Forearm Versus Femoral Approach for Cardiac Catheterization in End-Stage Renal Disease Patients

Abstract: Background. End-stage renal disease (ESRD) is considered a relative contraindication for forearm (radial or ulnar) cardiac catheterization. However, in everyday practice, many ESRD patients are catheterized from the forearm. The aim of this study was to compare femoral and forearm approach for cardiac catheterization in ESRD patients. Methods. All cardiac catheterization procedures performed in ESRD patients in three Greek hospitals in a 2-year period (2014-2015) were retrospectively evaluated. The primary endpoint of the study was major access-site complication, defined as any Blood Academic Research Consortium class ≥3 bleeding or limb ischemia requiring intervention or prolonging hospitalization. Results. During the study period, a total of 124 procedures were performed in 109 ESRD patients: 44 procedures (35.5%) were performed transfemorally and 80 procedures (64.5%) were performed from the forearm approach (77 transradial [96.3%] and 3 transulnar [3.7%]). Forearm access was always performed from the contralateral arm of a functional hemodialysis access site. Sixty-one procedures (49.6%) were diagnostic coronary artery angiographies (CAAs) and 63 procedures (50.4%) were percutaneous coronary interventions with or without CAA. Two deaths and 1 procedure-related myocardial infarction were recorded during hospitalization. Five patients suffered major access-site complications, all from the femoral group (5/44 vs 0/80; P<.01). Three transradial patients had asymptomatic radial artery occlusion after a diagnostic procedure. Five patients (4.0%) had problems with their hemodialysis access site during long-term follow-up, and required a new access site. Conclusion. Forearm approach for cardiac catheterization is feasible and safe in ESRD patients. All measures to preserve radial patency should be taken in this high-risk patient group, where a possible forearm artery occlusion might have serious consequences.

J INVASIVE CARDIOL 2018;30(3):110-114.

Key words: hemodialysis, end-stage renal disease, complications, cardiac catheterization

End-stage renal disease (ESRD) patients represent a high-risk and very challenging group of patients for cardiac catheterization. They suffer from aggressive coronary artery disease due to severe comorbidities (hypertension, diabetes, dyslipidemia) and impaired mineral metabolism,¹ which is often challenging to treat percutaneously.² The devastating effects of ESRD on the arterial tree are not only present in the coronary arteries, but also in the aorta and the carotid, iliac, and femoral arteries.³ The latter, coupled with renal anemia, which is attributed to relative lack of erythropoietin, renders these patients high risk for access-site complications during cardiac catheterization,⁴ especially when treated transfemorally. On the other hand, when the forearm (radial or ulnar) approach is selected, a possible postprocedure forearm artery occlusion or narrowing may have deleterious consequences, since this site cannot be used for the creation of an arteriovenous (AV) fistula in the future. 

The growing interest of interventional cardiologists in forearm artery patency after catheterization has produced a great volume of research on this topic, with new treatments proposed in order to minimize the incidence of forearm artery occlusion.^5-8 Additionally, new methods such as fistula angioplasty have been applied in order to increase AV fistula longevity.⁹ The aim of this study was to evaluate the practice used in our facilities when ESRD patients are catheterized and to compare procedures performed from the femoral and forearm approaches.

Methods

Patients treated with hemodialysis for ≥1 month (defined as ESRD patients) who underwent cardiac catheterization over a 2-year period (2014-2015) at three Greek hospitals (Second Cardiology Department of Red Cross General Hospital, Crete University Hospital, and Konstantopoulio General Hospital) were identified and retrospectively evaluated. Informed consent was obtained from all patients and the ethics committee of all three hospitals approved the study protocol. 

Procedures were grouped into those performed from the femoral approach and those performed from the forearm (radial or ulnar) approach. Access site was at the operator’s discretion, but all operators had a low threshold to choose the forearm approach. In the presence of an upper-extremity AV fistula or AV graft, the contralateral arm was considered a possible candidate for forearm artery cannulation. In procedures where an access-site switch was performed, patients were included in the initial access-site group. All physicians were high-volume operators (>400 procedures/year for the last 5 years) and experienced in both femoral and forearm approaches, although all participating centers are dedicated forearm centers, with approximately 80% of the procedures performed from the forearm approach. Procedures were performed with 5 Fr, 6 Fr, and 7 Fr sheaths for both femoral and forearm approach. Forearm access-site closure was performed using a closure device (KDL China) with either traditional patent hemostasis¹⁰ or by transient simultaneous compression of the ipsilateral forearm artery in order to augment blood flow in the catheterized forearm artery and prevent its occlusion (the ULTRA method).⁵ Femoral access-site closure was performed with AngioSeal closure device (St. Jude) or manual compression.

