Correlation of modified allen test with Doppler ultrasonography

The feasibility of using modified Allen tests to evaluate arterial circulation in the forearm for possible radial artery grafting, and the correlation of these tests with Doppler ultrasonography, were examined. The hand circulation of 50 patients scheduled for coronary artery bypass grafting was assessed by plethysmography, pulse oximetry, and pencil Doppler, as well as Doppler ultrasonography. Flow, velocity, and diameter of the radial, ulnar, and snuffbox arteries were recorded, and radiological screening indices were evaluated to establish a standard set of criteria. The results of modified Allen tests by plethysmography and pulse oximetry demonstrated the dominance of the ulnar artery. The indices of flow x diameter and velocity x diameter, obtained from Doppler ultrasound measurements, confirmed the dominance of the ulnar artery. When compression was applied to the arteries sequentially, significant alterations were found. The arterial circulation in the forearm can be safely evaluated by the modified Allen tests with plethysmography, pulse oximetry, and pencil Doppler, as these results correlated with Doppler ultrasound.     

Pushing wrist access to the limit

A 67‐year‐old man underwent primary percutaneous coronary intervention for acute anterior ST elevation myocardial infarction. The right radial artery was the access of choice. After easy cannulation, a 360‐degree loop was found at the elbow level. The brachial artery and a large ulnar artery were visible by injecting contrast through the radial loop. After an unsuccessful attempt to engage the loop, the operator switched entry site for the homolateral ulnar artery. Leaving the radial sheath in place, the cannulation of the ulnar artery was successful and uncomplicated. The operator could easily perform a successful intervention of the culprit vessel. An angiogram of the wrist, via the ulnar sheath showed the presence of a big interosseous artery with flow up to the hand and no flow in the radial and ulnar arteries distal to the sheaths. The ulnar and radial arteries were successfully sealed after a few hours, a valid pulsation was present on both arteries and no signs of ischemia were evident in the right hand the day after. © 2011 Wiley Periodicals, Inc.     

Hemodynamic and functional consequences of radial artery removal for coronary artery bypass grafting

Five years after surgery the echo-Doppler characteristics of the forearm circulation and the transcutaneous oxygen and carbon dioxide pressures of the operated and control arm were determined at rest and under conditions of hand exercise in 34 patients who received a radial artery graft for myocardial revascularization. Doppler measurements showed the ulnar compensation to radial artery removal, and transcutaneous measurements demonstrated a moderate degree of exercise-induced hand ischemia on the operated site.     

Dynamic Doppler evaluation of the hand arteries of the patients with Raynaud’s disease

The aim of this study was the determination of blood flow characteristics and parameters in the hand arteries of patients with primary Raynaud’s phenomenon (pRP) and comparison with the results of healthy subjects. The diameter, resistive index and flow volume of the digital, ulnar and radial arteries of the patients with pRP and the control group were measured at rest and after cold provocation. The flow starting time (FST) in the digital artery and the flow normalising time (FNT) of all three arteries were also recorded after cold provocation. The diameter and flow volume of the digital and ulnar arteries of the patients were lower at rest, but resistive index was significantly high in all arteries. After cold provocation, the diameters of the radial and ulnar arteries and the flow volume of the digital arteries of the patients were significantly lower than those of the controls. The mean FST was 3.6 ± 3.8 min for the patients and 0.9 ± 1.2 min for the controls. The mean FNT was significantly longer in all the arteries of the patients; FNT cutoff times for the radial, ulnar and digital arteries were 6.5, 5.5 and 6.5 min, respectively. The measurements of the diameter, resistive index and flow volume of all the arteries measured before and after cold provocation as well as FST of the digital artery and FNT of all the arteries may facilitate in providing additional information in pRP patients.     

Percutaneous ulnar artery approach for coronary angiography: a preliminary report in nine patients.

