Interosseous artery as an access artery in case of late radial artery occlusion

We report a new technique of arterial access through the ipsilateral interosseous artery in a case of late radial artery occlusion (RAO). RAO, although not frequent, is a limiting iatrogenic complication after transradial intervention (TRI) and precludes repeat use of the same radial artery for future procedures. Our technique involves obtaining access to the ipsilateral radial artery (RA) in the distal postocclusion segment and use of collateral channel between this segment and the interosseous artery (IOA) for advancing a guidewire and sheath in the IOA lumen and in brachial artery thereafter. © 2017 Wiley Periodicals, Inc.     

Comparison of a priori versus provisional heparin therapy on radial artery occlusion after transradial coronary angiography and patent hemostasis (from the PHARAOH Study)

Systemic anticoagulation decreases the risk of radial artery occlusion (RAO) after transradial catheterization and standard occlusive hemostasis. We compared the efficacy and safety of provisional heparin use only when the technique of patent hemostasis was not achievable to standard a priori heparin administration after radial sheath introduction. Patients referred for coronary angiography were randomized in 2 groups. In the a priori group, 200 patients received intravenous heparin (50 IU/kg) immediately after sheath insertion. In the provisional group, 200 patients did not receive heparin during the procedure. After sheath removal, hemostasis was obtained using a TR band (Terumo corporation, Tokyo, Japan) with a plethysmography-guided patent hemostasis technique. In the provisional group, no heparin was given if radial artery patency could be obtained and maintained. If radial patency was not achieved, a bolus of heparin (50 IU/kg) was given. Radial artery patency was evaluated at 24 hours (early RAO) and 30 days after the procedure (late RAO) by plethysmography. Patent hemostasis was obtained in 67% in the a priori group and 74% in the provisional group (p = 0.10). Incidence of RAO remained similar in the 2 groups at the early (7.5% vs 7.0%, p = 0.84) and late (4.5% vs 5.0%, p = 0.83) evaluations. Women, patients with diabetes, patients having not received heparin, and patients without radial artery patency during hemostasis had more RAO. By multivariate analysis, patent radial artery during hemostasis (odds ratio [OR] 0.03, 95% confidence interval [CI] 0.004 to 0.28, p = 0.002) and diabetes (OR 11, 95% CI 3 to 38,p <0.0001) were independent predictors of late RAO, whereas heparin was not (OR 0.45 95% CI 0.13 to 1.54, p = 0.20). In conclusion, our results suggest that maintenance of radial artery patency during hemostasis is the most important parameter to decrease the risk of RAO. In selected cases, provisional use of heparin appears feasible and safe when patent hemostasis is maintained.     

New technique for treatment of postcatheterization radial artery pseudoaneurysm

We report a new technique for treatment of radial artery pseudoaneurysm (RAP) caused by transradial access (TRA) for coronary angiography. Traditional extrinsic compression with radial flow cessation leads to a local milieu likely associated with an increase in probability of radial artery occlusion (RAO). Our technique involves obtaining ipsilateral radial artery access distal to the neck of the RAP followed by a prolonged sheath dwell time covering the neck of the RAP which allows the RAP sac to thrombose and maintains radial artery lumen patency. © 2016 The Authors. Catheterization and Cardiovascular Interventions Published by Wiley Periodicals, Inc.     

Chronic radial artery occlusion after transradial catheterization. Re-canalization via an ipsilateral ulnar artery

Transradial approach to coronary angiography is a progressive and increasingly more often used technique. Apart from its advantages, radial artery occlusion (RAO) represents the most serious drawback. Re-canalization of an iatrogenic RAO, although asymptomatic in the majority of cases, remains a discussed and challenging topic. Besides its clear indications in symptomatic patients, it still remains questionable whether to perform this procedure in order to enable future repeated cannulations using the same access site and preserving the other remaining sites. For this particular reason we performed an antegrade re-canalization of an unrecognized RAO, likely a result of a previous transradial approach intervention. After a failed radial approach, the intervention was successfully performed via an ipsilateral ulnar artery. Following an uncomplicated coronary re-catheterization, RAO was angiographically diagnosed and re-canalized via the same (ulnar) access site using standard coronary equipment. Radial and ulnar artery patency were examined and checked on the following day and one month later using duplex ultrasonography.     

