Radial Artery Patency After Transradial Catheterization

Balloon-assisted tracking technique as 'a way forward' for transradial intervention

BACKGROUND

In percutaneous coronary interventions, use of the radial artery may be limited by vascular anatomy or vascular complications, such as radial artery spasm, dissection or perforation. The balloon-assisted tracking (BAT) technique is a novel and innovative method to successfully perform transradial procedures in patients with difficult vascular anatomy, severe tortuosity or radial artery spasm. In addition, the BAT technique can serve as a bail-out technique when vascular complications such as artery dissection or perforation occur.

OBJECTIVE

We analysed data of all percutaneous coronary intervention patients in whom the BAT technique was undertaken in daily practice and report acute and long-term outcomes.

RESULTS

A total of 62 patients were included and, in most patients, the BAT technique was performed for radial spasm. Most patients were administered benzodiazepines or nitrates before the BAT technique was performed. The primary end point, defined as successful passage of the catheter through the artery of the arm using the BAT technique, was 98%. 11% of patients developed a complication within 24 h (haematoma, prolonged pain or visible vascular damage at the end of procedure); all completely recovered at follow-up. No complications occurred during long-term follow-up.

CONCLUSION

BAT is a low-risk and easy-to-use technique that increases the success rate of radial artery access and may prevent vascular complications.

Complex Large-Bore Radial percutaneous coronary intervention: rationale of the COLOR trial study protocol

INTRODUCTION

The radial artery has become the standard access site for percutaneous coronary intervention (PCI) in stable coronary artery disease and acute coronary syndrome, because of less access site related bleeding complications. Patients with complex coronary lesions are under-represented in randomised trials comparing radial with femoral access with regard to safety and efficacy. The femoral artery is currently the most applied access site in patients with complex coronary lesions, especially when large bore guiding catheters are required. With slender technology, transradial PCI may be increasingly applied in patients with complex coronary lesions when large bore guiding catheters are mandatory and might be a safer alternative as compared with the transfemoral approach.

METHODS AND ANALYSIS

A total of 388 patients undergoing complex PCI will be randomised to radial 7 French access with Terumo Glidesheath Slender (Terumo, Japan) or femoral 7 French access as comparator. The primary outcome is the incidence of the composite end point of clinically relevant access site related bleeding and/or vascular complications requiring intervention. Procedural success and major adverse cardiovascular events up to 1 month will also be compared between both groups.

ETHICS AND DISSEMINATION

Ethical approval for the study was granted by the local Ethics Committee at each recruiting center ('Medisch Ethische Toetsing Commissie Isala Zwolle', 'Commissie voor medische ethiek ZNA', 'Comité Medische Ethiek Ziekenhuis Oost-Limburg', 'Comité d'éthique CHU-Charleroi-ISPPC', 'Commission cantonale d'éthique de la recherche CCER-Republique et Canton de Geneve', 'Ethik Kommission de Ärztekammer Nordrhein' and 'Riverside Research Ethics Committee'). The trial outcomes will be published in peer-reviewed journals of the concerned literature.

TRIAL REGISTRATION NUMBER

NCT03846752.

The Ulnar Artery as a Favorable Primary or Alternative Access Site for Coronary Angiography and Interventions

The transulnar approach (TUA) has been considered both as primary access and as a secondary access site after transradial access (TRA) failure for coronary invasive procedures. However, there is little evidence supporting the use of the TUA as the first approach to diagnostic coronary angiography (CAG) or interventions. Patients (n = 587) who underwent CAG and/or angioplasty (292 patients via TRA, 295 patients via TUA) were included. The primary end points of the study were major adverse cardiac events and major vascular events (hematoma, vascular occlusion, vasospasm), and secondary end points included angiographic success, crossover rate, and angiographic procedural times. The mean age was 60 ± 21 years. The composite primary end points occurred in 34 (11.6%) patients in the TRA and 22 (7.4%) patients in the TUA arm (P < .001). More arterial occlusion and more arterial spasm than in the TUA and similar urgent target vessel revascularization were observed in the TRA group in 48 hours. Based on previous studies and our clinical experience, we speculated that the TUA performed by an experienced operator has equal status with the TRA for coronary catheterization, especially in patients with a palpable ulnar pulse.

Transradial approach for neurointerventions: a systematic review of the literature

Background

Despite the recent increase in the number of publications on diagnostic cerebral angiograms using transradial access (TRA), there have been relatively few regarding TRA for neurointerventional cases. Questions of feasibility and safety may still exist among physicians considering TRA for neurointerventional procedures.

Methods

A systematic literature review was performed following PRISMA guidelines. Three online databases (MedLine via PubMed, Scopus and Embase) were searched for articles published between January 2000 and December 2019. Search terms included “Transradial access”, “Radial Access”, “Radial artery” AND “Neurointerventions". The reference lists of selected articles and pertinent available non-systematic analysis were reviewed for other potential citations. Primary outcomes measured were access site complications and crossover rates.

Results

Twenty-one studies (n=1342 patients) were included in this review. Two of the studies were prospective while the remaining 19 were retrospective. Six studies (n=616 patients) included TRA carotid stenting only. The rest of the studies included treatment for cerebral aneurysms (n=423), mechanical thrombectomy (n=127), tumor embolization (n=22), and other indications (n=154) such as angioplasty and stenting for vertebrobasilar stenosis, balloon test occlusion, embolization of dural arteriovenous fistula and arteriovenous malformation, chemotherapeutic drug delivery, intra-arterial thrombolysis, and arterial access during a venous stenting procedure. Two (0.15%) major complications and 37 (2.75%) minor complications were reported. Sixty-four (4.77%) patients crossed over to transfemoral access for completion of the procedure. Seven (0.52%) patients crossed over due to access failure and 57 (4.24%) patients crossed over to TFA due to inability to cannulate the target vessel.

Conclusion

This systematic review demonstrates that TRA has a relatively low rate of access site complications and crossovers. With increasing familiarity, development of TRA-specific neuroendovascular devices, and the continued reports of its success in the literature, TRA is expected to become more widely used by neurointerventionalists.