The radial artery approach is becoming more popular for diagnostic cardiac catheterization and interventional procedures because of its lower incidence of access site complications and decreased patient discomfort after the procedure. However, Allen's test reveals inadequate blood supply through the ulnar artery to the hand, and therefore the approach does not seem to be suitable in 10%-30% of patients. Here we demonstrated a new percutaneous ulnar artery approach for coronary angiography in nine patients. We succeeded in obtaining an entry site into the left ulnar artery in seven patients. The average time for cannulation and that for catheterization procedure were comparable with those of the radial approach previously reported from other laboratories. Complications such as bleeding, loss of an ulnar pulse, ulnar nerve injury, and the formation of an aneurysm or fistula were not observed in any patient. The ulnar approach may be another technique that decreases patient discomfort and risk, while preserving the radial artery as a potential coronary bypass graft for surgical myocardial revascularization. Cathet Cardiovasc Intervent 2001;53:410-414.     

Color Doppler ultrasonography of hand and finger arteries to differentiate primary from secondary forms of Raynaud's phenomenon

OBJECTIVE: Modern ultrasound (US) equipment allows rheumatologists to directly visualize hand and finger arteries. How does US aid in diagnosis of Raynaud's phenomenon (RP)? METHODS: Color Doppler US of the proper and common palmar digital, radial, and ulnar arteries and the superficial palmar arch of both hands was performed in 135 consecutive patients who presented with suspected RP. RESULTS: US was pathologic in 63% of patients with secondary RP, in 6% with primary RP, and in none with pseudo-RP (p < 0.0001). We found 3 types of vascular pathology: Type 1 showed narrowing or chronic occlusion of some proper digital arteries; Type 2 was characterized by the same finding in all proper digital arteries; and Type 3 involved acute occlusions. Type 1 was found in 3 of 53 patients with primary RP and in 19 patients with secondary RP including 5 of 9 patients with anti-centromere positive systemic sclerosis (SSc); Type 2 occurred in 16 patients with SSc, MCTD, and dermatomyositis; and Type 3 was found in 8 patients with antiphospholipid antibody syndrome, thromboangiitis obliterans, vibration trauma, or vasculitis. The ulnar arteries were more commonly affected than the radial arteries. The 2nd radial, 3rd radial, 4th ulnar, and 5th ulnar proper palmar digital arteries were most commonly involved. CONCLUSION: Aiding in differentiating primary versus secondary RP, severe versus less severe disease, and acute versus chronic vascular occlusion, digital artery US depicts the same anatomical structures as angiography, but it is cheaper, faster, and noninvasive.     

Successful percutaneous angioplasty and stenting of the radial artery in a patient with chronic upper extremity ischemia and digital gangrene.

PURPOSE: To report percutaneous treatment of a chronic radial artery occlusion in a multimorbid patient with ischemic tissue loss. CASE REPORT: A 62-year-old man with multiple comorbidities, including renal failure and severe coronary artery disease, presented with painful, ulcerated lesions of his right hand. He has severe peripheral vascular disease, with a history of 4 digital amputations of the left hand, a right above-knee amputation, and a left femoral to peroneal artery bypass. Arteriography demonstrated chronic occlusion of the radial and ulnar arteries, with a patent interosseous and collateral flow to the distal radial artery filling the palmar arch. Angioplasty and stenting of the radial artery was performed, relieving the patient's symptoms and allowing the lesions to heal. CONCLUSION: Percutaneous intervention can treat severe upper extremity ischemia with gangrene in patients with severe chronic ischemia and multiple comorbidities.     

Measurement of ulnar flow is helpful in predicting ischemia after radial artery harvest

BACKGROUND: Despite a negative Allen test, some patients develop hand ischemia after radial artery harvesting. The presence of large interosseous collaterals may reduce the sensitivity of Allen test. To evaluate the combination of ulnar flow measurements and the Allen test as an effective screening technique, we performed Doppler ultrasonography during Allen's maneuver. METHODS: The Allen test was used to select candidates for harvesting radial artery from 80 patients undergoing coronary bypass surgery. RESULTS: Of 71 patients with a negative Allen test, one patient developed hand ischemia. This patient was one of six (7.5 %) possessing low ulnar flow levels (less than 40 ml/min/m(2) during compression of the radial artery). This low-flow group had a higher risk for ischemia of the 71 patients with a negative Allen test. The post-operative flow differed greatly from the pre-operative flow in eight patients (11.3 %), which was likely due to large sacrificed interosseous collaterals. CONCLUSION: Combined use of ulnar flow measurement with the Allen test appears to increase the sensitivity of the Allen test. Neither test, however, is sufficient for a group of patients with large interosseous collaterals.     

