Feasibility of Transradial Access for Coronary Interventions Via Percutaneous Angioplasty of the Radial Artery in Cases of Functional Radial Occlusion
Abstract: Aims. Transradial access (TRA) has become a standard approach for cardiac catheterization. However, an obstacle to TRA is the risk of radial artery occlusion (RAO) after radial access in about 5%-10% of patients. We analyzed the safety and efficacy of getting vascular access after RAO by percutaneous transluminal angioplasty in cases of chronic radial occlusion. Methods and Results. Chronic RAO was confirmed by Allen test and color Doppler in 8 patients. TRA was achieved by puncture in the distal tabatiere (anatomical snuffbox) using Seldinger’s technique followed by insertion of a 5 Fr radial introducer sheath. Angiogram was obtained before percutaneous transluminal angioplasty with a 2.0 mm coronary balloon to reopen the artery. Puncture of the occluded radial artery, percutaneous transluminal angioplasty, and subsequent coronary catheterization and PCI were successful in all 8 patients. One complication was a dissection of the radial artery without further adverse events. No hemorrhage or compartment syndrome occurred. Conclusions. With increased application of TRA, the incidence of RAO is also rising. Some patients with RAO require repeat cardiac catheterization. Given the risk of damaging the contralateral radial artery in subsequent procedures, using the same access site is desirable. We demonstrate that it is feasible to get access to an occluded radial artery by percutaneous transluminal angioplasty.
J INVASIVE CARDIOL 2018;30(10):355-359. Epub 2018 August 15.
Key words: PCI, PTA radial artery, radial artery occlusion, transradial access
In the last few years, using a transradial approach (TRA) for cardiac catheterization has become standard and its use is increasing. Advantages of TRA include reduced risk of hemorrhage, increased patient comfort, shorter time to ambulation, and lower mortality in cases of acute coronary syndrome.1-4 This technique should be preferred for rescue percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction according to the European Society of Cardiology guidelines.5 One potential obstacle is the development of radial artery occlusion (RAO) after cardiac catheterization, the incidence of which varies from 0.8% to 30% in recent studies.6-9 Spontaneous recanalization occurs over time in many patients, such that the prevalence of RAO is significantly decreased (about three-times lower) at 6 months post procedure when compared to day 1 post vascular intervention.10,11
With the rapid increase in the use of transradial cardiac catheterization, the number of patients with RAO is also rising. In 2013, the Society for Cardiovascular Angiography and Intervention (SCAI) published a “best practice” consensus statement to minimize RAO based on the following risk factors: sheath size; female sex; procedure duration; multiple catheter changes; low body mass index; diabetes mellitus; repeated TRA; lack of anticoagulation; long compression time; endothelial injury by large catheters; and experience level of the interventional cardiologist.12
Intraluminal imaging by optical coherence tomography has demonstrated vascular impairment and radial artery injuries after TRA. In about 32% of patients, so-called “intimal tears” (luminal surface discontinuities with or without an intimal flap to the media layer) are identified, mostly in the distal segment of the artery. These intimal tears are presumably caused by the introducer sheath. Medial dissection (defined as a luminal surface disruption extending into the tunica media) was seen in 16% of patients. Since these arterial injuries were more often located within the proximal or medial segments of the radial artery, they supposedly are caused by the catheter.13
Impairment of the radial artery is more common in patients who have had repeated TRA procedures. Previous studies using high-resolution ultrasound biomicroscopy or intravascular ultrasound have demonstrated reduced luminal diameter of the radial artery after TRA in almost all patients due to significant intimal thickening.14,15 Two small case series have demonstrated the feasibility of reopening recent (within 1 week) acutely thrombosed radial arteries post catheterization by PTA with a coronary balloon (2 cases) or by wire recanalization and dilation with the sheath introducer mandrin (12 cases).16,17
Methods
At our institution, patients who have undergone prior radial cardiac catheterization are routinely examined for RAO before repeat catheterization. If a radial pulse is absent, we perform a mobile ultrasound with color Doppler (Vscan; GE Healthcare). A representative case is shown in Figure 1. In the majority of cases, bedside imaging reveals the absence of continuous flow in the radial artery; true total occlusion is rarely observed. In addition, quite often we notice pronounced hyperplasia of the intima-media layer that severely narrows the arterial lumen. This usually results in a functional occlusion with reduced, monophasic slow blood flow rather than complete occlusion, as previously described by others.18,19
In this study, we aimed to reopen functionally occluded radial arteries via PTA. We diagnosed functional RAO after TRA for cardiac catheterization in a cohort of 8 patients (7 females, 1 male). Table 1 shows clinical characteristics of the study cohort. Previous TRA for cardiac catheterization was performed at least 12 weeks prior to the current procedure in all patients. Verbal and written consent for TRA was granted after critical discussion of the involved risks, benefits, and alternative approaches.
