Acute Hand Ischemia and Digital Amputation After Transradial Coronary Intervention in a Patient With CREST Syndrome

The radial artery approach for coronary angiography and intervention is rapidly replacing the femoral artery approach, largely because it reduces bleeding and vascular access site complications. However, complications associated with transradial access warrant attention, notably radial artery occlusion. This report focuses on a case of radial artery occlusion after percutaneous coronary intervention in a 46-year-old woman with CREST (calcinosis, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome, which ultimately led to acute hand ischemia necessitating amputation of her middle and index fingers.     

Transradial cardiac catheterization: A Review of Access Site Complications

Transradial catheterization (TRC) has been associated with a lower incidence of major access site related complications as compared to the transfemoral approach. With the increased adoption of transradial access, it is essential to understand the potential major and minor complications of TRC. The most common complication is asymptomatic radial artery occlusion, which rarely leads to clinical events, owing to the dual collateral perfusion of the hand. Adequate anticoagulation, appropriate compression techniques, and smaller sheath size can minimize the risk of radial artery occlusion. Hand ischemia with necrosis has never been reported during TRC with thorough pre‐examination of intact collateral circulation. Radial artery spasm is relatively common, and can result in access and procedural failure. It can be prevented by the use of vasodilator cocktails and hydrophilic sheaths. Radial artery perforation can lead to severe forearm hematoma and compartment syndrome if not managed promptly. Careful observation, prompt detection of the hematoma, and management with a pressure bandage dressing are critical to avoid serious complications. Pseudoaneurym and arteriovenous fistula are rare complications, which can likely be managed conservatively without surgical intervention. Nerve injury occurring during access has been reported. Close observation for improvement is necessary, although symptoms usually improve over time. In summary, to prevent access site complications, avoidance of multiple punctures, gentle catheter manipulation, use of guided compression, coupled with careful observation for adverse warning signs such as hematoma, loss of pulse, pain, are critical for safe and effective TRC. © 2011 Wiley Periodicals, Inc.     

Distal Versus Proximal Radial Artery Access for Cardiac Catheterization and Intervention: Design and Rationale of the DIPRA Trial

BackgroundRadial artery (RA) catheterization is the access of choice over femoral artery access for most interventional vascular procedures given its safety and faster patient recovery. There has been growing interest in distal radial artery (dRA) access as an alternative to the conventional proximal radial artery (pRA) access. Preserving the RA is important which serves as a potential conduit for future coronary artery bypass surgery, dialysis conduit or preserve the artery for future cardiovascular procedures. The dRA runs in close proximity to the radial nerve, which raises the concern of potential detrimental effects on hand function.Study designThe Distal versus Proximal Radial Artery Access for cardiac catheterization and intervention (DIPRA) trial is a prospective, randomized, parallel-controlled, open-label, single center study evaluating the outcomes of hand function and effectiveness of dRA compared to pRA access in patients undergoing cardiac catheterization. The eligible subjects will be randomized to dRA and pRA access in a (1:1) fashion.The primary end point is an evaluation of hand function at one and twelve months follow-up. Secondary end points include rates of access site hematoma, access site bleeding, other vascular access complications, arterial access success rate, and RA occlusion at one and twelve months follow up.ConclusionEffects of dRA on hand function remains unknown and it's use questionable in the presence of a widely accepted pRA. DIPRA trial is designed to determine the safety and effectiveness of dRA for diagnostic and interventional cardiovascular procedures compared to the standard of care pRA.     

Angioplastie périphérique par voie radiale

Radial access for coronary intervention has gained popularity due to a low rate of access site bleeding complications and the possibility for early discharge. The preferential access site for peripheral intervention remains femoral, via antegrade or retrograde puncture. Not all peripheral lesions are suitable for transradial intervention due to the distance between the access site and the lesion location. This technique requires a precise strategy planning and knowledge of the available devices. We describe accessible sites from radial approach and the techniques to be used.     