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.     

Effects of Skeletonized versus Pedicled Radial Artery on Postoperative Graft Patency and Flow

Background

Radial artery (RA) was the second arterial graft introduced in clinical practice for myocardial revascularization. The skeletonization technique of the left internal thoracic artery (LITA) may actually change the graft''s flow capacity with potential advantages. This leads to the assumption that the behavior of the RA, as a coronary graft, is similar to that of the LITA, when skeletonized.

Objective

This study evaluated ''free'' aortic-coronary radial artery (RA) grafts, whether skeletonized or with adjacent tissues.

Methods

A prospective randomized study comparing 40 patients distributed into two groups was conducted. In group I, we used skeletonized radial arteries (20 patients), and in group II, we used radial arteries with adjacent tissues (20 patients). After the surgical procedure, patients underwent flow velocity measurements.

Results

The main surgical variables were: RA internal diameter, RA length, and free blood flow in the radial artery. The mean RA graft diameters as calculated using quantitative angiography in the immediate postoperative period were similar, as well as the flow velocity measurement variables. On the other hand, coronary cineangiography showed the presence of occlusion in one RA graft and stenosis in five RA grafts in GII, while GI presented stenosis in only one RA graft (p = 0.045).

Conclusion

These results show that the morphological and pathological features, as well as the hemodynamic performance of the free radial artery grafts, whether prepared in a skeletonized manner or with adjacent tissues, are similar. However, a larger number of non-obstructive lesions may be observed when RA is prepared with adjacent tissues.     

Endovascular Treatment of Critical Hand Ischemia: A Single-Center Experience

PurposeTo clarify the role of endovascular treatment in patients with Critical Hand Ischemia of the distal upper extremity.MethodsFrom January 2012 to January 2017, 18 dialyzed patients presented chronic critical hand ischemia; 6 patients had a chronic occlusion of the ulnar artery and radial artery stenosis, 5 patients had a chronic occlusion of the radial artery and ulnar artery stenosis, 4 patients presented multiple stenosis of the ulnar, radial and interosseous arteries, 2 patients had only ulnar artery occlusion while one patient presented only radial artery occlusion. All patients underwent duplex ultrasound and a subsequent brachial angiography, in order to evaluate the distal run-off circulation. Revascularization was achieved via antegrade brachial puncture in all patients, with retrograde approach in 4 patients, with distal retrograde puncture in 3 patients and in one patient with loop technique.ResultsNo complications were observed during the periprocedural follow-up. One patient was not successfully revascularized (technical success rate: 94.4%). The patient had no direct flow after ulnar artery angioplasty. The procedure was clinical effective in 15 patients (clinical success rate: 83.3%). Clinical evaluation and Duplex-US were performed in the follow up period. TcpO2 evaluated in the perilesional skin surface increased from 20.2 ± 6.5 mmHg to 53.8 ± 13.1 mmHg in the follow up period (P < .01). We observed an improvement of pain, ulcers and infection healing in all treated remaining patients during the postoperative period.ConclusionPercutaneous intervention prevents hand loss and functional impairment in patients with Critical Hand Ischemia and multiple comorbidities.     

Hand ischemia caused by solitary humeral exostosis irritating the brachial artery

A 39-year-old woman presented with ischemia of the left hand. Angiography revealed thrombosis of forearm arteries. Surgical intervention was unsuccessful. CT angiography revealed an exostosis on the distal humerus close to the brachial artery which we believe was the cause of repetitive minor trauma to the brachial artery leading to embolic occlusion of the radial and ulnar arteries. Early diagnosis of the underlying cause is the key to successful treatment of hand ischemia. For patients without risk factors for arterial occlusive disease, imaging of bony structures must be performed in order not to miss the likely cause of an insidious repetitive vascular trauma.     

