular access complications and we favor this strategy whenever possible for that reason and it allows for earlier ambulation and is associated with improved patient satisfaction.”

  10. Then I’ll be ok having it done with me having copd asthma and chronic bronchitis plus I had breast cancer and reconstructive surgery of breast and implant of right breast

  11. I recently had a right hand wrist *Heart Catherization.
    Why am I experiencing wrist pain by thumb joint which was performed at the Massachusetts General Hospital at Boston, Massachusetts late September 2016?.

    • This response is from Dr. Van Crisco – “It’s very difficult to give an answer to a question which really should be directed toward the operating physician and should also include a clinical evaluation like an examination in order to come to a reasonable conclusion about what’s going on. It’s difficult to answer that question accurately over an inquiry on our website.

      I’d recommend seeking the advice of the operating position or anyone who performs this type of procedure on a regular basis. Discomfort several weeks after vascular access should be evaluated thoroughly by the operator or an experienced physician who does this procedure to come to a diagnosis which can then give you a prognosis and treatment plan.”

  12. I’m having an angiogram thru my wrist in 2 days. I can’t explain just how nervous I am. The reason? I can’t lay flat of my back as I have sciatica and a herniated disc in my back The Dr asked if I could lay at a 30 degree angle. I’m not sure. Please tell me how I can get thru this!! Will the sedation take away the pain and anxiety of laying on my back?

    • This response is by Dr. Van Crisco “Yes. Simply notifying the staff on arrival of your issues will begin the process of accommodating your specific needs safely and comfortably getting you through the procedure. Neck and back issues are common and we work with patients to safely get it done. The moderate conscious sedation used for the procedure will ease the pain and make you relaxed.”

  13. I just had a cardiac cath through my wrist today October 13th and noticed before I left a small amount of blood under the bandage. I’m now home and that small spot of blood is getting bigger but in a slow manner, is this normal? When should it stop completely?

    • This response is by Dr. Van Crisco. “This needs to be seen by a clinician. It’s hard to answer questions like this without a visual assessment of the problem. I would seek the care of your physician who did the procedure.”

  14. I had an angiogram done Oct 20, 2016. All turned out well. I noticed 2 blisters underneath the clear see through bandage the put over the wound site. They were itchy, but I put cream on them and have been trying not to bother them. Today I had a red pin point rash on my lower abdomen and upper thigh where they prepared the femoral artery site just in case the couldn’t access my arm. I didn’t pay too much attention to it. Then about 3:00 this afternoon, I noticed the same kind of rash on my arm from my wrist upwards on my forearm. No red streaks, just an itchy, hot feeling. I am getting a headache and just don’t feel very well. I had a staph infection one time due to an IV, but it affected the IV site. Could I be getting another infection?

    • This response is by Dr. Van Crisco> “Issues like this need to be seen in a clinic by a physician or mid-level practitioner who has experience in evaluating such things. Complaints like this need to be seen in a clinic by a physician or mid level practice who has experience in evaluating such things. 5 days after procedure, it is less likely to be related to procedure issues although one would have to take a look at it to confirm. This does not sound like a staph infection.”

  15. I had the heart catheter done through the wrist and yes it was sore fo a couple days but with regular arm movement and lifting my arm over my head the pain went away. You have to work the sore muscles and get them limber again. As they say, you get out of it what you put in it.

  16. I am having a right side heart cath to Stent both legs,left leg from knee up to belt line,right leg from knee to groin.A month ago I was supposed to have a cath preformed to Stent legs but when the doctor injected dye he said right leg was blocked to bad so he went through left arm at elbow,that’s when he determined I needed a bypass surgery.I went back to V.A. bypass surgern said he could do Stent instead of the bypass.My question is what can he do that the other doctor Couldn’t? How could he do what the other doctor said he couldnt?

    • This response is by Dr. Van Crisco. “This question is difficult to answer without looking at the angiogram. If the patient can bring angiogram for a 2nd opinion, I can answer this completely. I think the issue is that some doctors are comfortable with crossing chronic total occlusions (100% closed arteries) and others are not. We perform this procedure weekly, if not daily. Glad to see the patient in consultation with the angiogram or have it sent for my review and I will call the patient.”

  17. I had a heart cath done thru my wrist. the cath got stuck in my artery. was in a lot of pain, I cryed pain meds wouldn’t work. took almost 3 hrs to get it out. said it got a kink in it and was very hard to get out. my arm is black and blue. does this happen often

    • This response is from Dr. Van Crisco. “Happens where there is an artery spasm around the catheter or sheath, more common in women, sometimes difficult to deal with, rarely causes lasting problems. Taken as a whole though, radial access is FAR safer than femoral access in the groin related to vascular access complications. Should get better with time and ice and elevation and pain control.”