Slender versus conventional approach reduces post-procedural upper extremity dysfunction after transradial coronary procedures

AIMS

We compared the incidence of post-procedural radial artery occlusion (RAO) and upper extremity dysfunction (UED), in patients undergoing conventional versus slender transradial (TRA) coronary procedures.

METHODS AND RESULTS

UED was assessed by the QuickDASH, before conventional (i.e., ≥6F) and slender (i.e., "virtual" 3F to 5F) procedures, after 2 weeks and 2 months. RAO was assessed by Duplex in patients with an abnormal reversed Barbeau test (RBT). A total of 212 patients were included, UED after 2 weeks was 12%, and after 2 months 7% (p = <.001). RAO occurred in 3%. Multivariate analysis showed an OR of 0.26 (CI0.08-0.84) for UED at 2 weeks (p = .03) in favor of slender TRA. In patients with RAO, UED did not improve at 2 months (2/5, 40%, p = .046).

CONCLUSIONS

The occurrence of UED after TRA procedures is temporary except for patients with RAO. Slender TRA seems able to reduce short term UED.

Update on complications and their management during transradial cardiac catheterization

Introduction: Transradial artery access (TRA) was introduced in 1989 and has been universally used as an alternative approach to the traditional transfemoral access (TFA). Complications of TRA include asymptomatic and less likely symptomatic radial artery occlusion, nonocclusive radial artery injury, radial artery spasm, radial arterial perforation, radial artery pseudoaneurysm, arteriovenous fistula, granuloma formation, access-site bleeding, nerve damage, complex regional pain syndrome along with other rare complications.Areas covered: A literature search was performed using MedLine, PubMed, and Google Scholar (dating to 1 May 2019). Authors reviewed all articles related to transradial artery catheterization, its complications, as well as novel techniques for their management. The article provides insight on the incidence, risk factors, and prevention of such complications along with a description of usual and newer techniques to decrease morbidity.Expert opinion: With increasing experience, TRA complication rate is decreasing and new very uncommon complications are being described. A 'radial first' approach should be implemented in all catheterization laboratories and a physician's familiarity with minor and major complications is a must. Distal radial artery access through the snuff box might be the preferred site of accessing the radial artery and further studies will be needed to prove its superiority to the current access site.

Manual Radial Artery Compression After Transradial Coronary Procedures: Is It Safe to Go Bare-Handed?

Although the superiority of manual compression of the radial, mainly due to its selectivity and progressive grading, had been hypothesized from the early days of the transradial use, data on efficacy and safety of this method are only scarce. This review tries to delineate the aspects of manual hemostasis in transradial catheterization. Current data demonstrate that manual compression of the radial artery is a possible (second line) hemostatic option in transradial catheterization with main advantage the shorter hemostasis duration, and major disadvantage the need for larger involvement of post-procedural care team in hemostasis. Manual compression of the radial artery is a possible (second line) hemostatic option with main advantage the shorter hemostasis duration, and major disadvantages the need for larger involvement of post-procedural care team in hemostasis.

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.

BACKGROUND

Hemostasis of the radial artery after sheath removal can be achieved either by manual compression at the puncture site or by using a mechanical hemostasis device. Because mechanical compression exerts a more stable, continuous pressure on the artery, it could be hypothesized that it is more effective compared with manual compression regarding hemostasis time, bleeding, and RAO risks.

METHODS

A total of 589 patients undergoing diagnostic coronary angiography by transradial access with a 5-F sheath were randomized in a 1:1 ratio to receive either manual or mechanical patent hemostasis of the radial artery. Radial artery patency was evaluated by color duplex ultrasonography 24 h after the procedure. The primary endpoint was early RAO at 24 h. Secondary endpoints included access-site bleeding complications and duration of hemostasis.

RESULTS

Thirty-six (12%) early RAOs occurred in the manual group, and 24 (8%) occurred in the mechanical group (p = 0.176). There were no significant differences between the 2 groups regarding access-site bleeding complications (hematoma, 52 [17%] vs. 50 [18%]; p = 0.749; bleedings, 8 [3%] vs. 9 [3%]; p = 1.000). Duration of hemostasis was significantly shorter in the manual group (22 ± 34 min vs. 119 ± 72 min with mechanical compression; p < 0.001).

CONCLUSIONS

Manual and mechanical compression resulted in similar rates of early RAO, although the total duration of hemostasis was significantly shorter in the manual group.

Transradial Artery Access Complications

Transradial access (TRA) is favored over transfemoral access for performing coronary angiography and percutaneous coronary intervention due to the reduced risk for vascular and bleeding complications and the documented survival benefit in ST-segment–elevation myocardial infarction patients who undergo primary percutaneous coronary intervention. TRA complications can be categorized as intra- or postprocedural and further categorized as related to bleeding or nonbleeding issues. Major intra- and postprocedural complications such as radial artery perforation and compartment syndrome are rare following TRA. Their occurrence, however, can be associated with morbid consequences, including requirement for surgical intervention if not identified and treated promptly. Nonbleeding complications such as radial artery spasm and radial artery occlusion are typically less morbid but occur much more frequently. Strategies to prevent TRA complications are essential and include the use of contemporary access techniques that limit arterial injury. This document summarizes contemporary techniques to prevent, identify, and manage TRA complications.

Fast-track incorporation of the transradial approach in endovascular neurointervention

BACKGROUND

The transradial approach as a frontline approach is a novel technique in neuroendovascular procedures. In this study we aim to present our early experience with full transition to transradial access as the first-line approach for neuroendovascular procedures.

METHODS

We prospectively collected data on the first 100 consecutive patients who underwent a diagnostic or interventional neuroendovascular procedure using the transradial approach at our institution between March 22 and April 30, 2019. Baseline characteristics were collected in addition to the type of procedure, access site, catheters and wires used, complications, and whether there was crossover to transfemoral access.

