Ultrasound guided thrombin injection of pseudoaneurysm of the radial artery after percutaneous coronary intervention

Thrombin injection is frequently used to occlude iatrogenic pseudoaneurysms in larger vessels, but has never successfully been used in the radial artery location. Here we report the use of this treatment in a patient with radial artery pseudoaneurysm following coronary intervention. After Doppler sonographic visualization of the pseudoaneurysm cavity and its neck, an ultrasound-guided transcutaneous injection of thrombin was carried out. Immediately after the injection, the pseudoaneurysm was completely clotted and Doppler measurement confirmed the stop of blood flow. The result suggests that ultrasound-guided injection of thrombin into a radial artery pseudoaneurysm following coronary intervention is a feasible alternative to surgical intervention.     

Evaluation of the forearm blood flow with C.W. Doppler in patients submitted to myocardial revascularization with the radial artery

Before harvesting the radial artery for coronary bypasses, investigating forearm vascularization to avoid postoperative ischemia of the hand is mandatory. The study involved 192 consecutive patients, 155 males and 37 females age 39–76 years (mean 56.1). The CW Doppler static and dynamic test was performed to evaluate the patency of the upper limb's arteries and the adequacy of the ulnar supply in the nondominant arm. The use of the radial artery was contraindicated in 14 patients (3 for stenosis of the subclavian artery and 11 for inadequate collateralization). One hundred and four patients were operated on with the radial artery used as a graft; another conduit was used in the remaining 74 patients. The vascularization of the hand was restudied within 10 days in all patients who underwent surgery; in 82 patients, it was studied again at 1 year. The early Doppler control showed a significant increase of blood flow velocities in the ulnar artery, with a flow redistribution in the common digital palmar arteries (decreased in the 1st and slightly increased in the 3rd). The late Doppler control showed superimposable findings. No local ischemic complications were observed after radial artery removal. Three patients showed thumb dysesthesias with no functional damage, probably due to surgical trauma of the radial nerve collateral branches. The authors conclude that a Doppler study is a useful tool to detect patients for radial artery surgical removal and to predict the efficacy of the ulnar supply through the distal anastomosis.Presented in part at the 39th Annual World Congress, International College of Angiology, Istanbul, Turkey, June 1997.     

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.     

Intraluminal milrinone for dilation of the radial artery graft.

There is renewed interest in the use of the radial artery as a conduit for coronary artery bypass surgery. The radial artery is, however, a very muscular artery, prone to vasospasm. Milrinone, a potent vasodilator, has demonstrated vasodilatory properties superior to those of papaverine. In this report, we describe our technique of radial artery harvesting and the adjunctive use of intraluminal milrinone as a vasodilator in the preparation of this conduit for coronary artery bypass grafting. We have used these techniques in 25 patients who have undergone coronary artery bypass grafting using the radial artery. No hand ischemic complications have been observed in this group. Intraluminal milrinone appears to dilate and relax the radial artery, rendering this large conduit spasm free and very easy to use. We recommend the skeletonization technique for radial artery harvesting and the use of intraluminal milrinone as a radial artery vasodilator in routine myocardial revascularization.     

Noninvasive pulse wave analysis for the determination of central artery stiffness

Central artery stiffness predicts cardiovascular structural damage and clinical outcome. It is controversial whether central artery stiffness can be determined by noninvasive measurements. We compared noninvasive determination of central artery stiffness obtained from applanation tonometry of the peripheral radial artery waveform with invasive measurements of the ratio of pulse-pressure-to-stroke-volume. A total of 112 invasive measurements of the ratio of pulse-pressure-to-stroke-volume and noninvasive determinations of central artery stiffness were performed in 49 patients on the intensive care unit. In 13 out of 112 attempts of noninvasive measurements (12%) radial pulse could not be obtained using applanation tonometry because of cardiac arrhythmia or radial pulse could not be detected. These 13 failing noninvasive measurements were attempted in 7 patients. In the remaining cases we found a significant correlation between noninvasively obtained central artery stiffness and invasive measurements of the ratio of pulse-pressure-to-stroke-volume (Spearman r=0.40; p<0.0001). The association between invasive and noninvasive measurements was confirmed using Bland-Altman plots. Furthermore, a norepinephrine-induced increase of arterial stiffness was detected both invasively and noninvasively. Noninvasive determination of central artery stiffness obtained from peripheral radial artery waveform should be useful in clinical practice although it cannot be performed in every patient.     

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.     

Coronary and peripheral artery remodeling in patients undergoing PTCA: An intracoronary and transcutaneous ultrasound study.