  18. I went for a heart cath, but after the doctor tried through the groin. He was unable to do it . He said due to my weight. They could not get a good pulse to try the wrist. Now what do I do? Had a Stress test and echo. And there are to many shadows to see the entire heart. Having breathing issues.

    • This response is from Dr. Van Crisco. “Arterial access can be comprised through many sites. We prefer the radial artery in the wrist and we access through either the left one or the right one. It can be done. Consider a second opinion from a physician who has experience with radial access regularly.”

  19. I have a aortic vavle that is at 42 with stenosis.for the last year when I walk fast exert my self my sides of my head jaw and teeth ache.I have been telling my cardoligist about this he blows me off.went for Second opinion .
    He wants me to have a hesrt cath. I had a double masectomy. I had radiation. And lumpectamy before the double mastectomy. Plus i have carpal tunnel in both hands.I can i still do wrist hearth cath???

    • This response is be Dr. Van Crisco “I agree that you need a heart catherization. A right and left heart catheterization. Given your history, I would probably approach it from the femoral position at the groin. There’s nothing to be greatly concerned about as this is a very common access strategy. We use ultrasound for access to make sure we don’t damage any vessels. I’m glad to see this patient for a second opinion as I also perform transcatheter aortic valve replacement without surgery. She may or may not be a candidate for this but somebody with experience and knowledge needs to have the discussion with the patient. I probably would not approach the heart catherization from the wrist or arm given the history.”

  20. Hello, I had a heart cath done through my right wrist. How long should I wait before I write and/or type again as I am right handed? Thank you

  21. Is being sedated an absolute requirement for a cardiac cath? I have never reacted well to any sedation, be it the versed conscious sedation variety or anesthesia. I will be nauseous and with a headache for the rest of the day even if they add anti-nausea drugs into it, plus it takes me hours to come to afterwards. My last colonoscopy was without sedation. It wasn’t a big deal at all. I have a very high tolerance for pain and discomfort. Getting a cardiac cath itself doesn’t concern me, it is the sedation that I fear. Is it an absolute necessity?

    • This response is by Dr. Van Crisco. “Absolutely not. We can do a heart catherization without any intravenous moderate Conscious Sedation. Local is essentially all anybody needs. Many times we do this and only give something for anxiety like Benadryl orally before somebody goes back. We can accommodate any patient request.”

  22. I am a small 65 year old person. 140 lbs, 5 feet, 3 inches.
    Are my arteries and veins too small for catherization through the wrist?

    • This response is be Dr. Van Crisco. “Absolutely not. We typically downsize the catheter diameter to avoid complications according to people’s height. Please know however, no matter what your size, this procedure does involve vascular access either from the femoral position in the groin or from the wrist typically. Artery spasm does happen but we do everything we can to avoid it and it is very very rare.”

  23. I am scheduled to have a heart catherization next week. I have very small veins. Should the doctor use my wrist? Or should he use the groin? Am I high risk using the wrist? Need answer stat! Thank you. I have not said this before. This is my first time commenting.

    • This response is from Dr. Van Crisco. “The size of your veins has nothing to do with access. We access arteries to get to the heart. Radial access from the wrist has been associated with better outcomes, earlier ambulation, fewer vascular access complications and less bleeding. We prefer this access as the primary strategy for most patients.”

  24. I had a cardiac catheterization 2 weeks back via left radial artery and one stunt placed in LAD. There was no bleeding at the puncture site nor in the forearm. Took 7 days antibiotic prophylaxis. I am still feeling aching deep sitred pain in the left forearm and elbow area which is not improving even 2 weeks after the procedure. There is no swelling and no sign of infection. Diclofenac and Tramadol tabs are not helping. The doctors said that it will improve but I am worried as the pain is hard to bear with especially in the evening. Please advise.

  25. I had the right wrist cardiac cath done on the 25 and now the 28th my wrist hurts a little but the bottom of my arm from wrist to elbow very bad. Is this normal.

    • This response is from Dr. Van Crisco. “Sometimes discomfort happens due to bleeding from between the artery and the skin back up into the forearm. Other times there’s problems with spasm or artery occlusion which does not have much long-term consequences. I think you need to be seen by a doctor or the one who performed the procedure.”