RESULTS

Transradial access was attempted in 121 cases and 91 cases were completed successfully (72 diagnostic procedures and 19 interventional procedures). Mean (SD) age was 56.8 (14.7) years, 54.9% (50/91) underwent the procedure in the outpatient setting, and 60.4% (55/91) were women. Seven patients had minor immediate complications related to the radial access. Interventional procedures successfully performed included aneurysm embolization (ruptured (n=3) and unruptured (n=8)), tumor embolization (n=2), cervical internal carotid artery stenting (n=2), balloon occlusion test (n=1), vertebral artery sacrifice (n=1), and arteriovenous malformation embolization (n=2).

CONCLUSION

In this early experience, full transition to the transradial approach as the frontline approach is feasible with a low complication rate for both diagnostic and interventional neuroendovascular procedures.

Invasive Assessment of the Human Arterial Palmar Arch and Forearm Collateral Function During Transradial Access

Background:

The present study aimed to quantitatively measure the pressure-derived function of the palmar arch and forearm arterial collateral circulation during transradial access.

Methods and Results:

Palmar arch and forearm collateral function was determined using radial artery pressure signals in the nonobstructed vessel and during brief manual occlusions of the more proximal radial artery and of the radial plus ulnar arteries. Collateral flow index (CFI), the ratio of mean occlusive divided by mean nonocclusive arterial blood pressure, both subtracted by central venous pressure, was determined for CFI during radial artery occlusion (CFI rad ) and CFI during radial plus ulnar artery occlusion. Before invasive CFI measurements, arterial palmar arch and forearm function was tested noninvasively by the modified Allen test (MAT). Two hundred fifty patients undergoing transradial access coronary angiography were included in the study. CFI rad was equal to 0.802±0.150 (95% CI, 0.783–0.820). CFI during radial plus ulnar artery occlusion was equal to 0.424±0.188 (95% CI, 0.400–0.447). There was an inverse linear relation between CFI rad and MAT in seconds (s): MAT=64−63×CFI rad ( r 2 =0.229; P <0.0001). Two hundred eleven patients had a normal and 39 patients an abnormal (>15 seconds) MAT. The group with normal MAT had a CFI rad of 0.830±0.111, and patients with abnormal MAT had a CFI rad of 0.648±0.224 ( P <0.0001).

Conclusions:

Direct invasive hemodynamic assessment of the palmar arch and forearm arterial function reveals collateral supply to the briefly occluded in comparison to the patent radial artery of 0.802. During external occlusion of both radial and ulnar artery, CFI amounts to an unexpectedly high value of 0.424.

Distal radial artery access among cases with radial artery occlusion for primary percutaneous intervention

Radial artery access is associated with lower bleeding risks and higher patient satisfactions compared with femoral access. It is currently the preferred access for coronary catheterization and interventions, and increasingly used for peripheral and cranial vascular interventions. Herein, we present a patient who had a recent procedures included right transradial right vertebral artery and peripheral vascular interventions. She was admitted for abdominal aortic bifemoral artery bypass, and was complicated with ST elevation myocardial infarction that required immediate cardiac catheterization. Patient did not have palpable radial access and ultrasonography confirmed a total occlusion of right radial artery with thrombus. Although distal right radial artery - at the anatomical snuff box - was not palpable, artery was patent and could be accessed successfully with ultrasonography guidance.

Efficacy and safety of the distal transradial approach in coronary angiography and percutaneous coronary intervention: a Japanese multicenter experience

The novel distal transradial approach (dTRA) is expected to further build upon the advantages of transradial access. However, the incidence of radial artery occlusion (RAO) and hemorrhagic events with the dTRA has not been fully elucidated. The objective of this study was to investigate the effects of using the dTRA on RAO and postprocedural hemorrhage. From April 2018 to July 2018, 228 consecutive patients who underwent coronary angiography or intervention through the dTRA at two hospitals were analyzed. The RAO rate, change in the forearm and distal radial artery diameter and cross-section area after the dTRA (at 1 day and 1 month) on vascular ultrasonography, and incidence of hemorrhagic complications were investigated. Forearm and distal RAO occurred in 1 (0.4%) and 8 (3.1%) patients at 1 month, respectively. No forearm hematomas occurred. Ultrasonographic findings indicated that the radial artery diameter and cross-section area were significantly larger after the dTRA (2.9 ± 0.5 mm vs. 2.7 ± 0.5 mm, p < 0.001 and 6.5 ± 2.4 mm² vs. 5.6 ± 2.0 mm², p < 0.001, respectively). The distal radial artery diameter and cross-section area in the anatomical snuffbox were also significantly larger after the dTRA (2.5 ± 0.5 mm vs. 2.3 ± 0.4 mm, p < 0.001 and 4.7 ± 2.0 mm² vs. 4.2 ± 1.6 mm², p < 0.001, respectively). The DTRA was associated with a low incidence of RAO at both the puncture site and the forearm, postprocedural dilatation of the radial artery, and no bleeding complications extending to the forearm.

Randomized Comparison of Terumo® Coated Slender™ versus Terumo® Noncoated Traditional Sheath during Radial Angiography or Percutaneous Coronary Intervention

Background

The transradial approach is generally associated with few complications. However, periprocedural pain is still a common issue, potentially related to sheath insertion and/or arterial spasm, and may result in conversion to femoral access. Radial artery occlusion (RAO) following the procedure is also a potential risk. We evaluate whether the design of the sheath has any impact on these variables.

Methods

A total of 1,000 patients scheduled for radial CAG or PCI were randomized (1:1) to the use of a Slender or a Standard sheath during the procedure. Randomization was stratified according to chosen sheath size (5, 6, 7 French) and gender. A radial band was used to obtain hemostasis after the procedure, employing a rapid deflation technique. A reverse Barbeau test was performed to evaluate radial artery patency after removal of the radial band, and level of pain was assessed using a numeric rating scale (NRS).

Results

Use of the Slender sheath was associated with less pain during sheath insertion (median NRS 1 versus 2, p=0.02), whereas no difference was observed in pain during the procedure, radial procedural success rates, use of analgesics and sedatives during the procedure, and radial artery patency following the procedure. Rate of RAO was 1.5% with no difference between groups.

Conclusion

The use of the hydrophilic coated Slender sheath during radial CAG or PCI was associated with less pain during sheath insertion, whereas no difference in other endpoints was observed. A rapid deflation technique was associated with RAO of only 1.5%.