Brewing the right cocktail for radial intervention

Radial access angioplasty has increased in popularity worldwide due to its decrease of access site complications, early patient mobility, patient comfort and lower costs. In a minority of patients, radial artery occlusion and radial artery spasm occurs. Because of the dual blood supply to the hand, radial artery occlusion is not associated with major clinical sequelae but prevention is important. Radial artery spasm rarely leads to serious vascular complications but can cause patient discomfort and can result in prolonging or failure of the procedure. Pharmacological and non-pharmacological strategies have been evaluated to prevent radial artery occlusion and radial artery spasm. A number of pharmacological 'cocktails' have been successfully tested but there is currently no agreement on the optimal combination of agents. In order to evaluate the best strategy to prevent radial artery occlusion and radial artery spasm we reviewed the relevant studies to date. From these studies it is clear that a 'cocktail' of agents should be given before transradial coronary angiography or angioplasty. A combination of heparin, nitroglycerin and verapamil is associated with the best preventive outcome.     

Distal radial access for coronary angiography and percutaneous coronary intervention: A state‐of‐the‐art review

Since its introduction by Lucien Campeau three decades ago, percutaneous radial artery approach at the forearm has been shown to provide advantages over the femoral approach and has become the standard approach for coronary angiography and intervention. Though infrequent, vascular complications still remain, mainly radial artery occlusion. Therefore, a more distal radial approach at the snuffbox or at the dorsum of hand has been suggested, initially by anethesiologists for perioperative patient monitoring, and more recently by Babunashvili et al. for retrograde radial artery recanalization of radial artery occlusion and then for coronary angiography and intervention. This distal radial approach has been advocated to reduce the risk of radial artery occlusion at the forearm (which precludes reintervention through the same access site) and bleeding and vascular access site complications, as well as to improve operator and patient comfort, especially when using left radial approach. This review describes in detail the anatomy of the radial artery at the wrist and the hand, the history of distal radial access, the rationale underlying use of this technique, the results published by experienced operators, the technique, the limitations, and potential role of this approach. This journey from the very proximal to the very distal part of the radial artery was indeed initiated and conceptualized by Lucien Campeau himself.     

Transradial access in an occluded radial artery: new technique

Radial access is considered clearly impossible in patients who develop radial artery occlusion after a transradial procedure. Radial artery occlusion also prohibits an ipsilateral transulnar approach. For patient subsets such as those with dialysis access in the other upper extremity or an occluded left radial artery with left internal mammary artery bypass grafts, switching to the transfemoral approach becomes inevitable. In some instances, the femoral access is also not an option due to severe aortoiliac disease. We describe a technique that allows the operator to access the proximal circulation from the occluded radial artery.     

Transradial right and left heart catheterizations: a comparison to traditional femoral approach.

OBJECTIVES: This study compares the transradial versus transfemoral approach to combined right- and left-heart catheterization. BACKGROUND: Central venous access from peripheral veins has been a historically useful technique. Although the need for right-heart catheterization has been considered an exclusion for transradial catheterization, we have combined a peripheral approach to the central venous system with radial arterial access which permits bilateral heart catheterization using a transradial approach. METHODS: Over an 18-month period all right-heart catheterizations done in conjunction with arterial access were reviewed. Salvage procedures, mixed site access, and biopsy procedures were excluded. Radial procedures were performed using radial artery access and a forearm vein. Femoral procedures used femoral artery/vein. Demographics, procedural information, and postprocedural complications including those requiring vascular ultrasound or transfusion were recorded and used for comparison between groups. RESULTS: Total of 175 femoral/105 radial cases done by 4 operators met criteria for comparison. Both groups had similar procedural indications and age. Procedural durations were shorter (P < .01) with radial 70 +/- 5.0 min (+/-95% CI) vs. femoral 75 +/- 5.4 min (+/-95% CI). Crossover was noted in several patients from both groups; radial procedures (n = 2) failed due to previous shoulder trauma. Femoral crossover to radial involved difficult arterial access. Complications related to access site occurred in 12 femoral and 0 radial patients. CONCLUSIONS: Using the forearm for central venous access appears safer than using the femoral vessels. Transradial catheterizations can be done in combination with forearm venous access procedures with excellent results and enhanced patient safety.     

Transradial renal artery angioplasty and stenting in a patient with Leriche syndrome

Percutaneous interventional procedures in the renal arteries are usually performed employing a femoral or brachial vascular access. In contrast, the transradial approach has been established for coronary angiography and angioplasty. We encountered a patient with Leriche syndrome who had renovascular hypertension ascribed to a severe left renal artery stenosis. To stabilize his blood pressure, we made an attempt to relieve the renal artery stenosis with Leriche syndrome by transradial renal artery angioplasty and stenting, using devices for coronary intervention. The procedure was successful without complications or residual stenosis. His hypertension improved with less antihypertensive medications. This case suggests that the radial approach might become an alternative entry site for renal artery interventions.     

