Multicenter Randomized Evaluation of High Versus Standard Heparin Dose on Incident Radial Arterial Occlusion After Transradial Coronary Angiography

Open Radial Artery Study

Radial artery occlusion (RAO) has been the most common postprocedural complication of transradial artery access. The optimal method of prevention of RAO is still lacking. In our study, we aimed to evaluate the effect of patent hemostasis on early (24 hours) and late (2 weeks) RAO prevention. The Open Radial Artery Study was a single-arm, prospective, and multicenter study. The primary end points were early and late RAO at the vascular access site after transradial coronary procedures. Secondary end points were access site hematoma, pseudoaneurysm formation, arteriovenous fistula, and nerve injury. A total of 2,181 patients were analyzed (67% male, mean age 68 years). The mean interventional duration and hemostatic times were 75.6 ± 55.6 and 60 ± 5.6 minutes, respectively. Radial artery spasm occurred in 10% of patients (n = 218). Catheter kinking, radial artery rupture, or dissection were not observed during the procedure. RAO, hematoma, pseudoaneurysm, arteriovenous fistula, or nerve damage was not observed in any of the patients in the early or late period. In patients who undergo coronary diagnostic or interventional procedures through transradial artery access, the patent hemostasis method seems a critical step in the prevention of early and late RAO.

Predictors of radial to femoral artery crossover during primary percutaneous coronary intervention in ST-elevation myocardial infarction: A systematic review and meta-analysis

BACKGROUND

In contrast to traditional femoral artery access, radial artery access for primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) is associated with reduced mortality and bleeding but has higher crossover rates. Therefore, factors associated with crossover warrant exploration as crossover due to technical challenges associated with the radial route may be mitigated.

OBJECTIVE

The objective of this study was to identify predictors of radial access failure or crossover to femoral access in PPCI.

METHODS

A systematic review and meta-analysis was undertaken according to the Joanna Briggs Institute Systematic Reviews Checklist with searches conducted in Medline, EMBASE, CINAHL, and SCOPUS databases. Inclusion criteria for this study included patients with STEMI; PPCI; and primary research identifying predictors of radial access failures and/or crossovers, published in English, and after 2010. This study was registered with PROSPERO (CRD42020167122). Statistical analysis was performed using IBM SPSS Statistics for Windows version 26.0 (IBM Corp, Armonk, NY) and RevMan version 5.4 (Cochrane Collaboration, London, United Kingdom) with meta-analysis conducted by using the DerSimonian and Laird random-effects method. The National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was utilised for quality and risk of bias assessment, with EndNote software used for citations.

RESULTS

Eight observational studies met inclusion criteria, comprising 12,621 patients. Risk of bias of these studies was assessed using the National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The mean age was 61.2 ± 12.0 years, and 75.3% were male. Crossover from transradial to transfemoral artery occurred in 529 (4.2%) patients. Reasons for radial access failure included failed puncture (35.3%), peripheral occlusion or tortuosity (24.5%), and radial artery spasm (20.1%). Predictors of crossover included older age (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.44-2.65; p < 0.001), female sex (OR, 2.10; 95% Cl, 1.58-2.80; p < 0.001), weight ≤65 kg (OR, 2.95; 95% CI, 1.95-4.46; p < 0.001), and previous percutaneous coronary intervention (OR, 2.80; 95% Cl, 1.74-4.52; p < 0.001).

CONCLUSION

Older age, female sex, weight ≤65 kg, and previous percutaneous coronary intervention were predictors of crossover or failure from the radial to femoral artery. As these predictors are known to be associated with high bleeding and mortality, they should not preclude attempting a radial-first approach in all patients with STEMI. However, as these results were unadjusted, this study warrants further research to thoroughly investigate predictors of radial artery crossover.

Preventing and Managing Radial Artery Occlusion following Transradial Procedures: Strategies and Considerations

Τransradial artery access has recently gained widespread acceptance as the preferred approach for coronary angiography and interventions, due to its lower incidence of bleeding and vascular complications compared to transfemoral access. However, thrombotic occlusion of the radial artery has emerged as the most common complication of this method, impeding its use in future interventions, and in the creation of arteriovenous fistulae for hemodialysis patients, or as a graft for coronary artery bypasses grafting. In this comprehensive review, we delve into the anatomy of the radial artery, the pathophysiology and diagnosis of radial artery occlusion, the identification of potential risk factors and, finally, prevention and treatment strategies. We acknowledge that distal transradial access provides an effective alternative for coronary angiography and catheterizations, with a reduced incidence of radial artery occlusion.

Factors Affecting Radial Artery Occlusion After Right Transradial Artery Catheterization for Coronary Intervention and Procedures

Objective

To determine the factors influencing proximal radial artery occlusion (PRAO) right radial artery after coronary intervention.

Methods

This is a single-center prospective observational study. A total of 460 patients were selected to undergo coronary angiography (CAG) or percutaneous coronary intervention (PCI) via the proximal transradial approach (PTRA) or distal transradial approach (DTRA). The 6F sheath tube were received by all patients. Radial artery ultrasound was performed 1 day before procedure and 1-4 days after procedure. Patients were divided into the PRAO group (42 cases) and the non-PRAO group (418 cases). General clinical data and preoperative radial artery ultrasound indexes of the two groups were compared to analyze related factors leading to PRAO.

Results

The total incidence of PRAO was 9.1%, including 3.8% for DTAR and 12.7% for PTRA. The PRAO rate of DTRA was significantly lower than that of PTRA (p < 0.05). Female, low body weight, low body mass index (BMI) and CAG patients were more likely to develop PRAO after procedure (p < 0.05). The internal diameter and cross-sectional area of the distal radial artery and proximal radial artery were smaller in the PRAO group than in the non-PRAO group, and the differences were statistically significant (p < 0.05). Multifactorial model analysis showed that the puncture approach, radial artery diameter and procedure type were predictive factors of PRAO, and the receiver operating characteristic curve showed a good predictive value.

Conclusion

A larger radial artery diameter and DTRA may reduce the incidence of PRAO. Preoperative radial artery ultrasound can guide the clinical selection of appropriate arterial sheath and puncture approach.