Role of vascular ultrasound scanning in repeated trans-radial coronary artery intervention (prospective randomized study)

OBJECTIVES

We aimed to detect if pre-procedure vascular ultrasound scanning (VUS) of radial arteries (RAs) can increase the radial access success (RAS) rate and/or reduce the vascular access time (VAT), by guiding the choice of the proper access site for repeated trans-radial interventions (TRIs).

BACKGROUND

Currently, repeated-TRIs are encountered more frequently in most of the cath. labs. However, structural changes of the RAs after TRA may hinder it is usage for repeated-TRI. VUS is the most accurate noninvasive test for assessing RAs, nonetheless, its role in the setting of repeated-TRIs has not been studied before.

MATERIAL AND METHODS

We randomly assigned 300 patients undergoing repeated-TRI, to either planning the vascular access site based upon the result of VUS that was performed pre-procedural (group A, 150 patients) or to be left to the operator's discretion (group B, 150 patients).

RESULTS

In group A (143/145 [98.6%]), RAS rate was only numerically higher than group B (143/150 [95.3%]), P = 0.08. There was a statistically significant differences between both groups in VAT [(1.25 ± 0.17 min), vs. (4.95 ± 0.87 min) for group A and B, respectively, P = 0.02] and in procedure duration [(37.2 ± 19.8 min) vs. (51.8 ± 18.6 min) for group A and B, respectively, P = 0.04]. RA spasm was more common in group B [18% (27/150)] than group A [2% (3/145)], P = 0.001.

CONCLUSION

VUS of RAs prior to repeated-TRI is associated with significant reduction in VAT, procedure duration, RA spasm and a mild increase in the RAS rate.

Hand Laser Perfusion Imaging to Assess Radial Artery Patency: A Pilot Study

Objectives: To test a novel diagnostic technique to assess radial artery perfusion after transradial catheterization. Background: Despite being mostly asymptomatic, radial artery occlusion (RAO) is not a benign complication, and its diagnosis is frequently missed because it requires time-consuming diagnostic testing. We developed a novel operator-independent diagnostic test to assess RAO after coronary procedures through a transradial access (TRA) by means of hand Laser Perfusion Imaging (LPI). Methods: One hundred patients were evaluated before and after TRA by means of the LPI. A radial perfusion index (RPI) was calculated as the ratio between the total perfusion measured during ulnar occlusion and total basal perfusion. Vascular Duplex scan (VDS) was used as the standard of reference to assess the artery patency. Results: LPI correctly identified RAO in 100% of cases. Post-procedural RPI was 0.89 ± 0.13 in patients with radial patency vs. 0.15 ± 0.04 in patients with RAO (p < 0.001). In line with these results, ROC analysis showed an excellent diagnostic performance of the LPI, that correctly identified all RAO cases (Area Under the Curve, AUC = 1.0; p < 0.001), with an optimal diagnostic cutoff at 0.2 RPI. Conclusions: LPI is a reliable diagnostic technique for RAO, offering the advantages of being quick and simple to perform.

Comparison of Radial Artery Occlusion Following Transradial Access for Percutaneous Coronary Intervention Using Sheath-based versus Sheathless Technique

We compared the risk of radial artery occlusion (RAO) in patients undergoing coronary intervention with introducer sheath (SG) or without introducer sheath (SLG). 1251 consecutive patients, from 2 tertiary care center in Pennsylvania, USA, undergoing percutaneous coronary interventions (PCI) between 2008-2013 formed the study cohort (SLG: 161 patients, SG: 1090 patients). Radial artery patency was assessed using plethysmography. The association between sheath use and RAO was assessed using unadjusted, adjusted and propensity macthed logistic regression analyses. Mean age: 65 years, men: 63%, diabetics: 37%. SG was associated with lower RAO at band removal [unadjusted (OR: 0.31, 95% CI: 0.21-0.46), adjusted (OR: 0.10, 95% CI: 0.05-0.20) and propensity matched (OR: 0.20, 95% CI: 0.13-0.32)], at 24 hours [unadjusted (OR: 0.20, 95% CI: 0.12-0.34), adjusted (OR: 0.12, 95% CI: 0.06-0.24) and propensity matched (OR: 0.13, 95% CI: 0.07-0.25)] and 30 days [unadjusted (OR: 0.28, 95% CI: 0.14-0.54), adjusted (OR: 0.22, 95% CI: 0.10-0.50) and propensity matched (OR: 0.18, 95% CI: 0.10-0.40)], compared to SLG. Sheath use during radial access for PCI is associated with less RAO. It is unclear if use of introducer sheath during radial access for PCI reduces incidence of RAO. In this prospective cohort study involving 1251 concecutive patients undergoing PCI via radial access between 2008-2013, we assessed the difference in incidence of RAO between the SG (n = 1090) and the SLG (n = 161 patients) groups. SG group experienced lower incidence of RAO at band removal, 24 hours and 30 days post PCI in the unadjusted, adjusted, and propensity matched analyses compared to the SLG group. In conclusion sheath use during radial access for PCI is associated with less RAO.

Two HEmostasis Methods After TransradIal Catheterization: THEMATIC - protocol for a randomized clinical trial

OBJECTIVE

Randomized clinical trial protocol to evaluate the incidence of radial artery occlusion with two different arterial compression devices after transradial procedures.

METHODS

Barbeau's test will be performed in adults scheduled to undergo transradial interventional procedures. Those with A, B, or C plethysmographic patterns will be selected. At the end of the procedure, patients will be randomly assigned (1:1) to receive patent haemostasis with TR Band™ device or conventional haemostasis with an elastic adhesive bandage. The primary outcome is the incidence of radial artery occlusion. Secondary outcomes are Barbeau's test curve change, additional time to achieve haemostasis, incidence of bleeding at the puncture site, pain severity, development of arteriovenous fistula, radial pseudo aneurysm, any access-site complication requiring vascular surgery intervention and costs between the two devices.

DISCUSSION

The results of this trial should provide valuable additional information on the best approach for haemostasis after transradial percutaneous cardiovascular interventions.