Incidence and outcome of radial artery occlusion following transradial artery coronary angioplasty

Coronary angioplasty with 6F guiding catheters via the radial artery is associated with a minimal risk for major entry site-related complications. Although the incidence of radial artery occlusion (RAO) in the literature is approximately 30% after prolonged cannulations, little is known about the incidence and its clinical consequences of RAO following transradial percutaneous coronary angioplasty. In a prospective study, 563 patients with a normal Allen test were evaluated on patency and function of the radial artery after transradial angioplasty, by physical and ultrasound examination at discharge, and at 1 month follow-up. At discharge, 30 patients (5.3%) had clinical evidence of RAO. At follow-up, persistent RAO was found in 16 patients (2.8%). In this study we found a low incidence of RAO after transradial percutaneous coronary angioplasty. None of the patients with temporary or persistent RAO had any major clinical symptoms. Therefore, the occurrence of RAO can be considered a minor complication in patients with a previously good double blood supply to the hand. Cathet. Cardiovasc. Diagn. 40:156–158, 1997. © 1997 Wiley-Liss, Inc.     

Renal artery angiography: "the right ipsilateral oblique" myth.

BACKGROUND: Finding the optimal image intensifier angle of obliquity during renal intervention is important for accurate stent placement but can require multiple catheter rotations and test injections of contrast. OBJECTIVE: Explore the usefulness of axial magnetic resonance angiography (MRA) as a roadmap for predicting image intensifier position during subsequent renal intervention. METHODS: MRA images were reviewed in 137 consecutive patients (255 renal arteries) undergoing workup for renal artery stenosis. The axial angle of renal artery incidence perpendicular to the spine was estimated by two operators and results averaged. RESULTS: The average angle of incidence for the renal artery ostia was +21.24 degrees +/-2.31 degrees for the right and +8.81 degrees +/-2.0 degrees for the left (P < .0001). The positive numbers correlate with left anterior oblique (LAO) and negative right anterior oblique (RAO). CONCLUSIONS: MRA can be used to define the origin of the renal artery and is most likely to predict an LAO image window for subsequent angiography of the left and right renal arteries displacing the "ipsilateral oblique" axiom. In patients without baseline MRA the 10 to 20 degree LAO "empiric" position will allow coaxial imaging of both renal ostia in 75% of cases. However, there can be extreme variation in the renal origin (53 degrees RAO to 85 degrees LAO) and we advocate using the simple technique reported herein to define the renal origin in patients with pre-procedure MRA.     

Efficacy and safety of transient ulnar artery compression to recanalize acute radial artery occlusion after transradial catheterization

Radial artery occlusion (RAO) can result from transradial catheterization. We compared the incidence of RAO with 2 heparin dosage regimens after transradial coronary angiography, and we evaluated the efficacy and safety of transient homolateral ulnar artery compression to achieve acute radial artery recanalization. Patients referred for coronary angiography were randomized to very-low-dose heparin (2,000 IU) or low-dose heparin (5,000 IU). On sheath removal, hemostasis was obtained using the TR band with a plethysmography-guided patent hemostasis technique. In the case of RAO as assessed by duplex ultrasonography 3 to 4 hours after hemostasis, immediate 1-hour ulnar artery compression was applied. Hematomas >15 cm(2) were also assessed. We randomized 465 patients, 222 in the 2,000-IU group and 243 in the 5,000-IU group. The baseline and procedural characteristics were comparable in both groups. The incidence of initial RAO was 5.9% in the 2,000-IU group and 2.9% in the 5,000-IU group (p = 0.17), with a compression time of 2.10 ± 0.78 hours and 2.25 ± 0.82 hours, respectively (p = 0.051). After ulnar artery compression, the final incidence of RAO was 4.1% in the 2,000-IU group and 0.8% in the 5,000-IU group (p = 0.03). The incidence of local hematoma was 2.3% and 3.7% in the 2,000- and 5,000-IU groups, respectively (p = 0.42). In conclusion, acute RAO after transradial catheterization can be recanalized by early 1-hour homolateral ulnar artery compression. This simple nonpharmacologic method was effective and safe in patients with very-low- and low-dose heparin. Nevertheless, the incidence of final RAO remained significantly lower after a higher anticoagulation level.     

Manual Versus Mechanical Compression of the Radial Artery After Transradial Coronary Angiography: The MEMORY Multicenter Randomized Trial

Objectives

The aim of this study was to compare manual versus mechanical compression of the radial artery after coronary angiography via transradial access regarding radial artery occlusion (RAO), access-site bleeding complications, and duration of hemostasis.

Radial artery occlusion: Preventing Insult to Injury

• Intra‐arterial nitroglycerin prior to transradial sheath removal may reduce the incidence of radial artery occlusion (RAO).
• Operators must observe careful attention to all aspects of transradial catheterization, particularly patent hemostasis; as well as independently monitor the institutional incidence of RAO to prompt improvements in practice.
• Future studies on the impact of pre‐puncture ultrasound, novel sheaths, hemostatic devices, and potent oral and intravenous antithrombotic therapy on 30‐day RAO diagnosed by ultrasound may allow further reduction of RAO in a real‐world practice.