Rationale and Design of the Rivaroxaban Post-Transradial Access for the Prevention of Radial Artery Occlusion Trial (CAPITAL-RAPTOR)

INTRODUCTION

Transradial access (TRA) has rapidly emerged as the preferred vascular access site for coronary angiography and percutaneous coronary intervention. Radial artery occlusion (RAO) remains as an important complication of TRA as it precludes future ipsilateral transradial procedures. While intraprocedural anticoagulation has been studied extensively, the definitive role of postprocedural anticoagulation has not yet been established.

METHODS AND ANALYSIS

The Rivaroxaban Post-Transradial Access for the Prevention of Radial Artery Occlusion trial is a multicentre, prospective, randomised, open-label, blinded-endpoint design study investigating the efficacy and safety of rivaroxaban to reduce the incidence of RAO. Eligible patients will undergo randomisation to receive either rivaroxaban 15 mg once daily for 7 days or to no additional postprocedural anticoagulation. Doppler ultrasound to assess radial artery patency will be performed at 30 days.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Ottawa Health Science Network Research Ethics Board (approval number 20180319-01H). The study results will be disseminated via conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03630055.

Prevention of radial artery occlusion with rivaroxaban after trans-radial access coronary procedures: The RIVARAD multicentric randomized trial

Background

Radial artery occlusion (RAO) remains the most frequent complication of trans-radial access. Once the radial artery is occluded, its future use as an access site for coronary procedures, or as a conduit for coronary bypass grafting or fistula for hemodialysis, will be precluded. Therefore, we aimed to assess the value of the short-term use of Rivaroxaban to prevent RAO after a trans-radial coronary procedure.

Methods

This was a prospective, open-label, randomized study. The patients were randomly assigned (1:1) to one of two groups: those who received Rivaroxaban 10 mg for 7 days following the trans-radial coronary procedure (the Rivaroxaban Group) and those who received the standard treatment (the Control Group). The primary outcome was an occurrence of RAO evaluated by Doppler ultrasound at 30 days, and the secondary outcomes were hemorrhagic complications according to BARC classification.

Results

We included 521 patients randomized into two Groups: the Control Group (N = 262) and the Rivaroxaban Group (N = 259). The 1-month RAO was significantly reduced in the Rivaroxaban Group as compared to the Control Group [6.9% vs. 13%; p = 0.011, OR = 0.5, (95% CI, 0.27-0.91)]. We noted no cases of severe bleeding events (BARC3-5). The overall incidence of minor bleeding (BARC1) was 2.3%, with no significant difference between the two groups [Rivaroxaban Group = 2.7%, Control Group = 1.9%, p = 0.54, OR= 1.4, (95%CI 0.44-4.5)].

Conclusions

Short-term postoperative anticoagulation with Rivaroxaban 10 mg for seven days reduces the rate of 1-month RAO.

Enhanced external counterpulsation improves dysfunction of forearm muscle caused by radial artery occlusion

Objective

This study aimed to investigate the therapeutic effect of enhanced external counterpulsation (EECP) on radial artery occlusion (RAO) through the oscillatory shear (OS) and pulsatile shear (PS) models of human umbilical vein endothelial cells (HUVECs) and RAO dog models.

Methods

We used high-throughput sequencing data GSE92506 in GEO database to conduct time-series analysis of functional molecules on OS intervened HUVECs, and then compared the different molecules and their functions between PS and OS. Additionally, we studied the effect of EECP on the radial artery hemodynamics in Labrador dogs through multi-channel physiological monitor. Finally, we studied the therapeutic effect of EECP on RAO at the histological level through Hematoxylin-Eosin staining, Masson staining, ATPase staining and immunofluorescence in nine Labrador dogs.

Results

With the extension of OS intervention, the cell cycle decreased, blood vessel endothelial cell proliferation and angiogenesis responses of HUVECs were down-regulated. By contrast, the inflammation and oxidative stress responses and the related pathways of anaerobic metabolism of HUVECs were up-regulated. Additionally, we found that compared with OS, PS can significantly up-regulate muscle synthesis, angiogenesis, and NO production related molecules. Meanwhile, PS can significantly down-regulate inflammation and oxidative stress related molecules. The invasive arterial pressure monitoring showed that 30Kpa EECP treatment could significantly increase the radial artery peak pressure (p = 0.030, 95%CI, 7.236-82.524). Masson staining showed that RAO significantly increased muscle interstitial fibrosis (p = 0.002, 95%CI, 0.748-2.128), and EECP treatment can reduce this change (p = 0.011, 95%CI, -1.676 to -0.296). ATPase staining showed that RAO significantly increased the area of type II muscle fibers (p = 0.004, 95%CI, 7.181-25.326), and EECP treatment could reduce this change (p = 0.001, 95%CI, -29.213 to -11.069). In addition, immunofluorescence showed that EECP increased angiogenesis in muscle tissue (p = 0.035, 95%CI, 0.024-0.528).

Conclusion

EECP improves interstitial fibrosis and hypoxia, and increases angiogenesis of muscle tissue around radial artery induced by RAO.

Early prevention of radial artery occlusion via distal transradial access for primary percutaneous coronary intervention

BACKGROUND

Conventional transradial access (TRA) has been the preferred access for coronary intervention. Recently, distal radial access (DRA) is introduced as an alternative choice to reduce radial artery occlusion (RAO) risk. The study sought to assess the impact of DRA on early RAO using Doppler ultrasound in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI).

METHODS

This is a prospective, single-center, open-label randomized clinical trial in which patients with indications for primary PCI from January 2022 to September 2022 were assigned to DRA or TRA group with 100 cases in each group. The primary endpoint was the incidence of forearm RAO, evaluated by Doppler ultrasound before discharge.

RESULTS

The rate of access success was comparable between the DRA and TRA groups (98.0 vs. 94.0%, P = 0.279). Compared with the TRA group, longer puncture time was observed in the DRA group [2.4 (1.7-4.2) min vs. 1.7 (1.4-2.3) min; P < 0.001] whereas the door-to-wire time was not delayed in primary PCI [71 (54-88) min vs. 64 (56-82) min, P = 0.103]. Shorter hemostasis time was required in the DRA group [3.1 (2.7-3.3) h vs. 6.2 (5.9-6.4) h; P < 0.001]. Significant reduction of the incidence of forearm RAO was observed in the DRA group (2.0 vs. 9.0%, P = 0.030). Local hematomas ≤ 5 cm was similar in both groups (4.0 vs. 6.0%, P = 0.516), while those > 5 cm were significantly more frequent in the TRA group (0 vs. 6.0%, P = 0.029).