  26. I was told that I need a heart Cath but I’m researching Dr’s and different types of caths. I would prefer the radial Cath in my wrist but I had carpal tunnel surgery on both wrists and had a dual chamber pacemaker implanted in 2011. Would I still be a candidate for the radial? Thanks

  27. I had a heart cath through my right wrist 4 weeks ago. I have since developed an occlusive blood clot in that artery. It swells often and causes me pain in my hand. I was told by my cardiologist, my PCP and an ER Doc to be patient and it will go away on it’s own. I was also told no intervention was necessary. Since it’s been 4 weeks and has shown no improvement, when can I expect to have some relief? I work at a computer all day which is not helping my cause.

    • This response is by Dr. Van Crisco. “It is rare that radial artery occlusion is symptomatic because we have two arteries to our hand and if you close one and there’s good collateral flow through the hand, the overwhelming majority of patients don’t feel anything. I wonder if something else could be going on. It might be reasonable to be seen by your doctor and maybe get an ultrasound. If it is closed, there are data sets to suggest some benefit from anticoagulation or taking a blood thinner to allow recanalization of the artery. However, what you’re describing sounds more like vasculitis or inflammation around the outside of the artery. That’s a different story. Someone who’s experienced in radial access and looking at the access site to understand what’s going on should be consulted.”

  28. I had a wrist cardiac catherization yesterday at 2:00pm, I was out of the hospital by 7:00pm
    Absolutely no pain, bleeding, or other complications. I had previously had two groin caths and they were very difficult and hard on my body. I will never do another groin cath, the wrist was so much better. The sedation seemed far less then with the groin cath and i spent the procedure cracking jokes at my doctor. All in all my initial fear was not at all warranted.

  29. I had the heart cath on wrist 2 days ago. However I have a deep soreness in my chest and arm. Dr had trouble getting the cath to go in it took 4 times and I felt everything. I also have several little holes near the main site,what would it be? Also is it normal for this soreness even in chest and arm?

    • This response is by Dr. Van Crisco. “Some discomfort happens. Without looking at it it’s difficult to say. I would see the physician who did the procedure and have a frank discussion with them about what’s going on with you.”

  30. I am having a cardiac catherization tomorrow, they will probably go thru the wrist. I had a cordisone shot in each shoulder four days ago for pain i have been experiencing for 6 weeks. Do you think this will make my shoulders ache again. It seems the shots are working, Arline

    • This response is by Dr. Van Crisco. “Heart catherization from the radial artery goes inside the artery and is nowhere near the joint. Most shoulder problems that feel better after injection are a joint related issue. Heart catherization is highly unlikely to make things worse.”

  31. My doctor said he could not do a balloon or put a stent in my leg my leg. is blocked from my hip to my knee. Is it the doctor that isnt able to do so because of the blockage or is it that he doesnt know how to?

    • This response is provided by Dr. Van Criso. “Occluded vessels in the leg especially that length, are often difficult to open up, but not impossible. Physicians who have experience with this are often quite successful at intervention for closed vessels from the hip to the knee, especially the superficial femoral artery. This is a very common finding. Another approach would be bypass surgery to bypass from the hip to the knee to get a better blood supply to the calf and foot. The less invasive option with opening it up from a catheter based approach often involves taking out the plaque which is called atherectomy. You need to see a physician who’s experienced with this technique to get a very good outcome that will last.

      Most patients who face the surgical option just have not had a discussion with a doctor who does this procedure on a regular basis from a non surgical approach. We are happy to see the patient in consultation in our office as we provide this less invasive approach on a regular basis, often 5 to 10 times weekly..”

  32. My husband never asks questions,, he truly thinks doctors care,, not so much,, he was never talked to about an option to have this done in his hand,, going through the groin hurt him so bad and for what,, they didn’t even try to unclog his arteries,,, they just said he has 2 blockages and a heart valve that had gotten worse,,, now they want to do open heart,, I do not trust doctors to begin with but the VA doctors are the absolute worse,, now we are worried and scared for him until this surgery takes place and they are making him wait so long to even have it done,, is this safe

    • This response is from Dr. Van Crisco. “This patient certainly can have a heart catheterization as well as coronary intervention from the radial access site in the right or left wrist. Ambulation is early and vascular complications or fever. I am glad to see the patient for this discussion in consultation in our office. We can assess the valve without approach as well. We do it every day.”

  33. I had the angiogram done in my groin I have a very very large hematoma in that area over 3 weeks ago and it has gotten bigger and is still very large and painful and now they want to do another one in my wrist will I be in pain from that too?

    • This response is from Dr. Van Crisco. “Sounds like you might have a pseudoaneurysm in the right groin access site. This needs to be evaluated soon. Radial access from the wrist is associated with fewer complications so it would be fine to proceed, but the groin needs evaluation.”

Leave a Reply

Your email address will not be published. Required fields are marked *

Post comment