     

Best Practices for the Prevention of Radial Artery Occlusion After Transradial Diagnostic Angiography and Intervention: An International Consensus Paper

Transradial access (TRA) is increasingly used worldwide for percutaneous interventional procedures and associated with lower bleeding and vascular complications than transfemoral artery access. Radial artery occlusion (RAO) is the most frequent post-procedural complication of TRA, restricting the use of the same radial artery for future procedures and as a conduit for coronary artery bypass graft. The authors review recent advances in the prevention of RAO following percutaneous TRA diagnostic or interventional procedures. Based on the available data, the authors provide easily applicable and effective recommendations to prevent periprocedural RAO and maximize the chances of access in case of repeat catheterization or coronary artery bypass grafting surgery.     

Strategies to Prevent Radial Artery Occlusion After Transradial PCI

Radial artery occlusion (RAO) is the most common structural consequence of transradial access (TRA) with an estimated incidence ranging from 2-10 %. Its occurrence is free of any major clinical consequences, especially at rest, with most if not all cases of digital ischemia occurring as a result of embolization, rather than RAO. The incidence of RAO is unacceptably high if “best practices” are not followed. Strategies to prevent RAO need to be implemented to preserve radial artery patency in order to exploit other benefits of TRA.     

老年患者经桡动脉介入治疗术后急性桡动脉闭塞危险因素分析

目的:观察老年患者(≥60岁)接受桡动脉冠状动脉介入诊疗(TRI)术后桡动脉急性闭塞(RAO)的发生率,并探讨影响老年患者TRI术后发生RAO的相关因素。方法:选择2006年8月至2009年2月,于北京安贞医院12病房择期TRI≥60岁的老年患者1 256例,根据术后是否发生RAO分为正常组和RAO组,通过多因素Logistic回归分析与RAO有关的危险因素。记录手术相关参数,包括桡动脉穿刺次数、鞘管型号、手术时间、术中肝素用量及术后桡动脉压迫止血时间。疑有桡动脉闭塞的患者通过多普勒超声确诊。结果:1.1 256例TRI患者急性RAO发生率2.2%(28/1256例)。与正常组相比,RAO组患者中女性、糖尿病和既往行TRI患者的比例较高,RAO组术中平均肝素用量明显低于正常组〔(3 826±523)IU vs.(7 425±980)IU,P=0.008〕,术后压迫时间长于正常组〔(378.9±35.4)min vs.264.7±43.2)min,P=0.003〕,且RAO组患者应用7F动脉鞘的比例较高(10.7%vs.1.9%,P=0.029);Logistic回归分析显示,7F动脉鞘管、肝素用量偏低及术后桡动脉压迫时间过长,是影响RAO发生的独立危险因素。结论:老年患者TRI术中选择尺寸合适的动脉鞘管、足够强度的抗凝治疗、避免术后过长时间的压迫止血等均有利于减少RAO的发生。     

Distal Radial Access: Consensus Report of the First Korea-Europe Transradial Intervention Meeting

Among patients undergoing percutaneous coronary procedures, transradial access, compared with transfemoral access, is associated with a reduced risk for complications including mortality, especially in higher risk patients. However, transradial access is limited by radial artery occlusion (RAO) that despite being mostly asymptomatic because of the extensive anastomoses between the forearm arteries restricts future use of the same radial artery. Distal radial access (DRA) in the anatomic snuffbox or on the dorsum of the hand has recently gained global popularity as an alternative access route for vascular procedures. A strong anatomic and physiological rationale yields potential for significantly reduced risk for RAO and positive impact on procedural outcome for better patient care. Indeed, currently published studies buttress very low rates of RAO after DRA, hence supporting its development. The authors provide an analysis of the foundation of DRA, provide historical background, and offer a critical review of its current status and future directions. Also, given the limited evidence currently available to properly perform DRA in the real world, consensus opinion on what is considered optimal practice is also presented to supplement this document and enhance the implementation of DRA while minimizing its complications.     