CONCLUSION

Distal radial access is associated with a comparable lower incidence of forearm RAO, shorter hemostasis time, and lower rate of vascular complications compared to TRA in primary PCI.

SYSTEMATIC REVIEW REGISTRATION

[https://www.chictr.org.cn], identifier [ChiCTR2200061841].

Gandouling Mitigates CuSO4-Induced Heart Injury in Rats

We assessed the protective effects of Gandouling (GDL) on copper sulfate (CuSO4)-induced heart injuries in Sprague−Dawley rats, which were randomly divided into the control, CuSO4, GDL + CuSO4 and penicillamine + CuSO4 groups. The rats received intragastric GDL (400 mg/kg body weight) once per day for 42 consecutive days after 56 days of CuSO4 exposure, and penicillamine was used as a positive control. The levels of plasma inflammatory cytokines (IMA, hFABP, cTn-I and BNP) were determined using the enzyme-linked immunosorbent assay. The histopathological symptoms were evaluated using hematoxylin and eosin staining and transmission electron microscopy. To determine the underlying mechanism, Western blotting was conducted for the detection of the heme oxygenase 1 (HO-1) expression. The results revealed that GDL supplementation alleviated the histopathological symptoms of the rat heart tissue, promoted Cu excretion to attenuate impairment, and significantly decreased inflammatory cytokine levels in the plasma (p < 0.01). In addition, GDL increased the HO-1 expression in the rat hepatic tissue. The protective effect of GDL on the heart was superior to that of penicillamine. Overall, these findings indicate that GDL alleviates hepatic heart injury after a Cu overaccumulation challenge, and GDL supplements can be beneficial for patients with Wilson’s disease.

The protective role of low-dose acetylsalicylic acid use and relation with inflammatory and thrombotic parameters on radial artery occlusion in patients undergoing elective transradial coronary angiography

Aim: Transradial angiography (TRA) is recommended in clinical practice; it is better than the transfemoral route to prevent site-related complications. Radial artery occlusion is one of the most seen significant complications after TRA. In the present study, the protective effect of low dose acetylsalicylic acid (ASA) use against the radial artery occlusion (RAO) and the predictive ability of some thrombotic and inflammatory factors for the development of RAO were investigated. Material and Method: One thousand two hundred fifty-four patients who planned for elective coronary angiography were screened to include transradial coronary angiography. The patients have grouped group I, who took ASA (100 mg) (n= 56), and group II (n= 51), who did not. Blood samples were taken immediately after sheath insertion and after the six hours of the sheath removal. The D-dimer and C-reactive protein values were analyzed between groups. In the first 24 hours after the procedure, the radial Doppler ultrasonography assessment was performed to detect RAO. Multivariable regression analysis was used to evaluate the independent risk factors for the TRA. Results: Eligible one hundred seven stable patients were included in the study. The demographic, laboratory and procedural characteristics were similar between the two groups (Table 2). TRA was statistically lower in Group I compared to Group II. (n=3 vs. n=22, p=.001). Multivariable regression analysis demonstrated that postprocedural higher D-dimer levels and non-ASA status were found to be the independent risk factors for RAO (OR (95% CI=1.235(1.014-1.582) p=.001, 5.534 (3.376-9.252), p .05). Conclusion: Preprocedural ASA use may have a protective role against the RAO. Pre- and post-procedural D-dimer levels can predict the thrombotic process in the early phase of the RAO.

Radial Artery Access Complications: Prevention, Diagnosis and Management

The transradial approach for cardiac catheterization, coronary angiography, and percutaneous intervention is associated with a lower risk of access site-related complications compared to the transfemoral approach. However, with increasing utilization of transradial access for not only coronary procedures but also peripheral vascular procedures, healthcare personnel are more likely to encounter radial access site complications, which can be associated with morbidity and mortality. There is significant heterogeneity in the reporting of incidence, manifestations, and management of radial access site complications, at least partly due to vague presentation and under-diagnosis. Therefore, physicians performing procedures via transradial access should be aware of possible complications and remain vigilant to prevent their occurrence. Intraprocedural complications of transradial access procedures, which include spasm, catheter kinking, and arterial dissection or perforation, may lead to patient discomfort, increased procedure time, and a higher rate of access site cross over. Post-procedural complications such as radial artery occlusion, hematoma, pseudoaneurysm, arteriovenous fistula, or nerve injury could lead to patient discomfort and limb dysfunction. When radial access site complications occur, comprehensive evaluation and prompt treatment is necessary to reduce long-term consequences. In this report, we review the incidence, clinical factors, and management strategies for radial access site complications associated with cardiac catheterization.

Different Antiplatelet Strategies for Radial Artery Protection After Transradial Coronary Angiography—A Prospective Observational Cohort Study

Introduction

Radial artery occlusion (RAO) after transradial access is a common thrombotic complication. A meta-analysis has proven that RAO incidence in transradial coronary angiography (TRCA) settings was significantly higher than that in percutaneous coronary intervention settings. This prospective observational cohort aimed to evaluate radial artery protection after TRCA with different antiplatelet strategies.

Methods

A total of 2,316 patients undergoing TRCA was enrolled and divided into two groups: single-antiplatelet and dual-antiplatelet groups. Radial artery patency was evaluated by ultrasound before, at 24 h, and 30 days after TRCA. The primary endpoint was RAO incidence at 30 days after TRCA.

Results

A total of 66 RAO was found on ultrasonography at 30-day follow-up (incidence: 2.8%). In the dual-antiplatelet group, the rate of RAO was significantly lower compared with the single-antiplatelet group (1.8 vs. 4.0%; odds ratio (OR): 0.41; 95% confidence interval (CI): 0.24–0.70; p = 0.001). The rate of self-recanalization in the dual-antiplatelet group was significantly higher than that in the single-antiplatelet group (73.68 vs. 44.12%, p < 0.001). However, there was no statistical difference in delayed occlusion of radial artery between the two groups (0.5 vs. 0.2%, p = 0.140). Unexpectedly, this study also showed no significant difference in bleeding risk between the groups.

Conclusion

Dual-antiplatelet therapy for 1 month after TRCA was associated with a reduced risk of RAO and deemed safe.