The aim of this study was to assess the relationship between the plaque burden of nonstenotic coronary artery segments and the wall thickness of peripheral arteries using intracoronary and transcutaneous ultrasound imaging, respectively. Intracoronary ultrasound (CVIS, 3.5 Fr) was performed in 27 patients undergoing percutaneous transluminal coronary angioplasty. Carotid arteries were imaged by B-mode ultrasound with semiautomatic edge detection and radial arteries by high resolution A-mode echotracking (NIUS 2). Quantitative measurements included coronary artery intima-media cross-sectional area (IM(CSA)) and cross-sectional narrowing (CSN), as well as intima-media thickness (IMT) and lumen radius (r) of the common carotid and the radial arteries. Intima-media thickness was increased in coronary, carotid, and radial arteries. Coronary arteries had an IM(CSA) of 7.7 +/- 2.5 mm(2) and a CSN of 24% +/- 8%. Despite this moderate plaque burden, lumen area was preserved (12.3 +/- 4.2 mm(2)) because of compensatory enlargement of coronary arteries. Right and left carotid and right radial arteries had an IMT of 575 +/- 78 microm, 570 +/- 129 microm, and 328 +/- 61 microm, respectively. There was no correlation between coronary IM(CSA) and carotid IMT (r = 0.07) or radial IMT (r = 0.02), and there was no correlation between coronary CSN and carotid IMT/r (r = 0.12), or radial IMT/r (r = 0.25). In conclusion, in these patients with symptomatic ischemic disease no relationship between IMT of the coronary arteries and IMT of carotid or radial arteries was found. Although increasingly popular, IMT of peripheral arteries may be of limited value as surrogate marker for the severity of coronary artery disease. Cathet. Cardiovasc. Intervent. 48:12-17, 1999.     

Anterograde recanalisation of the radial artery followed by transradial angioplasty

We report a patient with critical hand ischemia after transradial coronary angioplasty. The radial artery occlusion was confirmed by angiography. The report discusses the role of angioplasty for the treatment of symptomatic radial artery occlusion.     

Routine use of the radial artery for coronary artery revascularization

Between January 1997 and December 2000, a total of 4,000 patients underwent myocardial revascularization using the radial artery as one of the conduits. The mean age of the patients was 54 +/- 7 years, and 92.8% of them were male. Of these patients, 31% had a left ventricular ejection fraction below 40% and 22.8% underwent urgent operation. A total of 4,225 distal anastomoses were performed using the radial artery. The average number of grafts was 3.3 +/- 0.5. The hospital mortality rate was 0.8%. Low cardiac output, inotropic support, perioperative myocardial infarction, reoperation for bleeding, atrial fibrillation, and sternal infection occurred in 1.8%, 2.8%, 1.2%, 1.2%, 16.8%, and 1.2% of the patients, respectively. None of the patients had major ischemia of the hand. The incidence of local hand wound complications was 0.7% (wound infection, 0.4%; wound dehiscence without infection, 0.1%; and hematoma, 0.2%). The average length of stay in the intensive care unit was 20 +/- 7 hours and in the hospital was 6 +/- 2 days. Postoperative angiography, performed in 106 patients at a mean interval of 18 months, showed that 92.4% of radial artery, 96.2% of internal mammary artery, and 76.2% of saphenous vein grafts were patent.     

Heparin-free distal radial artery approach to cardiac catheterisation and the small radial recurrent artery

Radial artery access has transformed cardiac catheterisation, allowing it to be performed in a daycase setting, saving both hospital beds, and nursing care costs. However, there are two common and seemingly diametrically opposite complications. These are radial artery occlusion and forearm haematoma; the former could be reduced by heparin, but at the expense of precipitating the latter. These complications increase proportionally to the size of radial artery sheath used. Interestingly, by cannulating the radial artery more distally beyond its bifurcation in the hand, the distal radial approach appears to be the ‘one stone, two birds’ or the synchronous Chinese idiom, ‘yīshí’èrniăo’s’ solution, reducing both complications at the same time. Extending this further and downsizing to a 4Fr catheter system, heparin use could be spared altogether, without complications, and haemostasis achieved with short manual pressure at the puncture site. Hence, further cost savings by foregoing commercial compression bands, and abolishing access site care for nurses. We illustrate the above strategy in a patient with challenging radial anatomy, made simple and easy.Key words: coronary angiography, distal radial artery, haemostasis, heparin, radial artery occlusion     

Symptomatic radial artery thrombosis successfully treated with endovascular approach via femoral access route

Radial access has been increasingly utilized for coronary intervention due to higher safety profile in comparison to femoral access site with lower bleeding rate. Radial artery occlusion is not uncommon with radial access site. This usually does not lead to any harm due to ulnar artery collaterals that are sufficient to prevent hand ischemia and is usually left alone. However, in the case of significant hand ischemia, treatment is often necessary. We are reporting an interesting case of symptomatic radial artery thrombosis leading to arm ischemia that was successfully treated percutaneously using femoral access. Using femoral access for radial artery intervention has not been reported previously. This case is followed by review of the literature.     