Frequency of a positive modified Allen's test in 1,000 consecutive patients undergoing cardiac catheterization

The modified Allen's test (A.T.) is used to prove the adequacy of the blood supply through the ulnar artery to the hand. The test is considered normal if, after compression of both the ulnar and radial arteries followed by repeated clenching of the fingers to squeeze out the blood, the normal or a slightly more pronounced red color of the palm of the hands returns within < 10 sec after release of only the ulnar artery. It is important to perform the test whenever intravascular access to the radial artery is planned. The objective of this study was to determine the percentage of patients presenting a clearly positive (< 5 sec), a moderately positive (between 5–9 sec), or a negative A.T. (10 sec and more). We performed an A.T. on 1,000 consecutive and different patients undergoing cardiac catheterization, on the right wrist, two times, each time by a different examinator trained in this test. An A.T. was performed on 1,000 patients: 640 men, 360 women, mean age 62,3 yr (range 28–90 yr). In our population of patients, the relative percentages of a clearly positive (< 5 sec), moderately positive (between 5–9 sec), or negative modified Allen's test (10 sec and more) is 49%, 24%, and 27%, respectively. © 1996 Wiley-Liss, Inc.     

Does radial artery harvesting cause any changes in the forehand circulation during the postoperative period? An angiographic study.

OBJECTIVE: The aim of this study was to evaluate angiographic changes in the ulnar and interosseous arteries, and the collateral circulation of forehand after harvesting radial artery. METHODS: Forty patients were studied between June 1998 and June 2001. Study group consisted of 30 patients who received radial artery as a conduit for coronary artery bypass operation, and control group consisted of 10 patients who did not undergo any cardiac or vascular operation before. Preoperative risk factors were similar between the two groups. All patients underwent angiographic evaluation to detect coronary artery and left forehand arterial circulation. RESULTS: Angiographic evaluation was performed 25.5 +/- 2.0 months after the initial operation in the study group. Mean diameter of ulnar artery was 2.9 +/- 0.59 mm (range 2.1 - 4.8) in the study group and 3.2 +/- 0.8 mm (range 1.5 t- 4.7) in the control group (p >0.05). Mean diameter of interosseous artery was significantly higher in the study group than in control one: 2.06 +/- 0.57 mm (range 1.2 t- 4.2) versus 1.46 +/- 0.79 mm (range 0.8 t- 3.6); (p = 0.003). CONCLUSION: Although angiography was performed in a limited number of patients, interosseous artery rather than ulnar artery enlarged to compensate blood supply of forehand 25 months after harvesting the radial artery for coronary artery bypass grafting.     

Involvement of peripheral arteries in giant cell arteritis: a color Doppler sonography study

OBJECTIVE: To investigate the involvement of arteries other than the temporal arteries in active giant cell arteritis using color Doppler sonography. METHODS: The occipital, facial, vertebral, carotid, subclavian, axillary, brachial, ulnar radial, femoral, popliteal, posterior tibial, and dorsal pedal arteries, and the abdominal aorta of 33 consecutive patients with acute giant cell arteritis and 33 age- and sex-matched controls were investigated. RESULTS: In 10 patients (30%), but in none of the controls, a characteristic inflammatory mural thickening (halo) could be demonstrated in these arteries. The subclavian, external carotid, and/or facial arteries were involved in 4 patients, the occipital and/or axillary arteries in 3 patients, the brachial and/or ulnar arteries in 2 patients, and the common carotid, vertebral, popliteal, and/or radial arteries in 1 patient each. Two patients had symptomatic large vessel giant cell arteritis with arm claudication. The other patients were asymptomatic concerning the involved arteries. Furthermore the ulnar artery was occluded in 3 cases, the posterior tibial artery in 2 cases, and the dorsal pedal and the vertebral artery in 1 case each. No occlusions were found in the controls. Occlusion of the temporal arteries occurred more frequently in patients with peripheral artery involvement than in those without peripheral involvement (60% versus 26%). In most of the non-stenotic, small arteries the halo disappeared within 9 to 21 days. Mural thickening remained in large, stenotic arteries. CONCLUSION: Peripheral artery involvement occurs more frequently in acute temporal arteritis than has been assumed up to now. Color Doppler sonography offers a new method to evaluate this peripheral involvement.     