Contemporary Arterial Access in the Cardiac Catheterization Laboratory

Obtaining femoral and radial arterial access in the cardiac catheterization laboratory using state-of-the-art techniques is essential to optimize outcomes, patient satisfaction, and procedural efficiency. Although transradial access is increasingly used for coronary angiography and percutaneous coronary intervention, femoral access remains necessary for numerous procedures, many requiring large-bore access, including complex high-risk coronary interventions, structural procedures, and procedures involving mechanical circulatory support. For femoral access, contemporary access techniques should combine the use of fluoroscopy, ultrasound, micropuncture needle, femoral angiography, and vascular closure devices, when feasible. For radial access, ultrasound may reveal important anatomic features and expedite access. Despite randomized controlled trials supporting use of routine ultrasound guidance for femoral and/or radial arterial access, ultrasound remains underused in cardiac catheterization laboratories. This article reviews contemporary techniques to achieve optimal arterial access in the cardiac catheterization laboratory.

The ACRA Anatomy Study (Assessment of Disability After Coronary Procedures Using Radial Access): A Comprehensive Anatomic and Functional Assessment of the Vasculature of the Hand and Relation to Outcome After Transradial Catheterization

BACKGROUND

The palmar arches serve as the most important conduits for digital blood supply, and incompleteness may lead to digital ischemia when the radial artery becomes obstructed after cardiac catheterization. The rate of palmar arch incompleteness and the clinical consequences after transradial access are currently unknown.

METHODS AND RESULTS

The vascular anatomy of the hand was documented by angiography in 234 patients undergoing transradial cardiac catheterization. In all patients, a preprocedural modified Allen test and Barbeau test were performed. Upper-extremity function was assessed at baseline and 2-year follow-up by the QuickDASH. Incompleteness of the superficial palmar arch (SPA) was present in 46%, the deep palmar arch was complete in all patients. Modified Allen test and Barbeau test results were associated with incompleteness of the SPA (P=0.001 and P=0.001). The modified Allen test had a 33% sensitivity and 86% specificity for SPA incompleteness with a cutoff value of >10 seconds and a 59% sensitivity and 60% specificity with a cutoff value of >5 seconds. The Barbeau test had a 7% sensitivity and 98% specificity for type D and a 21% sensitivity and 93% specificity for types C and D combined. Upper-extremity dysfunction was not associated with SPA incompleteness (P=0.77).

CONCLUSIONS

Although incompleteness of the SPA is common, digital blood supply is always preserved by a complete deep palmar arch. Preprocedural patency tests have thus no added benefit to prevent ischemic complications of the hand. Finally, incompleteness of the SPA is not associated with a loss of upper-extremity function after transradial catheterization.

Impact of anticoagulation and vasoactive medication on regained radial artery patency after catheterization: a case-control study

Background

Radial artery access is the primary approach for coronary interventions due to higher safety profile in comparison to femoral access. Radial artery occlusion (RAO) is the main complication of transradial catheterization that can lead to severe symptoms and a permanent artery occlusion. The incidence of RAO after transradial access ranges from 5 to 38% and data regarding treatment is scarce. Whether anticoagulation and vasoactive medication provides an additional benefit in recovery of radial artery patency (RAP) after catheterization has not been investigated in detail.

Aim

The objective was to investigate the impact of anticoagulation and vasoactive medication on regained patency after documented RAO following transradial catheterization.

Patients and methods

Overall 2635 patients were screened. 2215 (84%) catheterizations were performed by femoral and 420 (16%) by radial access. In 30 patients RAO was observed. In case of RAO patients were classified in three groups: Anticoagulation, anticoagulation added with alprostadil and controls. Follow-up was conducted after 3 months with ultrasound and clinical examination.

Results

Eight patients received anticoagulation and 11 patients anticoagulation together with alprostadil. Eleven patients served as controls. Recovery of RAP after catheterization was higher following either treatment (79.5%) compared to controls (0%, p = 0.006). Subgroup analysis yielded a higher RAP recovery in patients treated with anticoagulation (62.5%) as compared to controls (0%, p = 0.002). No effect on regained RAP was found with additional alprostadil therapy (33.3%) compared to anticoagulation therapy (62.5%, p = 0.229).

Conclusion

RAO should be treated with anticoagulation to regain patency. Addition of vasoactive medication does not lead to further beneficial effects. Further research is needed regarding preventive and therapeutic strategies following RAO.

Transradial versus transfemoral approach for diagnostic coronary angiography and percutaneous coronary intervention in people with coronary artery disease

BACKGROUND

Cardiovascular disease (CVD) is the major cause of mortality worldwide. Coronary artery disease (CAD) contributes to half of mortalities caused by CVD. The mainstay of management of CAD is medical therapy and revascularisation. Revascularisation can be achieved via coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Peripheral arteries, such as the femoral or radial artery, provide the access to the coronary arteries to perform diagnostic or therapeutic (or both) procedures.

OBJECTIVES

To assess the benefits and harms of the transradial compared to the transfemoral approach in people with CAD undergoing diagnostic coronary angiography (CA) or PCI (or both).

SEARCH METHODS

We searched the following databases for randomised controlled trials on 10 October 2017: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Web of Science Core Collection. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform in August 2017. There were no language restrictions. Reference lists were also checked and we contacted authors of included studies for further information.

SELECTION CRITERIA

We included randomised controlled trials that compared transradial and transfemoral approaches in adults (18 years of age or older) undergoing diagnostic CA or PCI (or both) for CAD.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. At least two authors independently screened trials, extracted data, and assessed the risk of bias in the included studies. We contacted trial authors for missing information. We used risk ratio (RR) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) for continuous data, with their 95% confidence intervals (CIs). All analyses were checked by another author.