Radial Hemostasis Is Facilitated With a Potassium Ferrate Hemostatic Patch: The STAT2 Trial

OBJECTIVES

The aim of this trial was to test whether the potassium ferrate hemostatic patch (PFHP) as an adjunct to the TR Band (TRB) facilitated an early deflation protocol.

BACKGROUND

Shorter TRB compression times may reduce the rate of radial artery occlusion (RAO) and reduce observation time after transradial access.

METHODS

A total of 443 patients were randomized to the TRB or PFHP + TRB, with complete TRB deflation attempted 60 minutes postprocedure. The primary outcome was the time to successful full deflation of the TRB without bleeding, with secondary outcomes of time to discharge and complications including hematoma, RAO, or bleeding requiring intervention beyond TRB reinflation.

RESULTS

Time to complete TRB deflation was 66 ± 14 minutes with the PFHP vs 113 ± 56 minutes for the TRB alone (P < 0.001). Minor rebleeding requiring TRB reinflation was much more frequent without the PFHP (0% vs 67.7%; P < 0.001) with 2.3 ± 1.3 additional reinflation and deflation attempts needed for hemostasis. Hematomas developed in 4.0% of the PFHP group and 6.8% of the TRB group (P = 0.20). RAO was rare (<1%), although 41% of patients received <5,000 U heparin. Among percutaneous coronary intervention patients, time to TRB deflation (68 ± 15 minutes vs 138 ± 62 minutes; P < 0.001) and composite complications (10.0% vs 24.2%; P = 0.04) were reduced with the PFHP.

CONCLUSIONS

Compared with the TRB alone, the PFHP facilitated early 60-minute TRB deflation following transradial catheterization, with a numeric reduction in vascular complications. RAO occurs rarely with early deflation regardless of heparin dose. (Comparing TR Band to StatSeal in Conjunction With TR Band II [StatSeal II]; NCT04046952).

Short-Term Postoperative Use of Rivaroxaban to Prevent Radial Artery Occlusion After Transradial Coronary Procedure: The RESTORE Randomized Trial

BACKGROUND

Adequate procedural anticoagulation is crucial for radial artery occlusion (RAO) prevention in patients undergoing transradial access coronary catheterization, although the effect of postprocedural anticoagulation lack thorough investigation. The aim of this study was to evaluate the clinical value of short-term postoperative anticoagulation with rivaroxaban for 24 hours and 1-month RAO prevention in patients who received transradial coronary procedures.

METHODS

A total of 382 patients were randomized to receive either placebo (control group) or rivaroxaban 10 mg once daily for a period of 7 days (rivaroxaban group) to evaluate the effect of the rivaroxaban in the prevention of 24 hours and 1-month RAO assessed by Doppler ultrasound.

RESULTS

There was no significant difference in the incidence of 24-hour RAO (8.9% versus 11.5%; P=0.398) between the rivaroxaban group and control group (odds ratio, 0.75 [95% CI, 0.39-1.46]; P=0.399). In contrast, the 1-month RAO (3.8% versus 11.5%; P=0.011) was significantly reduced in patients who received rivaroxaban as compared with those who did placebo (odds ratio, 0.22 [95% CI, 0.08-0.65]; P=0.006). For patients with 24-hour RAO, the rivaroxaban group was associated with higher recanalization rate of the radial artery (69.2% versus 30.0%; P=0.027) compared with the control group. No significant differences can be observed between the 2 groups for access-site complications or bleeding events.

CONCLUSIONS

Short-term postoperative anticoagulation with rivaroxaban did not reduce the rate of 24-hour RAO but improved 1-month RAO, because of higher recanalization of the radial artery. However, larger clinical trials are needed to prove our results.

REGISTRATION

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR1900026974.

Association of Palmar Arch Collateral Function and Radial Artery Occlusion After Transradial Access

The prevalence and implications of radial artery occlusion (RAO) after transradial catheterization are an intensely discussed topic, resulting in numerous preventive strategies such as adjusted anticoagulation, residual-patency hemostasis, or distal puncture site. The present study aimed at assessing an association of palmar arch, in particular radial artery collateral function and RAO after transradial access (TRA) catheterization. Radial artery collateral function was determined using radial artery pressure signals in the nonobstructed vessel and during brief manual occlusion of the more proximal radial artery. Collateral flow index, the ratio of mean occlusive divided by mean nonocclusive arterial blood pressure, both subtracted by central venous pressure, was determined during manual RAO (radial artery collateral flow index [CFI_rad]). The presence or absence of RAO was determined by Doppler ultrasound at least 3 months after TRA. A total of 630 patients with TRA coronary angiography underwent palmar arch, that is, radial and radial plus ulnar artery collateral function assessment. CFI_rad was equal to 0.808 ± 0.144 (95% confidence interval 0.797 to 0.819). A total of 200 patients underwent Doppler ultrasound examination of their forearm arterial circulation 301 ± 140 days after TRA. Eight (4%) patients showed signs of RAO, 4 of whom (2%) had a complete RAO and 4 (2%) a stenosis above 30%. Patients with RAO showed a higher CFI_rad than those without RAO: 0.900 ± 0.074 versus 0.801 ± 0.154 (p = 0.006). In conclusion, complete RAO as determined by Doppler ultrasound later than 3 months after TRA is rare (2%). In the long run, RAO appears to be related to a very well-developed radial artery collateral function.

Transradial versus transfemoral access for acute stroke endovascular thrombectomy: a 4-year experience in a high-volume center

PURPOSE

To compare clinical outcomes and safety of transradial (TRA) versus transfemoral access (TFA) for endovascular mechanical thrombectomy in acute stroke patients.

METHODS

Retrospective analysis of 832 consecutive patients with acute stroke undergoing interventional thrombectomy using TRA (n = 64) or TFA (n = 768).

RESULTS

Direct TFA failures occurred in 36 patients, 18 of which underwent crossover TFA to TRA, while direct TRA failures occurred in 2 patients having both crossovers to TFA. Successful catheterization was achieved in 96.8% (62/64) and 95.3% (732/768) of patients undergoing direct TRA and direct TFA, respectively, without significant differences. The median (IQR) catheterization time was 10 (8-16) min in the direct TRA group and 15 (10-20) in the direct TFA group (P < 0.001). This difference was also significant in the subgroup of anterior circulation strokes and in patients younger and older than 80 years of age. The majority of procedures yielded thrombolysis in cerebral infarction grade 2b/2c/3 revascularization in patients undergoing direct TRA (88.5%) and direct TFA (90.8%), without statistically significant differences. The median (IQR) puncture to recanalization time was 37 (24-58) min for the direct TRA group and 42 (28-70) min for the direct TFA group. Significant differences in access site complications, symptomatic ICH, and mRS score 0-2 at 90 days between both TRA and TFA accesses were not found.