Same wrist intervention via the cubital (ulnar) artery in case of radial puncture failure for percutaneous cardiac catheterization or intervention: The multicenter SWITCH registry

Aims

The radial approach is safer than the femoral for percutaneous coronary procedures. However its feasibility is lower, mainly for technical issues, often related to failure to puncture or cannulate the radial artery. The ulnar approach is a valid alternative to radial. We aimed to test the incidence, feasibility and safety of a direct homolateral ulnar approach in case of failed radial sheath insertion.

Methods and results

Five operators collected their 1-year activity (diagnostic and interventional) with focus on entry site. Entry site choice was left to operators' discretion. In case of failed radial sheath insertion, an attempt to cannulate the homolateral ulnar artery was mandated, if ulnar pulse was present. All patients in whom this attempt was performed were followed until discharge.Out of 2403 procedures (1271 interventions), the final successful entry site was radial in 66.5%, femoral in 31.0%, ulnar in 2.1% and brachial in 0.4%. Radial failure occurred in 117 patients (6.9%). In 75 patients, the radial failure was not due to sheath insertion (which was successful), but to lack of catheter support or to tortuosity of the subclavian/brachial arteries. In the remaining 42 (35.9% of all radial failures), a homolateral ulnar approach was attempted. A successful cannulation of the ulnar artery occurred in 36 patients (85.7%) with further performance of the complete procedure. Concerning local complications, 1 radial pseudo-aneurysm (treated with additional compression) occurred, while no cases of early hand ischemia were reported.

Conclusions

In this multicenter registry, in case of failed radial sheath insertion, switching directly to the homolateral ulnar artery for percutaneous coronary procedures is feasible and it appears to be safe, without cases of symptomatic hand ischemia.     

Procedural and clinical utility of transulnar approach for coronary procedures following failure of radial route: Single centre experience

Objectives

To assess the feasibility and safety of transulnar approach whenever transradial access fails.

Background

Radial access for coronary procedures has gained sound recognition. However, the method is not always successful.

Methods

Between January 2010 and June 2013, diagnostic with or without percutaneous coronary intervention (PCI) was attempted in 2804 patients via the radial approach. Transradial approach was unsuccessful in 173 patients (6.2%) requiring crossover to either femoral (128 patients, 4.6%) or ulnar approach (45 patients, 1.6%). Patients who had undergone ulnar approach constituted our study population. Selective forearm angiography was performed after ulnar sheath placement. We documented procedural characteristics and major adverse cardio-cerebrovascular events.

Results

Radial artery spasm was the most common cause of crossover to the ulnar approach (64.4%) followed by failure to puncture the radial artery (33.4%). Out of 45 patients (82.2%), 37 underwent successful ulnar approach. The eight failed cases (17.8%) were mainly due to absent or weak ulnar pulse (75%). PCI was performed in 17 cases (37.8%), of which 8 patients underwent emergency interventions. Complications included transient numbness, non-significant hematoma, ulnar artery perforation, and minor stroke in 15.5%, 13.3%, 2.2% and 2.2%, respectively. No major cardiac-cerebrovascular events or hand ischemia were noted.

Conclusion

Ulnar approach for coronary diagnostic or intervention procedures is a feasible alternative whenever radial route fails. It circumvents crossover to the femoral approach. Our study confirms satisfactory success rate of ulnar access in the presence of adequate ulnar pulse intensity and within acceptable rates of complications.     

Transulnar cardiac catheterization and percutaneous coronary intervention: techniques,transradial comparisons,anatomical considerations,and comprehensive literature review

Ulnar arterial access for cardiac catheterization and intervention is an alternative approach compared with radial or femoral access. Ulnar access is infrequently performed since the radial artery is readily palpable and is commonly used worldwide to minimize vascular complications from femoral access. Nevertheless, ulnar access provides a suitable access site in patients who are poor candidates for femoral access, have pre‐existing radial occlusion, radial artery hypoplasia or hyperplasia from prior radial artery procedures, radial stenosis, radial loops, radial tortuosity, small radial arteries, and/or have future need for radial graft for dialysis or coronary artery bypass graft. Furthermore, femoral access is the standard default option if radial access fails. Consequently, learning ulnar access provides a suitable forearm alternative to avoid femoral access when deemed high risk or undesirable. This review discusses the techniques of ulnar access, advantages and disadvantages of ulnar versus radial access, the clinical trials on ulnar cardiac catheterization and its associated complications.     