Comparison of Diagnostic Accuracy of Digital Plethysmography Versus Duplex Ultrasound in Detecting Radial Artery Occlusion After Transradial Access

BackgroundDuplex Doppler ultrasonography (USG) remains the gold standard for evaluation of radial artery occlusion (RAO) after transradial access (TRA). The diagnostic accuracy of digital plethysmography, which is cheaper and widely available, for evaluation of RAO after TRA is not known.MethodsPatients undergoing TRA were prospectively studied. After undergoing TRA for diagnostic or interventional coronary procedure and obtaining radial artery hemostasis, the radial artery was evaluated for presence or absence of RAO using digital plethysmography of the ipsilateral index finger and the thumb using modified reverse Barbeau's test (MRBT) and USG. Sensitivity, specificity, predictive values, likelihood ratios and other metrics of evaluation of diagnostic performance of MRBT in reference to USG, the current gold standard, were evaluated.Results503 patients who underwent TRA for coronary procedures were studied. MRBT demonstrated a sensitivity = 96.2%, specificity = 99.8%, positive predictive value = 96.1, negative predictive value = 99.8, likelihood ratio (+) = 481, likelihood ratio (−) = 0.38, diagnostic accuracy = 99.6, diagnostic odds ratio = 11,904, Youden's index = 0.96, receiver operator characteristic derived c-statistic = 0.98 and Cohen's k = 0.98 when compared to USG. MRBT performed using the ipsilateral index finger and the thumb was no different. Agreement between absence of ipsilateral radial artery pulsation and RAO was weak (Cohen's k = 0.69).ConclusionsMRBT using ipsilateral digital plethysmography performs comparably to USG for assessment of presence of RAO after TRA. There is no significant difference between MRBT performed using the ipsilateral thumb or the index finger.     

Prevention of Radial Artery Occlusion of 3 Hemostatic Methods in Transradial Intervention for Coronary Angiography

ObjectivesThe main objective of this study was to compare the efficacy of 3 hemostatic methods for the prevention of early radial artery occlusion (RAO): standard patent hemostasis, patent hemostasis with ulnar compression or the ulnar artery transient compression facilitating radial artery patent hemostasis (ULTRA) method, and facilitated hemostasis with a hemostatic disc.BackgroundThere are no prospective randomized studies that compare early RAO rates with the 3 most used nonocclusive hemostatic methods.MethodsThis was a prospective, longitudinal, comparative, and randomized study. The final population analyzed was 1,469, and they were randomized into 3 groups: 491 patients in group 1 with standard patent hemostasis, 490 patients in group 2 with the ULTRA method, and 488 patients in group 3 with facilitated hemostasis with a hemostatic disc.ResultsThe RAO rate at 24 hours of the total population analyzed was 4.6%. By hemostasis groups, it was 3.6% for patent hemostasis, 5.5% for the ULTRA method, and 4.7% for facilitated hemostasis with a hemostatic disc, with no statistical difference among the 3 groups (P = 0.387). At 30 days, the overall rate of RAO was 1.8%, and by groups, it was 1.4% for the patent hemostasis group, 1.8% for the ULTRA method group, and 2.2% for the facilitated hemostasis with a hemostatic disc group, respectively (P = 0.185).ConclusionsThe rates of RAO at 24 hours evaluated by plethysmography oximetry and confirmed by ultrasound among 3 current radial hemostasis methods (ie, patent hemostasis, the ULTRA method, and facilitated hemostasis with a hemostatic disc) are not different.     

Effect of hemostatic device on radial artery occlusion: A randomized comparison of compression devices in the radial hemostasis study

BackgroundAsymptomatic radial artery occlusion (RAO) is a major limitation of transradial catheterization (TRC). Two radial compression hemostatic devices are compared for their respective effects on RAO.MethodsIn a prospective, randomized, single center, blinded trial, 320 patients were randomly treated with a TR band (Terumo Corporation) or Safeguard Radial (Merit Medical). Institution wide protocols consisting of anticoagulation, patent hemostasis, duration of compression, and use of 6 French slender sheaths (Terumo Corporation) were observed. Patient discomfort related to the device was recorded using the universal pain scale. Radial artery patency was evaluated by reverse Barbeau's test prior to discharge (1-hour post-diagnostic catheterization or 6–24 hour post-intervention) and at 30-days.ResultsOf the 320 patients, 155 were randomized to the TR group (TRG) and 159 to the Safeguard group (SGG). 6 patients were excluded due to the inability to insert 6 Fr slender sheaths or patient withdrawing consent. Demographic and procedural characteristics were similar with the exception of the type of coronary procedure performed. Both bands were equally effective in achieving patent hemostasis. Despite having a higher rate of post-procedure hematoma (1.29% TRG vs. 3.1% SGG, p = 0.04) and acute RAO (3.8% TRG vs. 6.28% SGG, p = 0.05) with the Safeguard band, at 30 days RAO was similar in both groups (1.9% TRG vs. 2.5% SGG; p = 0.21). Patients in the SGG reported significantly less band discomfort and were found to require less air to achieve patent hemostasis.ConclusionEvidence-based contemporary TRC protocols of using smaller diameter access, anticoagulation, and use of just enough pressure for the shortest duration of time to achieve hemostasis is associated with very low RAO rate at 30 days irrespective of the radial compression device used.     