CONCLUSIONS

TRA is not inferior to TFA in the probability of catheterization, times of catheterization and revascularization, and other clinical outcomes for mechanical thrombectomy in acute stroke.

Prospective Study of Radial Artery Occlusion Following Transradial Arterial Access during IR Procedures

PURPOSE

To prospectively determine the rate of radial artery occlusion (RAO) in patients undergoing transradial access for intra-arterial interventions.

MATERIALS AND METHODS

Seventy-seven patients undergoing transradial access from August 2019 to March 2021 for 120 intra-arterial procedures (yttrium-90 mapping [n = 39] and radioembolization [n = 38], uterine artery embolization [n = 19], transarterial chemoembolization [n = 10], active bleed embolization [n = 8], angiomyolipoma embolization [n = 4], and other [n = 2]) were enrolled. The average patient age was 59 years ± 13.1 (range, 30-90 years), and 43 (55.8%) of the 77 patients were men. The patients underwent radial artery (RA) palpation, ultrasound evaluation, the Barbeau test, and the reverse Barbeau test prior to and following the intervention. Verapamil, nitroglycerin, and heparin were administered in a total of 114 (95%) of the 120 procedures prior to starting the procedure. The incidence of RAO and radial artery spasm (RAS) was calculated, and univariate logistic regression was performed to analyze the predictors of RAS.

RESULTS

The preprocedural RA diameter (3.0 mm ± 0.67) was not significantly different from the postprocedural RA diameter (3.0 mm ± 0.65, P = .904). The RAO rate was determined to be 0.8% (1/120), and this artery recanalized within 1 week. Due to the small number of occlusions, statistical analysis of predictors of RAO was not performed. The rate of RAS was 22.7% (27/119). None of the variables tested-including age, sex, RA diameter, initial versus repeat access, operator experience, and artery puncture technique-showed significant prediction for RAS. Patients were seen for follow-up after 111 (92.5%) of the 120 procedures.

CONCLUSIONS

Transradial access resulted in a <1% rate of RAO.

Patent hemostasis of radial artery: Comparison of two methods

BACKGROUND

Radial artery obstruction is the most common complication of coronary angiography performed via transradial access. Patent hemostasis can significantly reduce the risk of radial artery occlusion. Previous studies utilized sophisticated methods to evaluate radial artery patency. Simplified and easily applicable methods for successful patent hemostasis are currently lacking.

AIM

To determine which method (pulse oximeter vs the traditional radial artery palpation) is better to achieve patent hemostasis.

METHODS

This prospective, single center study included 299 consecutive patients who underwent coronary angiography or percutaneous coronary intervention between November 2017 and July 2019. Patients less than 18 years old, with a history of radial artery disease, or no palpable artery pulse were excluded from the study. Patients were randomly assigned to two groups. In the first group, radial artery flow was assessed by palpation of the artery during hemostasis (traditional method). In the second group, radial artery patency was estimated with the use of a pulse oximeter. Two different compression devices were used for hemostasis (air chamber and pressure valve). The primary study endpoint was the achievement of successful patent hemostasis.

RESULTS

The two groups (pulse oximeter vs artery palpation) had no significant differences in age, sex, body mass index, risk factors, or comorbidities except for supraventricular arrhythmias. The percentage of patients with successful patent hemostasis was significantly higher in the pulse oximeter group (82.2% vs 68.1%, P = 0.005). A lower percentage of patients with spasm was recorded in the pulse oximeter group (9.9% vs 19.0%, P = 0.024). The incidence of local complications, edema, bleeding, hematoma, vagotonia, or pain did not differ between the two groups. In the multivariate analysis, the use of a pulse oximeter (OR: 2.35, 95%CI: 1.34-4.13, P = 0.003) and advanced age (OR: 1.04, 95%CI: 1.01-1.07, P = 0.006), were independently associated with an increased probability of successful patent hemostasis. The type of hemostatic device did not affect patent hemostasis (P = 0.450).

CONCLUSION

Patent hemostasis with the use of pulse oximeter is a simple, efficient, and safe method that is worthy of further investigation. Larger randomized studies are required to consider its clinical implications.

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.

Distal Radial Artery Approach to Prevent Radial Artery Occlusion Trial

OBJECTIVES

The aim of this study was to compare the rate of proximal radial artery occlusion (RAO) with Doppler ultrasound between distal and conventional radial access 24 h and 30 days after a transradial coronary procedure.

BACKGROUND

The use of distal radial access to prevent proximal RAO (PRAO) in the proximal segment at 24 h and 30 days after a procedure, compared with conventional radial access, is unknown.

METHODS

This was a prospective, comparative, longitudinal, randomized study. A total of 282 patients were randomized to either proximal radial access (n = 142) or distal radial access (n = 140) to evaluate the superiority of the distal approach in the prevention of PRAO with Doppler ultrasound 24 h and 30 days after a transradial coronary procedure.

RESULTS

In the per protocol analysis, the rates of PRAO at 24 h and 30 days were 8.4% and 5.6% in the proximal group and 0.7% and 0.7% in the distal group, respectively (24 h: odds ratio [OR]: 12.8; 95% confidence interval [CI]: 1.6 to 100.0; p = 0.002; 30 days: OR: 8.2; 95% CI: 1.0 to 67.2; p = 0.019). In an intention-to-treat analysis, the 24-h and 30-day rates of PRAO were 8.8% and 6.4% for proximal radial access and 1.2% and 0.6% in the distal radial access group (24 h: OR: 7.4; 95% CI: 1.6 to 34.3; p = 0.003; 30 days: OR: 10.6; 95% CI: 1.3 to 86.4; p = 0.007).

CONCLUSIONS

Distal radial access prevents RAO in the proximal segment at 24 h and 30 days after the procedure compared with conventional radial access.