Entry sites for coronary angiography and therapeutic interventions: from the proximal to the distal radial artery

When coronary angiography was introduced at the Montreal Heart Institute, Montreal, Quebec, in 1964, a cutdown arteriotomy of the proximal radial artery 2 to 3 cm distal to its origin was selected as the standard access site used instead of the brachial artery approach described by Mason Sones Jr. The risk of symptomatic local thrombosis requiring surgical care appeared less at that site on the basis of collateral circulation to the hand by the ulnar and palmar arches. Attempts to replace the time-consuming cutdown arteriotomy by a percutaneous transarterial approach led successively to the axillary, femoral and brachial arteries and finally, over 20 years later, to the radial artery. The transradial approach for diagnostic angiography, first reported in 1989 and adapted by others several years later for angioplasty, is now used in over 44 countries. The only contraindication for this approach is the rare, inadequate ulnar artery collateral circulation to the hand, clinically recognized by an abnormal Allen test. The transradial approach is advantageous in that there is an easier and safer postprocedural hemostasis at the entry site, it is preferred by patients and ambulation within hours is compatible with an outpatient procedure.     

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.     

Value of echography in the diagnosis of post traumatic pathology of the ulnar artery, in manual workers

Three cases of hypothenar hammer syndrome are reported in manual workers who experienced repeated traumatism of the palm of the hand either because of personal habit or the use of professional tools. Hemodynamic examination of the upper limb was performed by plethysmography (Perivein Etna) and Doppler ultrasound (8 MHz) complemented by angiography by direct puncture of the humeral artery. Ultrasonography was performed using a 7.5 MHz probe (Sononranger) for exploration of the ulnar artery at the wrist and in its course through the palm. The 3 patients presented aneurysmal dilatation of the ulnar artery in the palm, complicated by postembolic thrombosis of the collateral arteries of the fingers. The ulnar artery lesion was permeable 1 time, already thrombosed 1 time and thrombosed secondarily 1 time. Ultrasonography of the palm showed suspected aneurysm of the ulnar artery in 2 patients: one case was confirmed by angiography, whereas the other remained only suspect since the thrombosed ulnar artery was not opacified. The third patient presented an ulnar artery thrombosis without true aneurysmal dilatation. It may be concluded that ultrasonography can show suspected aneurysmal dilatation of the ulnar artery and be complementary to arteriography when the ulnar artery is thrombosed.     

Percutaneous brachial approach in left heart catheterization with 5 French catheters. Preliminary experience

This describes our preliminary experience with percutaneous brachial approach for cardiac catheterization, by using 5 French (F) preformed catheters. Thirty patients (pts) were studied from the left arm (Group A) with a 5F sheath and 5F Judkins catheters and 30 from the right arm (Group B) with 5F sheath and 5F Amplatz catheters. Pigtail catheters (5F) were used for the left ventricular angiograms in all patients. In 10 patients arterial velocity signals and radial and ulnar artery blood pressures were monitored with the Doppler ultrasonic velocity detector before and immediately after each procedure, and 24 hours later. Arterial puncture was carried out successfully in each patient by using a 18-gauge Potts-Cournand needle. The puncture site was as close as possible to the ante cubital fossa where the artery is less mobile. Both coronary arteries were selectively opacified and the left ventricular angiography was done on every patient. The diagnostic quality of the angiograms was evaluated by the visual analogue scale and the results were not different from those obtained with the femoral approach in our catheterization laboratory. In 3 out of 30 pts in group B it was impossible to obtain a good left coronary opacification with Amplatz catheters for anatomical reasons, thus the right femoral approach was preferred. Brachial artery occlusion occurred in 1 patient from group B and needed surgical thrombectomy carried out to restore normal radial and ulnar pulses.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effectiveness of ulnar artery catheterization after failed attempt to cannulate a radial artery

Transradial artery catheterization has become an accepted alternative approach to performing diagnostic and interventional coronary procedures. However, its usefulness can be limited by access site failure. We report on 12 patients in whom there was failure to cannulate the radial artery. Angiograms of the hand were performed on all patients through the ulnar sheath to determine the possible mechanism of failure to cannulate the radial artery and to determine the source of the blood supply to the hand. Irrespective of the mechanism of failure, each of the 12 procedures was subsequently successfully completed using the ipsilateral ulnar artery approach.