The radial artery was identified and its anatomic route was marked on the cutaneous surface via ultrasonographic techniques. This was helpful for successful arterial puncture. The right wrist was hyperextended, and after local anesthesia puncture of the radial artery was performed with a 20 G angiocatheter needle (Terumo) and a 0.025˝ guidewire (Terumo) was inserted through the needle. Upon removal of the needle, a 7 cm, 5 Fr sheath (Terumo) was advanced over the guidewire. The 5 Fr sheath only needs to be inserted for a few millimeters to perform an angiogram through the sheath, which confirmed the presence of a functional occlusion. After sheath insertion, 2.5 mg verapamil and a bolus of 5000 IE heparin were administered via the sheath. To obtain access for cardiac catheterization, we introduced a 0.014˝ Choice-PT PCI wire (Boston Scientific) into the aortic arch under fluoroscopic guidance and performed PTA with a 2.0 x 30 mm Maverick PTCA balloon (Boston Scientific) over the entire length of the lesion. We inflated the balloon to 6-10 atm for only a few seconds. Thereafter, the sheath was inserted over the deflating balloon at the tip of the sheath. With a 5 Fr, JR 4.0 catheter (Cordis) introduced over the Choice PT wire, access to the aortic arch was possible. Once accessed, we changed over to the usual J-wire to place the 5 Fr diagnostic.
For PCI, we performed a simple mother-daughter technique using a 5 Fr pigtail catheter in a 6 Fr PCI guiding catheter to limit the so-called “razor-effect” on the intimal layer of the radial artery from the edge between the J-wire and guiding catheter (Figure 2).20 With our technique, the pigtail catheter is 8 mm longer than the guiding catheter and straightening the guiding catheter results in a seamless transition without an edge to the J-wire. In our experience, the incidence of RAO is reduced with this technique.
After performing cardiac catheterization or PCI, the sheath was removed using standard technique with a TR Band (Terumo) inflated with 12-15 mL of air to ensure adequate hemostasis.
Results
Figures 3-5 illustrate three different representative cases. The first case (Figure 3) is a 62-year-old male bilateral lower-extremity amputee on renal dialysis with an occlusion of both iliac arteries and an arteriovenous shunt in the left arm. The second case (Figure 4) is a 64-year-old female patient with RAO after PCI performed at another hospital. The third case (Figure 5) is an 82-year-old female with RAO after coronary intervention 12 weeks previously at our institution.
Discussion
After reopening occluded radial arteries by PTA, coronary angiography was able to be performed using standard technique in all cases. Placing and manipulating catheters was more difficult than in uncomplicated TRA without RAO because friction within the radial artery is moderately painful. With some anesthesia and conscious sedation with morphine and diazepam, this procedure was comfortable for the patients. The procedure durations and radiation times were longer than typical TRA procedures without RAO, but no coronary catheterization procedure lasted longer than 30 minutes and x-ray duration times did not exceed 5 minutes.
In 4 PCI cases, we changed to a 6 Fr sheath over the lying J-wire. For PCI, we used the described mother-daughter catheter technique with a 5 Fr pigtail inside the 6 Fr guiding catheter. This was possible in all 8 patients, but caused some difficulties in placing and manipulating the guiding catheter. No bleeding complications were observed, but each patient complained of moderate pain in the forearm the day after the procedure. Prescription of non-steroidal anti-inflammatory drugs such as ibuprofen (400 mg three times daily) was sufficient for analgesia. In the color Doppler studies performed after the vascular intervention, radial arteries were patent in each case, but prominent increases in the thickness of the intima-media layers were noted. This finding was associated with a small residual arterial lumen and a weak or missing radial pulse. The duplex studies showed monophasic reduced flow; no total occlusions occurred in this series of 8 patients.
Study limitations. This study only addresses the feasibility of reopening an occluded radial artery by PTA, instead of resorting to using the contralateral radial artery and incurring the risk of damaging both arteries.
References
1. Campeau L. Entry sites for coronary angiography and therapeutic interventions: from the proximal to the distal radial artery. Can J Cardiol. 2001;17:319-325.