MAIN RESULTS

We identified 31 studies (44 reports) including 27,071 participants and two ongoing studies. The risk of bias in the studies was low or unclear for several domains. Compared to the transfemoral approach, the transradial approach reduced short-term net adverse clinical events (NACE) (i.e. assessed during hospitalisation and up to 30 days of follow-up) (RR 0.76, 95% CI 0.61 to 0.94; 17,133 participants; 4 studies; moderate quality evidence), cardiac death (RR 0.69, 95% CI 0.54 to 0.88; 11,170 participants; 11 studies; moderate quality evidence). However, short-term myocardial infarction was similar between both groups (RR 0.91, 95% CI 0.81 to 1.02; 19,430 participants; 11 studies; high quality evidence). The transradial approach had a lower procedural success rate (RR 0.97, 95% CI 0.96 to 0.98; 25,920 participants; 28 studies; moderate quality evidence), but was associated with a lower risk of all-cause mortality (RR 0.77, 95% CI 0.62 to 0.95; 18,955 participants; 10 studies; high quality evidence), bleeding (RR 0.54, 95% CI 0.40 to 0.74; 23,043 participants; 20 studies; low quality evidence), and access site complications (RR 0.36, 95% CI 0.22 to 0.59; 16,112 participants; 24 studies; low quality evidence).

AUTHORS' CONCLUSIONS

Transradial approach for diagnostic CA or PCI (or both) in CAD may reduce short-term NACE, cardiac death, all-cause mortality, bleeding, and access site complications. There is insufficient evidence regarding the long-term clinical outcomes (i.e. beyond 30 days of follow-up).

Ultrahigh-resolution ultrasound characterization of access site trauma and intimal hyperplasia following use of a 7F sheathless guide versus 6F sheath/guide combination for transradial artery PCI: Results of the PRAGMATIC trial

There exist limited data on the relative degree of acute injury and late healing of the radial artery after transradial artery (TRA) percutaneous coronary intervention (PCI) with a 7F sheathless guide catheter compared with a 6F sheath/guide combination. We used ultrahigh-resolution (55 MHz) vascular ultrasound to compare intimal-medial thickening (IMT) and early and late radial artery (RA) injury resulting from a sheathless 7F guide catheter versus a 6F sheath/guide combination for TRA-PCI.

METHODS

Forty-one consecutive consenting patients undergoing elective nonemergent TRA-PCI at a single institution from June 2016 to December 2016 were included. Patients were randomized (stratified by sex) to undergo TRA-PCI using a 7F sheathless guide catheter versus a 6F sheath/6F guide combination. Ultrahigh-resolution vascular ultrasound (55MHz) of the RA access site was performed at 24hours and 90days post-TRA-PCI. The primary outcome of the study was a noninferiority comparison of radial artery IMT thickness at 90days. PCI success rates, fluoroscopy times, number of guides used, and crossover rates to a femoral approach were also compared.

RESULTS

Baseline characteristics were similar between groups. Radial arterial IMT (mm) was similar between the 7F sheathless and 6F sheath/guide groups at 24hours (0.27 vs 0.29, respectively; P=.43) and at 90days (0.35 vs 0.34, respectively; P=.96). The P value for the noninferiority testing of a 0.07-mm limit was .002. Limited access site intimal tears were relatively common in both groups at 24hours (4 vs 5, P=.53) but often healed by 90days. Radial artery occlusion was infrequent at 90days (2 vs 1, P=.10), and no frank dissections were noted. PCI success rates (100% vs 95%, P=.59), fluoroscopy times (16 vs 12minutes, P=.17), number of guides used (1.1 vs 1.2, P=.48), and femoral crossover rates (0% vs 0%) were similar between the 2 respective groups.

CONCLUSIONS

A 7F sheathless approach to TRA-PCI results in no more IMT and early or late RA trauma than a standard 6F sheath/guide combination, rendering the 7F sheathless technique an attractive option for complex TRA-PCI.

Percutaneous access planning, techniques and considerations for endovascular aortic repair (EVAR)

Percutaneous endovascular aortic repair (EVAR) has transformed the field of aortic repair. As techniques and devices improve, interventionalists continue to expand the boundaries of what is possible, enabling these life-saving procedures to be performed on a wider range of more technically challenging cases. This article discusses endovascular access considerations for EVAR including; ultrasound guidance, preclose technique, access vessel options, innovative devices, and bailout strategies that interventionalists should be familiar with to optimize patient outcomes.

Combined Radial and Femoral Access Strategy and Radial-Femoral Rendezvous in Patients With Long and Complex Iliac Occlusions

We present cases of complex, calcified iliac occlusive disease revascularized via a combined radial-femoral access strategy. Through a 6-French, 125-cm transradial guiding catheter, antegrade guidewires and catheters are advanced into the iliac occlusion, while retrograde devices are advanced transfemorally. The transradial and transfemoral channels communicate, allowing the devices to cross the occlusion into the true lumen (radial-femoral antegrade-retrograde rendezvous).

Safety and efficacy of ulnar artery approach for percutaneous cardiac catheterization: Systematic review and meta-analysis

BACKGROUND

Trans-radial access has rapidly become the standard for percutaneous coronary procedures in the last decade. As proceduralists overcome the learning curve and become more competent in trans-radial access, alternative safe access sites such as the ulnar artery have been increasingly used for emergent and elective procedures. The aim of this study was to synthesize the best available evidence of the impact on major adverse cardiac events (MACE) of ulnar artery compared to radial artery cardiac catheterization.

METHODS

This review considered randomized controlled trials that included adult patients who had a percutaneous coronary procedure via the radial or ulnar artery. The intervention of interest was the use of ulnar compared to radial artery for cardiac catheterization. An extensive search was undertaken for published and unpublished trials up to May 2017. Methodological quality was assessed independently by two reviewers using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) checklist. Data were analyzed using Review Manager.

RESULTS

A total of six trials were included in the review. There was no statistically significant difference in the incidence of MACE between patients who underwent trans-ulnar or trans-radial artery catheterization (OR 0.90; 95% CI 0.65-1.25). Complications associated with access including hematoma formation, (n = 6 trials) pseudo-aneurysm, and arterio-venous fistulae formation (n = 5 trials), were investigated in a total of 5,276 patients, with no difference in these complications noted between the two groups. There were no differences in arterial access time, fluoroscopy time, and contrast load between the two groups.

CONCLUSIONS

There is evidence to support safe use of the ulnar artery as an alternative to the radial artery for access for cardiac catheterization.