Randomized trial comparing radial hemostasis techniques; catechol conjugated chitosan pad (InnoSEAL) versus pneumatic compression band

OBJECTIVES

Primary objectives: to compare radial artery occlusion rate (RAO) after cardiac catheterization between catecholamine-chitosan pad (InnoSEAL) and pneumatic compression device (PCD) and to compare difference in hemostasis time and radial monitoring termination time between two arms. Secondary objectives: to compare radial site bleeding and ease of use of two methods by cath-lab technicians.

BACKGROUND

Hemostatic pads may be an effective alternative to PCD with lesser chance of access site complications with advantage of shortened compression time.

METHODS

Patients (N = 606) undergoing trans-radial, diagnostic or interventional procedures were randomized to either InnoSEAL arm or PCD. RAO was assessed using US Duplex; performed 6-24 hr posthemostatic device removal. Time to hemostasis was recorded as per defined protocols. Ease of use among cath-lab technicians was assessed through 5 point Likert scale.

RESULTS

Data of 597 patients was analyzed (299 InnoSEAL, 298 PCD). RAO rate was 8.5% in InnoSEAL and 9.4% in PCD arm (p value >.05). The pooled median hemostasis time and time to termination of radial monitoring was 42 versus 225 min and 50 versus 240 min in InnoSEAL and PCD arms, respectively (p value: <.01). There was no difference in Grade I/II hematoma (InnoSEAL: 1.3% vs. PCD: 3.4%). InnoSEAL was marginally acceptable compared to PCD by technicians.

CONCLUSION

Hemostasis time is significantly shorter in InnoSEAL arm with reasonable acceptability to its usage among cath lab staff. RAO and bleeding complications are comparable between the arms. Based on our findings, it seems feasible to include Chitosan based hemostasis pad routinely in cath lab.

The high dose unfractionated heparin is related to less radial artery occlusion rates after diagnostic cardiac catheterisation: a single centre experience

BACKGROUND

Transradial approach (TRA) has increasingly become the default strategy for cardiac catheterisation. However, TRA can result in several complications; radial artery occlusion (RAO) is the most unwilling complication. Unfractionated heparin (UFH) is an effective therapy in preventing RAO. The goal of this study was to evaluate whether weight-adjusted high dose UFH reduces the rate of RAO after diagnostic cardiac catheterisation compared to weight-adjusted standard dose UFH.

METHODS

A total of 1215 patients screened and after exclusion criteria, 686 consecutive patients were enrolled. 100 IU/kg UFH (high dose UFH group) and 50 IU/kg UFH (standard dose UFH group) were given the patients undergoing diagnostic cardiac catheterisation. RAO was evaluated with vascular Doppler ultrasonography at 10 days after cardiac catheterisation.

RESULTS

Among 686 patients undergoing diagnostic cardiac catheterisation, RAO was detected in 36 (5.2%) patients. There was no significant difference with respect to baseline characteristics and co-morbid diseases between high dose UFH group and standard dose UFH group. RAO was significantly higher in standard dose UFH group than high dose UFH group (7.9% vs. 3.0%, p = .004). Multivariate logistic regression analysis was demonstrated that age (OR: 0.958, 95% CI: 0.924-0.993, p = .019) and standard dose heparin (OR: 2.811, 95% CI: 1.347-5.866, p = .006) were independent factor for RAO.

CONCLUSIONS

High dose UFH was independently associated with a lower rate of RAO. Given that RAO nearly affects about 10% patient underwent TRA, prefer to high dose UFH may be a reasonable choice for RAO prevention.

Vascular Complications of Transradial Access for Cardiac Catheterization

Transradial access has been increasingly adopted for cardiac catheterization. It is crucial for operators to recognize potential vascular complications associated with radial artery access. Prevention, early detection, and prompt treatment of vascular complications are essential to prevent serious morbidities. This review aims to raise awareness of transradial access vascular complications. Radial artery spasm is treated with intra-arterial verapamil and/or nitroglycerine. Hemorrhagic complications, such as perforation, hematoma, arteriovenous fistula, and pseudoaneurysm, are treated with prolonged compression. Patent hemostasis and adequate anticoagulation are used to prevent radial artery occlusion. Hand ischemia is a rare complication not associated with abnormal results of the Allen or Barbeau test, and can be treated with intra-arterial verapamil, IV heparin, and IV diltiazem. Finally, an attentive monitoring protocol for the timely detection of vascular complications should be implemented in daily practice.

Radial Access for Neurointerventions

Transradial access (TRA) has become the standard approach for cardiac intervention, with a large body of evidence demonstrating a lower incidence of vascular complications, better patient experience and cost reduction. There has been increasing interest in using TRA both for diagnostic neuroangiography and for interventional neurovascular procedures. This aim of this article is to discuss the advantages and limitations of TRA for neurointerventions. General technical details, such as pre-procedure recommendations, prevention of spasm and occlusion, haemostasis protocols and distal TRA puncture, are also described, along with the specific technical details of TRA for aneurysm embolisation, stroke thrombectomy and other neurovascular interventions. TRA provides additional tools to the neurointerventionist and – with appropriate training – the whole spectrum of intervention procedures can be achieved using this approach.

Reaccessing an occluded radial artery for neuroendovascular procedures: techniques and complication avoidance

BACKGROUND

Radial artery occlusion (RAO) occurs in 1% to 10% of cases following transradial arterial access (TRA) for neuroendovascular procedures. When repeat access is required in patients discovered to have RAO, a transfemoral approach is often used. This study reports experience with repeat TRA procedures at a single center and techniques for reaccessing an occluded radial artery in select patients.

METHODS

The electronic records of all patients who underwent multiple neuroendovascular procedures with an attempted TRA as the index procedure at a single center from July 2019 through February 2020 were reviewed.

RESULTS

There were 656 TRA attempts for diagnostic angiography or intervention from July 2019 through February 2020. A total of 106 patients underwent a repeated attempt at TRA. Techniques for reaccessing an occluded radial artery were implemented halfway through the study period. One hundred patients (94.3%) had a successful second radial catheterization. Six patients required conversion to a transfemoral approach: five for RAO and one for radial branch perforation during the index procedure. After we implemented our techniques for reaccess, four additional patients with RAO successfully underwent TRA. There were no short-term complications, including pain, vessel perforation, forearm hematoma, or hand ischemia, following successful repeat catheterization of a previously occluded radial artery.