经桡动脉冠状动脉介入诊疗术后桡动脉损伤的影响因素分析

目的:探讨接受桡动脉冠状动脉介入诊疗患者术后,桡动脉损伤的情况及影响因素。方法:入选2008年5月至2009年10月,于安贞医院就诊拟行冠状动脉造影的患者966例,随机分为4F动脉鞘管组和6F动脉鞘管组。分析两组患者桡动脉并发症〔如桡动脉闭塞(RAO)、桡动脉痉挛(RAS)等〕的发生率,通过多因素Logistic回归分析RAO的危险因素。结果:4F鞘管组和6F鞘管组中,RAO(0.8%vs.2.9%,P=0.018),RAS(1.2%vs.3.5%,P=0.021),桡动脉内膜增厚率(1.0%vs.4.1%,P=0.002),前臂小血肿(0.6%vs.2.5%,P=0.020),患肢疼痛(1.2%vs.4.1%,P=0.006)等的发生率及压迫止血时间〔(4.62±0.98)vs.(6.36±0.93)h,P<0.001〕,4F组均低于6F组,差异有统计学意义。两组患者均未出现前臂大血肿、假性动脉瘤、动静脉瘘及骨筋膜室综合征。RAO经多因素回归分析显示,大尺径动脉鞘管、术后压迫止血时间过长是发生RAO的危险因素。结论:经桡动脉PCI中选择小直径动脉鞘管,避免术后长时间的压迫止血有利于降低RAO的发生率,同时减少桡动脉内膜损伤,提高患者舒适度。     

Distal Versus Conventional Radial Access for Coronary Angiography and Intervention: The DISCO RADIAL Trial

BackgroundCurrently, transradial access (TRA) is the recommended access for coronary procedures because of increased safety, with radial artery occlusion (RAO) being its most frequent complication, which will increasingly affect patients undergoing multiple procedures during their lifetimes. Recently, distal radial access (DRA) has emerged as a promising alternative access to minimize RAO risk. A large-scale, international, randomized trial comparing RAO with TRA and DRA is lacking.ObjectivesThe aim of this study was to assess the superiority of DRA compared with conventional TRA with respect to forearm RAO.MethodsDISCO RADIAL (Distal vs Conventional Radial Access) was an international, multicenter, randomized controlled trial in which patients with indications for percutaneous coronary procedure using a 6-F Slender sheath were randomized to DRA or TRA with systematic implementation of best practices to reduce RAO. The primary endpoint was the incidence of forearm RAO assessed by vascular ultrasound at discharge. Secondary endpoints include crossover, hemostasis time, and access site–related complications.ResultsOverall, 657 patients underwent TRA, and 650 patients underwent DRA. Forearm RAO did not differ between groups (0.91% vs 0.31%; P = 0.29). Patent hemostasis was achieved in 94.4% of TRA patients. Crossover rates were higher with DRA (3.5% vs 7.4%; P = 0.002), and median hemostasis time was shorter (180 vs 153 minutes; P < 0.001). Radial artery spasm occurred more with DRA (2.7% vs 5.4%; P = 0.015). Overall bleeding events and vascular complications did not differ between groups.ConclusionsWith the implementation of a rigorous hemostasis protocol, DRA and TRA have equally low RAO rates. DRA is associated with a higher crossover rate but a shorter hemostasis time.     

Ultrasound-guided distal transradial access for cardiac catheterization: Technical notes for the interventionalist

Over the latest years, the use of distal radial access (dTRA), also called “snuffbox,” has become more and more popular for cardiac catheterization. Indeed, dTRA has several advantages compared to the traditional proximal radial approach, such as a lower risk of hand ischemia, radial artery occlusion (RAO) and faster post-procedural hemostasis. However, due to the presence of different muscular-skeletal structures, as well as to the small diameter of the distal radial artery (dRA), an ultrasound-guided cannulation would be preferred since a blind puncture increases the risk of tendon damage and/or the irritation of the underlying periosteum. The present article is aimed to provide the key tips for performing US-guided access using the dRA in patients undergoing percutaneous cardiac procedures.     

Multicenter Randomized Evaluation of High Versus Standard Heparin Dose on Incident Radial Arterial Occlusion After Transradial Coronary Angiography: The SPIRIT OF ARTEMIS Study

Objectives

The aim of this study was to test the hypothesis that more intensive over standard anticoagulation administered during coronary angiography would significantly reduce rates of radial artery occlusion (RAO).