Endovascular treatment for acute basilar thrombosis via a transradial approach: Initial experience and future considerations

Acute basilar artery occlusion (BAO) secondary to emergent large vessel occlusion (ELVO) has an extremely poor natural history, with a reported mortality rate up to 95%. Mechanical thrombectomy in the setting of ELVO is generally performed via a transfemoral approach. However, radial access is increasingly being utilized as an alternative. We report our initial multi-institutional experience using primary radial access in the treatment of acute BAO in nine consecutive cases. Technical success defined as a TICI score of 2B or 3 was achieved in 89% of cases. Average puncture to revascularization time was 35.8 minutes. There were no complications related to radial artery catheterization. We contend radial access should potentially be considered as the first-line approach given inherent advantages over femoral access for mechanical thrombectomy for BAO.

Same-day dual radial artery puncture examination in patients requiring percutaneous coronary intervention and the incidence of radial artery occlusion

BACKGROUND

We sought to investigate the rate of radial artery occlusion (RAO) after same-day dual radial artery puncture. The trans-radial arterial approach (TRA) for diagnostic and interventional procedures has risen significantly in the United States. Although becoming more commonly performed, TRA is not without risk, and a potential complication is RAO. The rate of RAO after same-day dual artery puncture is unknown.

METHODS

A retrospective analysis of 27 patients who underwent same-day dual radial artery puncture for percutaneous coronary intervention (PCI) at our institution (Providence Heart Institute in Southfield, MI, USA) from November 2011 to December 2013 were included after initially presenting for cardiac catheterization at a non-PCI-capable facility. The study patients were asked to follow up for evaluation of the radial artery, including obtaining a duplex ultrasound evaluation.

RESULTS

The mean age of the patients was 65 years old with 66% of the patients being male. Of the 27 study participants, there were no symptoms reported that were related to RAO. Overall, one (3.7%) patient had an absent radial pulse. The modified Allen's test was normal in all of the patients with a mean return of palmar flush time of 4 seconds. Duplex ultrasound revealed subtotal RAO in four (14.8%) patients and no patients experienced total occlusion following the intervention.

CONCLUSION

Dual radial artery puncture appears to be a well-tolerated and viable strategy in patients that are transferred to a PCI-capable hospital for coronary interventions.

Randomized study comparing incidence of radial artery occlusion post-percutaneous coronary intervention between two conventional compression devices using a novel air-inflation technique

AIM

To compare post-percutaneous coronary intervention (PCI) radial artery occlusion (RAO) incidence between two conventional radial artery compression devices using a novel air-inflation technique.

METHODS

One hundred consecutive patients post-PCI were randomized 1:1 to Safeguard or TR band compression devices. Post-radial sheath removal, each compression device was inflated with additional 2 mL of air above index bleeding point during air-filled device application and gradually down-titrated accordingly. RAO was defined as absence of Doppler flow signal performed at 24 h and at 6 wk post-PCI. Patients with missing data were excluded. Statistical significance was defined as P < 0.05.

RESULTS

All patients had 6F radial sheath inserted. No significant differences were observed between Safeguard Radial (n = 42) vs TR band (n = 42) in terms of age (63 ± 11 years vs 67 ± 11 years), clinical presentation (electives, n = 18 vs n = 16; acute coronary syndrome, n = 24 vs n = 26) and total procedural heparin (7778 ± 2704 IU vs 7825 ± 2450 IU). RAO incidence was not significantly different between groups at 24 h (2% vs 0%, P = 0.32) and 6 wk (0%, both).

CONCLUSION

Safeguard Radial and TR band did not demonstrate significant between-group differences in short-term RAO incidence. Lack of evidence of RAO in all post-PCI patients at 6 wk follow-up, regardless of radial compression device indicate advantage of using the novel and pragmatic air-inflation technique. Further work is required to more accurately confirm these findings.

Hemostasis pad combined with compression device after transradial coronary procedures: A randomized controlled trial

BACKGROUND

Arterial access and hemostasis are important processes during percutaneous coronary procedures. In this study, we tested if the use of chitosan-based pads on top of compression devices could improve hemostasis efficacy compared with compression devices alone after transradial coronary angiography or interventions.

METHODS

This study was a single-center open-label randomized controlled trial. Patients who underwent coronary angiography or intervention with the transradial approach were randomly assigned to the study (compression device and a chitosan-based pad) or control (compression devices alone) group in a 2:1 fashion. The primary endpoint was time to hemostasis, categorized into ≤5, 6-10, 11-20, and >20 minutes.

RESULTS

Between April and July 2016, 95 patients were enrolled (59 were assigned to the study arm and 36 to the control arm). Time to hemostasis, the primary endpoint, was significantly lower in the study group than in the control group (p<0.001). Both groups showed low rates of vascular complications.

CONCLUSIONS

This study suggests that the use of a hemostasis pad in combination with rotatory compression devices is a safe and effective hemostasis strategy after radial artery access.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02954029.

Endovascular Crossing of Chronic Total Occlusions Using an Impulse: An Explorative Design Study

In this study we investigated whether exerting an impulse on a Chronic Total Occlusion (CTO) improves the success rate of CTO crossing as compared to the currently used method of statically pushing the guidewire against the CTO. A prototype (Ø2 mm) was developed that generates translational momentum using a spring-loaded indenter and converts it to an impulse during impact. Mechanical performance was evaluated by measuring the peak force and momentum for different spring compressions and strike distances in air and blood-mimicking fluid. Puncture performance, in terms of number of punctures, number of strikes to puncture, and energy transfer from the indenter to the CTO, was assessed for six tip shapes (stamp, wedge, spherical, pointed, hollow spherical, and ringed) on three CTO models with different weight percentages of gelatin and calcium. As a control, a Ø0.4 mm rigid rod was tested. A maximum indenter momentum of 1.3 mNs (velocity of 3.4 m/s), a peak force of 19.2 N (vs. 1.5 N reported in literature and 2.7 N for the control), and CTO displacement of 1.4 mm (vs. 2.7 mm for the control) were measured. The spherical and ringed tips were most effective, with on average 2.3 strikes to puncture the most calcified CTO model. The prototype generated sufficient peak forces to puncture highly calcified CTO models, which are considered most difficult to cross during PCI. Furthermore, CTO displacement was minimized, resulting in a more effective procedure. In future, a smaller, faster, and flexible clinical prototype will be developed.