Transradial intervention of iliac and superficial femoral artery disease is feasible

Background: Percutaneous intervention of iliac artery (IA) and superficial femoral artery (SFA) disease is often performed via ipsilateral or contralateral femoral access. However, this approach may be difficult in patients with severe iliac or common femoral artery atherosclerosis, morbid obesity, or conditions prohibiting prolonged bed rest. Percutaneous transradial coronary intervention has gained popularity due to the low frequency of access site complications, early ambulation, and perhaps cost savings with early discharge. Transradial intervention (TRI) of IA and SFA disease has been previously described only in anecdotal case reports. Methods: Out of 159 patients who underwent IA and SFA intervention, 15 had their intervention attempted via the radial artery. TRI was attempted at the operator's discretion for one of the following reasons: absent femoral pulses, severe bilateral IA disease, obesity, or conditions prohibiting prolonged supine rest. Clinical and procedural characteristics were collected retrospectively. Results: Fourteen patients (93%) had successful intervention completed through the transradial approach. One patient needing an intervention of the distal SFA was converted to contralateral femoral approach because of the inadequate stent shaft length. Eighteen IA lesions and six SFA lesions were treated successfully with a good final angiographic result via a 6 FR radial access system. The ankle brachial index improved from a mean of 0.66 to 0.93. None of the patients had any procedural or access site–related complications. Conclusions: TRI is a feasible and safe alternative for percutaneous treatment of IA and SFA disease in carefully selected patients.     

Lesion complexity and angiographic outcomes in radial access percutaneous coronary intervention

Background: Percutaneous coronary intervention (PCI) is increasingly performed from the radial arterial (RA) access site. Few studies have examined the interaction between a default radial approach, lesion complexity, and angiographic outcome. This study investigates lesion complexity, arterial access route, and angiographic outcome in routine clinical practice by default radial operators. Methods: All cases of PCI over a 12‐month period (Jan 2005 to Jan 2006) at our regional cardiac center were prospectively entered into a database detailing arterial access route, target vessel and lesion characteristics, and lesion‐specific angiographic outcome. Angiographic success was defined as residual stenosis <50% for balloon angioplasty alone or <20% for a stented lesion in the presence of TIMI 3 flow in the target vessel. All procedures carried out by default radial operators were selected for further retrospective analysis. Reasons for not completing a case via the radial route were recorded. Radial and femoral cases by default radial operators were evaluated on grounds of lesion complexity and angiographic outcome for each treated lesion. Results: RA was the intended route in 91.5% of 1,324 procedures (91.5% of 2,239 lesions), and the final route in 90.1% of procedures (90.2% of lesions). There were 19 crossover procedures (30 lesions), all from radial to femoral access (FA). Crossovers were due to failed radial artery cannulation or sheath placement (9 procedures), inability to advance the guide catheter into the aortic root (7 procedures), and other guide catheter handling or support issues (3 procedures). Counting crossovers as failures, angiographic success rate was 96% among lesions for which RA was the primary intention. Complexity of cases was high (80.1% of RA lesions ACC/AHA type B2 or C). Conclusions: A default radial approach is compatible with successful treatment of a wide range of coronary lesions, with a low incidence of crossover to femoral access. When the radial approach fails, it is usually due to access problems rather than issues of guide catheter handling and support.     

Transradial stenting of the iliac artery: a case report.

In this case report, stenting of the common iliac artery via the radial access route with 6 Fr equipment, including an extra long multipurpose catheter, is presented. Radial access avoids bleeding and ischemia that may complicate retrograde or crossover access to the iliac artery.     

Transulnar carotid artery stent placement

Carotid artery stenting (CAS) has increased in popularity as an alternative to carotid artery endarterectomy for the treatment of significant carotid artery stenosis. The access site is predominantly the femoral artery, with radial or brachial access used less often. Here, we describe a case of CAS after failure of brachial access. Transulnar CAS was performed successfully without complications. Transulnar access represents an additional option in a patient undergoing CAS when conventional femoral, brachial, and radial arteries are not applicable. © 2012 Wiley Periodicals, Inc.     