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.     

Postoperative evaluation of radial artery grafts for coronary artery bypass grafting by transit-time Doppler flow measurements.

Due to the histological configuration of the vessel wall, the radial artery is prone to spasm as a result of handling or harvesting. Therefore, certain degrees of arterial wall spasm are unpreventable, even with appropriate pharmacologic treatment, while using the radial artery as a bypass graft in CABG. Consequently, the radial artery is only reluctantly used compared to saphenous vein grafts in CABG. In our clinical experience, the radial artery, if harvested carefully, has proved to be an excellent bypass graft. This investigation was undertaken to study the differences in blood flow measured directly after extracorporeal circulation in radial artery grafts and venous grafts. Both grafts were compared to the left internal mammarian artery anastomosed to the LAD. METHODS: Between January 1998 and December 1999, 198 patients who were undergoing coronary artery revascularization with two grafts were retrospectively investigated. In all patients, the left internal mammarian artery (LIMA) was anastomosed to the left anterior descending branch (LAD). For the second graft, either the saphenous vein or the radial artery was used. Proximal anstomoses were performed as end-to-side into the ascending aorta. Patients were divided into four groups: Group 1: n = 79 IMA-LAD, vein to the circumflex artery; Group 2: n = 56 IMA-LAD, vein to the right coronary artery; Group 3: n = 34; IMA-LAD, radial artery to the circumflex artery; Group 4: n = 29 IMA-LAD, radial artery to the right coronary artery. Graft-flow measurements were performed using the transit-time method after extracorporeal circulation was terminated. The mean systolic, diastolic, and mean blood flow were measured, and the pulsatility index was calculated. Statistical analysis was performed using the of t-test analysis between the variables mean blood flow and pulsatility index. A p-value of < 0.05 was defined as statistically significant. RESULTS: There were no statistically significant differences in mean blood flow or pulsatility index between radial artery and saphenous vein grafts to the right coronary artery and the circumflex artery, respectively. Also, there were no differences regarding vein grafts to the right coronary artery and to the circumflex artery, or regarding radial artery grafts to the two coronaries, respectively. In group 4, significantly lower blood flow to the LAD was found compared to group 1, and a significantly higher pulsatility index compared to groups 2 and 3. CONCLUSIONS: Radial artery grafts compared to saphenous vein grafts do not show significant differences early after operation in mean blood flow or pulsatility index. Further studies are needed to evaluate long-term performance of radial arteries as coronary bypass grafts and to compare the radial artery to the right mammarian artery and the standard saphenous vein graft.     

Fluctuations of radial artery distensibility throughout the menstrual cycle.

Estrogen administration has a number of favorable cardiovascular effects, and recent evidence suggests that these include an increase in arterial distensibility. Whether this is also the case for the physiological changes in estrogen production during the menstrual cycle has never been determined, however. In 21 premenopausal healthy women, we continuously measured radial artery diameter and blood pressure by an echo-tracking device and a beat-to-beat finger device, respectively. Arterial distensibility was calculated as distensibility/blood pressure curve. The measurements were made during the follicular, ovulatory, and luteal phases of the menstrual cycle. As expected, compared with the follicular phase, plasma estradiol, follicle-stimulating hormone, luteinizing hormone, and prolactin were increased in the ovulatory phase, whereas progesterone was increased in the luteal phase, together with antidiuretic hormone. Radial artery distensibility was increased in the ovulatory and reduced in the luteal phase, the changes being independent of the small, concomitant blood pressure changes. The arterial wall stiffening seen in the luteal phase was associated with a reduction in the flow-dependent endothelial dilatation of the radial artery as assessed by the hyperemia after short-term ischemia of the hand. Thus, the natural menstrual cycle is characterized by alterations in radial artery distensibility. The mechanisms responsible for this phenomenon remain to be clarified. It is possible, however, that the greater arterial distensibility of the ovulatory phase is due to an estrogen-dependent reduction in vascular smooth muscle tone, whereas the arterial stiffening of the luteal phase depends on vascular smooth muscle contraction due to more complex hormonal phenomena, ie, an endothelial impairment due to estrogen reduction but also to an increase in progesterone and antidiuretic hormone levels.     