CONCLUSION

RAO is not an absolute limitation for attempting TRA in patients undergoing repeat catheterization. Reaccessing the radial artery after occlusion is feasible for repeat neuroendovascular procedures.

Transradial artery access for percutaneous cardiovascular procedures: state of the art and future directions

The transradial access (TRA) for cardiac catheterization and percutaneous coronary intervention (PCI) has been widely adopted in the last decades since its first description in the late 40s. The transradial approach has been associated with favorable outcomes as compared with transfemoral access (TFA) in several registries and randomized clinical trials, mainly due to the lower incidence of access-site bleedings, vascular complications and improved patient comfort. This review aimed to summarize the body of evidence supporting the use of TRA, to discuss clinical implications, possible technical limitations and future directions, such as the implementation of TRA as the primary access for complex procedures and structural interventions.

Radial artery occlusion after cardiac catheterization and impact of medical treatment

Summary: Background: The transradial artery approach is the preferred access for cardiac catheterization according to current guidelines. However, the most common complication is radial artery occlusion (RAO). Despite the rare indication for surgical reopening, the occluded radial artery is not available for further procedures or as a potential bypass graft. Still, treatment regimens for RAO are scarce. We now determined whether the addition of antithrombotic to antiplatelet therapy improves the rate of partial or complete regain of patency in RAO following transradial cardiac catheterization in a retrospective analysis. Patients and methods: In a two-center tertiary referral hospital retrospective analysis 4135 files of patients who had undergone transradial catheterization were screened for documented RAO. 141 patients were identified and 138 patients with complete information on the medical regimen and ultrasound examinations for a maximum of 3 months were included in the analysis, whereas 3 patients were excluded due to missing or incomplete follow-up information. Results: 3.3% of all patients that had undergone transradial catheterization featured an oligosymptomatic RAO, confirmed by color-coded duplex sonography. 21% of patients with additional anticoagulation regained full patency vs. 9% without additional anticoagulation (p = 0.07). 40% of patients with anticoagulation featured a partial or full regain of patency vs. 16% of patients without additional anticoagulation for a maximum of 3 months treatment (p = 0.006). No major bleedings were reported during the follow-up visits. Conclusions: RAO remains a rare complication of cardiac catheterization. The addition of antithrombotic therapy for 3 months appears to safely improve the partial or even full regain of radial patency in case of postinterventional RAO.

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

BACKGROUND

Duplex Doppler ultrasonography (USG) remains the gold standard for evaluation of radial artery occlusion (RAO) after transradial access (TRA). The diagnostic accuracy of digital plethysmography, which is cheaper and widely available, for evaluation of RAO after TRA is not known.

METHODS

Patients undergoing TRA were prospectively studied. After undergoing TRA for diagnostic or interventional coronary procedure and obtaining radial artery hemostasis, the radial artery was evaluated for presence or absence of RAO using digital plethysmography of the ipsilateral index finger and the thumb using modified reverse Barbeau's test (MRBT) and USG. Sensitivity, specificity, predictive values, likelihood ratios and other metrics of evaluation of diagnostic performance of MRBT in reference to USG, the current gold standard, were evaluated.

RESULTS

503 patients who underwent TRA for coronary procedures were studied. MRBT demonstrated a sensitivity = 96.2%, specificity = 99.8%, positive predictive value = 96.1, negative predictive value = 99.8, likelihood ratio (+) = 481, likelihood ratio (-) = 0.38, diagnostic accuracy = 99.6, diagnostic odds ratio = 11,904, Youden's index = 0.96, receiver operator characteristic derived c-statistic = 0.98 and Cohen's k = 0.98 when compared to USG. MRBT performed using the ipsilateral index finger and the thumb was no different. Agreement between absence of ipsilateral radial artery pulsation and RAO was weak (Cohen's k = 0.69).

CONCLUSIONS

MRBT using ipsilateral digital plethysmography performs comparably to USG for assessment of presence of RAO after TRA. There is no significant difference between MRBT performed using the ipsilateral thumb or the index finger.

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

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

Pre-Liver Transplant Cardiac Catheterization Is Associated With Low Rate of Myocardial Infarction and Cardiac Mortality

BACKGROUND AND AIMS

A study at Indiana University demonstrated a reduction in myocardial infarction (MI) incidence with increased frequency of cardiac catheterization (CATH) in liver transplant (LT) candidates. A strict protocol for performing CATH based upon predefined risk factors, rather than noninvasive testing alone, was applied to a subgroup (2009-2010) from that study. CATH was followed by percutaneous coronary intervention (PCI) in cases of significant coronary artery disease (CAD; ≥50% stenosis). The current study applies this screening protocol to a larger cohort (2010-2016) to assess post-LT clinical outcomes.

APPROACH AND RESULTS

Among 811 LT patients, 766 underwent stress testing (94%) and 559 underwent CATH (69%), of whom 10% had CAD requiring PCI. The sensitivity of stress echocardiography in detecting significant CAD was 37%. Predictors of PCI included increasing age, male gender, and personal history of CAD (P < 0.05 for all). Compared to patients who had no CATH, patients who underwent CATH had higher mortality (P = 0.07), and the hazard rates (HR) for mortality increased with CAD severity (normal CATH, HR, 1.35; 95% confidence interval [CI], 0.79-2.33; P = 0.298; nonobstructive CAD, HR, 1.53; 95% CI, 0.84-2.77; P = 0.161; and significant CAD, HR, 1.96; 95% CI, 0.93-4.15; P = 0.080). Post-LT outcomes were compared to the 2009-2010 subgroup from the previous study and showed similar 1-year overall mortality (8% and 6%, P = 0.48), 1-year MI incidence (<1% and <1%, P = 0.8), and MI deaths as a portion of all deaths (3% and 9%, P = 0.35).

CONCLUSIONS

Stress echocardiography alone is not reliable in screening LT patients for CAD. Aggressive CAD screening with CATH is associated with low rate of MI and cardiac mortality and validates the previously published protocol when extrapolated over a larger sample and longer follow-up period.

Predictors of patent and occlusive hemostasis after transradial coronary procedures

OBJECTIVES

To assess the independent predictors of patent and occlusive hemostasis (PH and OH, respectively) during radial hemostasis after coronary procedures.

BACKGROUND

Radial artery occlusion (RAO) is a thrombotic complication of transradial catheterization that can lead to permanent occlusion of the radial artery. Sheath-vessel diameter ratio, postprocedure compression time, occlusive hemostasis, inadequate, and excessive anticoagulation are all predictors of RAO.