Radial artery occlusion after transradial coronary catheterization

The transradial approach (TRA) for coronary angiography and interventions is increasingly utilized around the world. Radial artery occlusion (RAO) is the most common significant complication after transradial catheterization, with incidence varying between 1% and 10%. Although RAO is rarely accompanied by hand ischemia, it is an important complication because it prohibits future transradial access and radial artery utilization as a conduit for coronary artery bypass grafting or arteriovenous fistula formation. In this review, we discuss factors predicting the occurrence of RAO, aspects of accurate and prompt recognition, methods that contribute to its prevention and possible treatment options.

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.

Transradial Access for Interventional Radiology: Single-Centre Procedural and Clinical Outcome Analysis

PURPOSE

The study sought to describe a single centre's technical approach to transradial intervention and report on clinical outcomes and safety.

METHODS

A total of 749 transradial access (TRA) procedures were performed at a single hospital in 562 patients (174 women and 388 men). Procedures included 445 bland embolizations or chemoembolizations of the liver, 88 uterine artery embolizations, and 148 procedures for Selective Internal Radiation Therapy (Y90), which included mapping and administration. The mean age of the patients was 62 years (range 27-96 years).

RESULTS

Four cases (0.5%) required crossover to transfemoral (tortuous anatomy, inability to secure a stable position for embolization, vessel spasm and base catheter not being of a sufficient length). A single asymptomatic, short-segment radial artery occlusion occurred (0.3%), 3 patients (0.4%) developed small hematomas postprocedurally, and 2 patients (0.7%) had transient neurological pain, which was resolved within a week without treatment. It was found that 98% of patients who had a previous femoral access procedure would choose radial access for subsequent procedures.

CONCLUSIONS

Transradial access is a safe, effective technique, with a learning curve; however, this procedure has the potential to significantly improve departmental workflow and cost savings for the department and patient experience.

Effects of methods used to achieve hemostasis on radial artery occlusion following percutaneous coronary procedures: a systematic review

BACKGROUND

Transradial access to percutaneous coronary procedures is becoming the preferred access route, and it is being increasingly used for emergent and elective procedures. However, radial artery occlusion (RAO) continues to remain an adverse occurrence following sheath removal or in the first 24 hours following sheath removal due to the smaller diameter of the artery.

OBJECTIVES

The overall objective of this study was to synthesize the best available research evidence related to the effects of methods used to achieve hemostasis on RAO rates after percutaneous coronary procedures.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

The current review considered trials that included adult patients (18 years and over) who have had a coronary angiography or coronary re-vascularization intervention via the radial artery.

TYPES OF INTERVENTION(S)

The interventions of interest were the use of various hemostatic methods compared to traditional interventions to prevent RAO.

TYPES OF STUDIES

All randomized and quasi-randomized controlled trials evaluating the effect of various hemostatic methods on RAO rates after percutaneous coronary procedures were included in the review.

OUTCOMES

The primary outcome of interest was the incidence of RAO at the time of discharge and persistent occlusion at the time of follow-up.

SEARCH STRATEGY

The search aimed to find published and unpublished trials through electronic databases, reference lists and key reports. An extensive search was undertaken for the following databases - CINAHL, Embase, PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL). Databases were searched up to May 2016. The search for unpublished trials included Dissertation Abstracts International, World Cat, Clinicaltrials.gov, ProQuest Dissertation and Theses and MedNar.

METHODOLOGICAL QUALITY

Methodological quality was assessed independently by two reviewers using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) checklist. Disagreements that arose between the reviewers were resolved through discussion.

DATA EXTRACTION

Quantitative data were extracted from papers included in the review by one reviewer using the standardized data extraction tool from JBI-MAStARI. The data extracted were checked by a second reviewer. Disagreements that arose between the reviewers were resolved through discussion. All results were subject to double data entry in Review Manager.

DATA SYNTHESIS

Statistical pooling of the data was not possible due to the heterogeneity of the trials; therefore, the findings are presented in narrative form. However, figures have been used to illustrate the results.

RESULTS

A total of seven trials were included in the review. One trial demonstrated a significant reduction in RAO rates in patients who had a mean arterial pressure (MAP)-guided TR band to a standard TR band (odds ratio [OR] 0.08; 95% confidence interval [CI] 0.02, 0.37). A statistically significant reduction in the incidence of RAO was observed among patients who received a biopolymer dressing (Chitosen) compared to those who received the TR band (OR 2.20; 95% CI 1.20, 4.02). No statistically significant difference in the incidence of RAO was reported between those who received the TR band and those who received either the elastic bandage (P = 0.08) or T band (P = 0.76). Similarly, no statistically significant difference in rates of RAO among patients was reported among those who had pro-coagulant dressings compared to those who had short or long manual compression. One trial that compared the TR band to a MAP-guided TR band demonstrated no statistically significant difference in the time taken to obtain hemostasis between the two groups (P = 0.61). A statistically significant reduction in the time taken to obtain hemostasis was observed among patients who received the hemostatic biopolymer dressing compared to the TR band. No statistically significant difference in the incidence of hematoma was identified among patients who received pneumatic compression or traditional compression to achieve hemostasis.

CONCLUSION

There is limited evidence to support the use of any single hemostatic method to prevent RAO rates after percutaneous coronary procedures. Although used extensively, there is evidence of no effect of the pneumatic compression method using the TR band on the incidence of RAO at discharge or follow-up, the time taken to obtain hemostasis and the incidence of hematoma. The MAP-guided compression method and the Biopolymer dressing (Chitosen) were superior to the TR band compression method, and patent hemostasis was superior to hemoband in the prevention of RAO. However, these results are based on single trials and should be interpreted with caution. The evidence obtained from the review does not provide a concrete base for the development of practice guidelines. Until more robust evidence is available, practices will continue to be dictated by local preferences and available resources.