Radial artery occlusion and hand strength after percutaneous coronary procedures: Results of the HANGAR study

Objectives: The aim of this prospective study was to evaluate muscle force of the hand, thumb, and forefinger in patients with prolonged radial occlusion after transradial percutaneous coronary procedures. Background: There are no data on hand strength and function in patients with prolonged radial occlusion after percutaneous coronary procedures. Methods: Elective patients with chronic stable angina undergoing percutaneous coronary procedures were evaluated the day before the procedure for radial artery patency, Allen test, hand grip, and thumb and forefinger pinch tests. The same measures were performed the day after the procedure and at follow‐up. At follow‐up, patients were divided in two groups according to the radial patency (group 1) or occlusion (group 2). Results: Of the 99 patients included in the study, 90 patients had a patent radial artery (group 1), and nine (9.1%) patients had an occluded artery (group 2). At baseline, there were no significant differences in hand grip test between the two groups (42 ± 11 kg in group 1 and 41 ± 17 kg in group 2, P = 0.74). In both groups, after the procedure, the hand grip test values was significantly reduced compared with baseline values (40 ± 11 kg in group 1, P < 0.0001 and 37 ± 17 kg in group 2, P = 0.007). Finally, at follow‐up, in both groups, the hand grip test values returned to baseline values. Thumb and forefinger pinch tests did not show significant differences after the procedure and at follow‐up, compared with baseline. Conclusions: Radial artery occlusion after percutaneous coronary procedures was not associated with a reduction in hand and finger strength. © 2015 Wiley Periodicals, Inc.     

Tetralogy of fallot and congenital connection between the left subclavian artery and the pulmonary artery: possible relationship to a congenital left-hand deformity

A patient with tetralogy of Fallot was found to have pulmonary sling and an anomalous connection of the left subclavian artery with the pulmonary artery. At birth, she had a left split-hand deformity with preaxial (radial) syndactyly. Anomalous connection of a systemic vessel with the pulmonary artery is an uncommon cardiovascular defect. It is suggested that this cardiac defect may have caused intrauterine limb ischemia and the hand defect.     

Endoscopic radial artery harvesting may be the procedure of choice for coronary artery bypass grafting.

BACKGROUND: This study assessed the neurologic and cosmetic outcome of the endoscopic radial artery harvesting (ERH) technique in coronary artery bypass grafting (CABG). METHODS AND RESULTS: The study group comprised 257 consecutive patients who underwent CABG between January 2001 and August 2005 at Kyungpook National University Hospital. The first 157 patients (open group) underwent conventional open harvesting of the radial artery and the second 100 (endoscopic group) had endoscopic harvesting. The severity of both the motor and sensory symptoms, as well as the cosmetic results, was evaluated immediately and at least 6 months after surgery. In the open group, 29 patients experienced neuralgia along the distribution of the lateral antebrachial cutaneous nerve, but none in the endoscopic group patients experienced any sensory abnormalities (p<0.05). However, neuralgia along the distribution of the superficial radial nerve was similarly observed in both groups. No one in either group complained of any motor symptoms. The patients in the endoscopic group were also satisfied with the cosmetic results. CONCLUSIONS: ERH resulted in less neurologic complications of the hand and forearm, and outstanding aesthetics. ERH may be the procedure of choice for radial artery harvesting.     

Hand ischemia resulting from a transradial intervention: Successful management with radial artery angioplasty

We describe a case of hand ischemia resulting from transradial catheterization. This was successfully treated with angioplasty of the radial artery occlusion, but stresses the importance of a preprocedure evaluation of the dual blood supply to the hand before transradial access. © 2010 Wiley‐Liss, Inc.     

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.     

Impact of radial artery cannulation for coronary angiography and angioplasty on radial artery function

The radial artery is commonly used as a conduit in coronary artery bypass grafting. No data exist on the effects of radial sheath insertion on radial artery function. Because many patients considered for coronary artery bypass grafting have had previous radial procedures, it is important to understand any effects radial sheath insertion may have on radial artery function. Twenty-two patients who underwent elective coronary angiography or angioplasty with a 6Fr sheath through the right radial artery were studied. Radial artery function was assessed using ultrasound to measure flow-mediated dilation (FMD). Reactive hyperemia was produced by 5-minute cuff inflation on the arm to suprasystolic pressures. Radial artery diameter was measured at rest and 1 minute after cuff deflation. FMD was expressed as percent change in radial diameter compared with at rest. In all cases, the left radial artery was studied as a control. Patients were studied before sheath insertion, immediately after sheath insertion, and 6 weeks after sheath insertion. The FMD of the cannulated arm was 13.2% before sheath insertion versus 3.6% immediately after sheath insertion (p <0.01) and 0.2% (p <0.01) 9 weeks after sheath insertion. In contrast, there were no significant changes in the noncannulated arm at either time point. In conclusion, radial artery sheath insertion for coronary angiography or angioplasty results in immediate and persistent blunting of FMD, suggesting severe vasomotor dysfunction. Radial artery sheath insertion has important effects on radial artery function that must be considered when selecting radial conduits for coronary artery bypass grafting.