METHODS

As a part of a previously published study investigating the relationship between residual anticoagulation and risk of RAO, 837 patients undergoing transradial diagnostic coronary angiography or percutaneous coronary interventions were enrolled. Cumulative heparin dose used during the procedure and ACT measured before sheath removal were recorded. PH with reverse Barbeau test was attempted in all patients (NCT02762344).

RESULTS

PH was less frequently obtained for increasing cumulative heparin dose and ACT values (p < .0001 and p = .0034, respectively). At logistic regression analysis both cumulative heparin dose and ACT values were independent predictors of OH (OR 1.017, 95% IC 1.011-1.023 p < .0001 and OR 1.004, 95% IC 1.001-1.006, p = .0004) while adjusted probability for RAO showed exponential relationship with both parameters.

CONCLUSIONS

The level of anticoagulation is strongly related to the incidence of RAO, and should be taken into account when choosing hemostasis protocol.

Short Durations of Radial Hemostatic Device After Diagnostic Transradial Cardiac Catheterization: The PRACTICAL-2 Randomized Trial

BACKGROUND

Radial artery occlusion (RAO) is the most common complication following transradial approach (TRA) for cardiac catheterisation. Our aim was to assess if decreasing radial hemostatic device (RHD) time reduces the risk of RAO among individuals receiving small sheath sizes with no adjunctive heparin.

METHODS

We randomised 450 individuals undergoing diagnostic cardiac catheterization via TRA to 3 durations of RHD time: 10, 20, or 30 minutes. After these time periods, the RHD was gradually released over 20 minutes. The primary efficacy end point was forearm hematoma grade ≥ 2 (5-10 cm) and the primary safety end point was RAO (as determined by Doppler ultrasound) 1 hour after RHD removal (before discharge).

RESULTS

The mean age was 66 years and 64% were male. Five-French sheaths were used in all patients. Hematoma grade ≥ 2 occurred in only 1 patient, who was in the 20-minute group (P = 0.39). RAO occurred in 6.7% of patients in the 10-minute group, 10.7% in the 20-minute group and 6% in the 30-minute group (P = 0.26).

CONCLUSIONS

Among patients receiving small-caliber sheaths without adjunctive heparin, the incidence of forearm hematoma and RAO are low. Shorter durations of RHD time did not further reduce the risk of these complications.

[Radial artery occlusion ofter coronarography: is it really a problem?]

The use of transradial access for cardiac procedures has increased worldwide over the past two decades. Despite the many advantages this technique offers, there remains some concern that radial artery occlusion, a potential complication of radial cannulation, might lead to significant ischemic sequelae in the hand. This paper reviews the major causes, its possible consequences and the strategies for its prevention and treatment. It appears however from multiple studies that there is little or no correlation between radial occlusion and symptomatic hand ischemia.

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.

Transarterial and transvenous access for neurointerventional surgery: report of the SNIS Standards and Guidelines Committee

The purpose of this publication is to provide a comprehensive review on the techniques and tools used for vascular access in neurointerventional procedures. Using published literature, we reviewed data on access methods, sites, tools, and techniques for neurointerventions. Recommendations are provided based on quality of data/levels of evidence and, where appropriate, expert consensus. While tools and techniques continue to be developed, current literature and experience supports certain principles regarding vascular access for neurointerventional procedures.

Vascular Complications of the Wrist: Prevention and Management

Transradial access has increased in utilization and has been shown to be superior compared with transfemoral access. Although infrequent, several transradial access site-related complications occur. By understanding potential mechanisms related to these complications, several prevention and treatment strategies can be implemented to mitigate adverse outcomes.

RadialFirst in CHIP and Cardiogenic Shock

This article highlights the advantages and disadvantages of transradial arterial (TRA) access for a variety of presentations including acute coronary syndromes; cardiogenic shock; unprotected left main, heavily calcified coronaries; bifurcations; and chronic total occlusions. It includes techniques for overcoming challenges of using TRA access, including spasm and the need for larger bore guides. In addition, the authors review the use of ultrasound for access, percutaneous hemodynamic support via axillary approach, and tips and tricks to performing right heart catheterizations from the antecubital vein.

Complications of Transradial Catheterization and Cannulation

Transradial catheterization and cannulation are typically well-tolerated procedures, but they are associated with various vascular, infectious, and orthopedic complications. Potential complications include radial artery occlusion, hematoma formation, radial artery laceration, pseudoaneurysm, abscess formation, and compartment syndrome. Hand surgeons are commonly consulted to treat such complications. We review recent evidence available to guide decisions about nonsurgical and surgical interventions to treat and prevent the complications associated with transradial access procedures.

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.

The Activated Clotting Time Paradox

Background:

Radial artery occlusion (RAO) is a thrombotic complication of transradial catheterization that can lead to permanent occlusion of the radial artery. Sheath-vessel diameter ratio, postprocedure compression time, occlusive hemostasis, and insufficient anticoagulation are all predictors of RAO. However, excessive anticoagulation can lead to longer time to achieve complete hemostasis and less patent hemostasis rate. This study was designed to assess the relationship among residual anticoagulation at the end of a percutaneous coronary procedure and the risk of RAO.

Methods:

Eight hundred thirty-seven patients undergoing transradial catheterization were enrolled. Activated clotting time (ACT) was measured before sheath removal. Patients were divided into 3 groups according to ACT values (ACT <150 s, ACT between 150 and 249 s, ACT >250 s), patent hemostasis with reverse Barbeau test was attempted in all patients, and compression device removed as soon as possible. Within 24 hours, patency of radial artery was checked by Doppler using reverse Barbeau technique.

Results:

Incidence of RAO was higher for the extreme ACT values. Patent hemostasis were less frequently obtained and time to hemostasis significantly longer for increasing ACT values ( P =0.004 for trend and <0.0001 for trend, respectively). At logistic regression analysis, ACT values <150 s were an independent predictor of RAO (odds ratio, 3.53; 95% IC, 1.677–7.43; P =0.001) while adjusted probability for RAO confirmed U-shaped relationship with ACT values.

Conclusions:

The level of anticoagulation is strongly related to incidence of RAO and should be measured objectively by ACT.

Clinical Trial Registration:

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02762344.