Novel oral anticoagulants in the treatment of radial artery occlusion

Transradial access of the vascular system for coronary angiography and percutaneous coronary intervention has become the primary approach in several cardiac catheterization laboratories across the world. The paradigm shift from transfemoral access has been driven by improved outcomes in patients undergoing these cardiac procedures by transradial access. Radial artery occlusion is the most common vascular complication of transradial coronary procedures. Only a few studies have reported on the optimal treatment of radial artery occlusion, with ulnar artery compression and anticoagulation, especially with low-molecular-weight heparin, having shown the best results. In this case series, four patients who were found to have evidence of post-cardiac catheterization radial artery occlusion on ultrasound imaging were treated with a 30-day course of apixaban. Three of the four patients showed complete resolution of radial artery occlusion with addition of apixaban to current standard therapeutic strategies. This case series shows that treatment with novel oral anticoagulants can be an alternative and more convenient option compared to subcutaneous injection of low-molecular heparin for anticoagulation in patients with post-coronary angiography radial artery occlusion.     

Transulnar Catheterization in Patients with Failed Ipsilateral Transradial Access: Novel TR Band Modification for Dual-Site Hemostasis

ObjectivesThis study investigated the feasibility and safety of transulnar access (TUA) and efficacy of novel TR band modification for dual site hemostasis in patients with failed ipsilateral transradial approach.BackgroundFailed transradial access requires cross over to alternative access site. There is paucity of data on feasibility and safety of ipsilateral TUA due to concern of potential risk of hand ischemia.MethodsWe retrospectively reviewed ten patients who underwent coronary angiography and intervention via ulnar artery in the setting of failed ipsilateral transradial access. Patent hemostasis for both ulnar and radial arteries was achieved with novel modification of the TR band to compress both arteries at the same level of puncture sites.ResultsTUA after failed ipsilateral transradial access was successful in all ten cases. All patients were followed within 7 days and there were no adverse complications such as ulnar artery occlusion, nerve injury, or hand ischemia.ConclusionTUA maybe a safe and viable option when cross over is necessary from failed ipsilateral transradial access. Modification of the TR band for both radial and ulnar access site can achieve patent hemostasis effectively at the level of both puncture sites.     

Systematic review of alternative access for cardiac catheterization and percutaneous coronary intervention: Dorsal distal radial and ulnar artery catheterization

The femoral and radial arteries are the standard access routes for cardiac catheterization. In cases where the right radial artery has been previously utilized or is not suitable for repeat procedures, the left dorsal distal radial artery (anatomical snuff box) or the ulnar artery may be an alternative access site. In this systematic review, alternative access sites are described along with the techniques of cannulation, technical considerations, ultrasound imaging, clinical studies, and their complications. As we routinely perform more radial procedures, increased complications will arise, so it becomes important to gain expertise in alternative access for future coronary interventions. Such a systematic review has not been previously published so it will enhance the reader's knowledge of alternative access.     

Distal Radial Secondary Access for Transcatheter Aortic Valve Implantation: The Minimalistic Approach

BackgroundAlthough not yet recommended by the guidelines, distal radial access, a new site for cardiovascular interventions, has been rapidly acknowledged and adopted by many centers due to its high rate of success, safety and fewer complications. We present our experience using secondary distal radial access during transcatheter aortic valve implantation (TAVI), proposing a new, even more minimal approach.MethodsAs of November 2020, a systematic distal radial approach as secondary access site for TAVI was adopted in our center. Primary endpoints were technical success and major adverse events (MAEs). Secondary endpoints: the access site complication rate, hemodynamic and clinical results of the intervention, procedural related factors, crossover rate to the femoral access site, and hospitalization duration (in days).ResultsFrom November 2020, 41 patients underwent TAVI using this strategy. Patients had a mean age of 76 ± 11.2 years, 41% were male. Six (14.63%) patients received a balloon-expandable valve and 35 (85.37%) received a self-expandable valve. TAVI was successful in all cases. No complications occurred due to transradial access. Puncture success, defined as completed sheath placement was maximum (N = 41/41,100%) and emergent transfemoral secondary access was not required in any case. Primary transfemoral vascular access site complications occurred in 7 cases (17%) of which 4 (13.63%) were resolved through distal radial access: one occlusion, two flow-limiting stenoses and four perforations of the common femoral artery. There were no additional major vascular complications at 30 days. Overall MACE rate was 2.4%.ConclusionThe use of the distal radial approach for secondary access in TAVI is safe, feasible and has several advantages over old access sites.