2. Kiemeneij F, Laarman GJ, de Melker E. Transradial artery coronary angioplasty. Am Heart J. 1995;129:1-7.
3. Brueck M, Bandorski D, Kramer W, Wieczorek M, Höltgen R, Tillmanns H. A randomized comparison of transradial versus transfemoral approach for coronary angiography and angioplasty. JACC Cardiovasc Interv. 2009;2:1047-1054.
4. Anjum I, Khan MA, Aadil M, Faraz A, Farooqui M, Hashmi A. Transradial vs transfemoral approach in cardiac catheterization: a literature review. Cureus. 2017;9:e1309.
5. Ibanez B, James S, Agewall S, et al. ESC Scientific Document Group. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39:119-177.
6. Jolly SS, Amlani S, Hamon M, et al. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J. 2009;157:132-140.
7. Baklanov DV, Kaltenbach LA, Marso SP, et al. The prevalence and outcomes of transradial percutaneous coronary intervention for ST-segment elevation myocardial infarction: analysis from the National Cardiovascular Data Registry (2007 to 2011). J Am Coll Cardiol. 2013;61:420-426.
8. Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;377:1409-1420.
9. Stella PR, Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. Incidence and outcome of radial artery occlusion following transradial artery coronary angioplasty. Cathet Cardiovasc Diagn. 1997;40:156-158.
10. Goswami R, Oliphant CS, Youssef H, Morsy M, Khouzam RN. Radial artery occlusion after cardiac catheterization: significance, risk factors, and management. Curr Probl Cardiol. 2016;41:214-227.
11. Sinha SK, Jha MJ, Mishra V, et al. Radial artery occlusion - incidence, predictors and long-term outcome after transradial catheterization: Clinico-Doppler ultrasound-based study (RAIL-TRAC study). Acta Cardiol. 2017;72:318-327.
12. Rao SV, Tremmel JA, GilchristI C, et al. Best practices for transradial angiography and intervention: a consensus statement from the Society for Cardiovascular Angiography and Intervention’s Transradial Working Group. Catheter Cardiovasc Interv. 2014;83:228-236.
13. Yonetsu T, Kakuta T, Lee T, et al. Assessment of acute injuries and chronic intimal thickening of the radial artery after transradial coronary intervention by optical coherence tomography. Eur Heart J. 2010;31:1608-1615.
14. Shen H, Zhou Y-J, Liu Y-Y, et al. Assessment of early radial injury after transradial coronary intervention by high-resolution ultrasound biomicroscopy: innovative technology application. Chin Med J. 2012;125:3388-3392.
15. Wakeyama T, Ogawa H, Iida H, et al. Intima-media thickening of the radial artery after transradial intervention: an intravascular ultrasound study. J Am Coll Cardiol. 2003;41:1109-1114.
16. Babunashvili A, Dundua D. Recanalization and reuse of early occluded radial artery within 6 days after previous transradial diagnostic procedure. Catheter Cardiovasc Interv. 2011;77:530-536.
17. Pancholy SB. Transradial access in an occluded radial artery: new technique. J Invasive Cardiol. 2007;19:541-544.
18. Zhang BB, Zhou YJ, Du J, et al. Comparison of very-high-frequency ultrasound assessment of radial arterial wall layers after first and repeated transradial coronary procedures. J Geriatr Cardiol. 2017;14:245-253.
19. Nagai S, Abe S, Sato T, et al. Ultrasonic assessment of vascular complications in coronary angiography and angioplasty after transradial approach. Am J Cardiol. 1999;83:180-186.
20. Garg N, Sahoo D, Goel PK. Pigtail assisted tracking of guide catheter for navigating the difficult radial: overcoming the “razor effect.” Indian Heart J. 2016;68:355-360.
From the 1Department of Cardiology, Pneumology, and Angiology, Prosper Hospital Recklinghausen, University of Witten/Herdecke, Recklinghausen, Germany; 2Department of Cardiology, Katholisches Klinikum Essen, Philippusstift, University of Witten/Herdecke, Essen, Germany; and 3Department of Cardiology, Helios University Hospital Wuppertal, University of Witten/Herdecke, Wuppertal, Germany.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted April 20, 2018 and accepted May 2, 2018.
Address for correspondence: Dr med Michael Schulte-Hermes, Head of the Department of Cardiology, Pneumology, and Angiology, Prosper Hospital Recklinghausen, Academic Teaching Hospital of the University of Bochum, Mühlenstr. 27, 45659 Recklinghausen, Germany. Email: michael.schulte-hermes@ prosper-hospital.de