All patients treated from the forearm approach received 5000 IU unfractionated heparin and 5 mg verapamil intrasheath as soon as successful forearm sheath insertion was documented; if ad hoc PCI was decided, more unfractionated heparin was administered intravenously in order to reach 100 IU/kg. In patients treated transfemorally, no heparin was administered for diagnostic procedures; if ad hoc PCI was decided, 100 IU/kg heparin was administered intravenously. Other anticoagulation medications, such as bivalirudin and glycoprotein IIb/IIIa inhibitors, were administered at the treating physician’s discretion and mostly as a bailout therapy.

All patients who underwent percutaneous coronary intervention (PCI) were loaded with 325 mg aspirin and 600 mg clopidogrel, if not already on antiplatelet medication. 

New-generation everolimus- eluting and zotarolimus-eluting stents were used in all patients undergoing PCI.

Rotational atherectomy was performed for heavily calcified lesions at the treating physician’s discretion and was always started with a 1.25 mm burr.

Procedural success was defined as residual luminal stenosis <20% in patients receiving stents and <50% in patients undergoing plain old balloon angioplasty. 

Same-day discharge was considered in patients who underwent uncomplicated procedures.

Major access-site complications were defined as any Blood Academic Research Consortium (BARC) class ≥3¹¹ bleeding or limb ischemia requiring intervention or prolonging hospitalization. 

Forearm artery patency was evaluated with palpation in all patients, and with predischarge color duplex ultrasonography in patients with clinically suspected forearm artery occlusion. 

In-hospital outcomes were collected from the individual hospital registries, while long-term outcomes were collected by telephone contact that was performed in all patients at 30 days after the procedure and in August 2016. The following endpoints were recorded: death; stroke; new myocardial infarction; definite and probable stent thrombosis; new amputation; and new AV fistula formation. Stent thrombosis was defined according to the Academic Research Consortium criteria.¹²Myocardial infarction at 30 days included periprocedural myocardial infarction and was defined according to the third universal definition of myocardial infarction.¹³ 

Statistical analysis. Demographics and clinical characteristics were expressed as mean ± standard deviation or median (first quartile-third quartile). Comparative analysis of categorical variables was performed using a Chi-square test or Fisher’s exact test. Continuous variables were analyzed using independent t-tests for normal distribution; otherwise, the Mann-Whitney U-test was employed. All P-values are two-tailed, and P<.05 was considered statistically significant. All statistical analyses in this study were performed using SPSS software, version 20.0 (IBM, Inc). 

Results

During the study period, a total of 124 procedures were performed in 109 ESRD patients at the three participating hospitals. These procedures were performed in patients undergoing hemodialysis via an AV fistula (106 procedures; 85.5%), via an AV graft (6 procedures; 4.8%), or via central vein catheter (CVC) (12 procedures; 9.7%). The site of hemodialysis was left arm for 92 cases (74.2%), right arm for 20 cases (16.1%), and CVC for 12 cases (9.7%). Sixty-one procedures (49.2%) were diagnostic coronary angiographies, 57 procedures (45.9%) were diagnostic procedures followed by ad hoc PCI, and 6 procedures (4.8%) were planned PCIs. 

Forty-four procedures (35.5%) were performed transfemorally and 80 procedures (64.5%) were performed from the forearm approach (70 right radial, 7 left radial, 2 left ulnar, and 1 right ulnar). Demographic characteristics are presented in Table 1. Patients treated transfemorally were less often current smokers and more often had a history of prior coronary artery bypass graft surgery. Procedural characteristics did not vary significantly between the two groups (Table 2). Access-site switch was performed in 3 cases from the forearm group and in no cases from the femoral group (P=.55). Those 3 cases were all initially performed from the right radial approach; 1 patient was switched to ipsilateral ulnar approach, resulting in the insertion of 2 sheaths in the same wrist, while 2 patients were switched to femoral approach. Extreme calcifications of forearm arteries were identified in 3 patients from the forearm group, and resulted in a switch to the femoral approach in 1 of them (Figure 1). 

Rotational atherectomy was used in 4 procedures (3 from the forearm group and 1 from the femoral group; 6.3% of all PCIs) without any periprocedural complications.

One patient underwent diagnostic coronary angiography from the right radial approach; 1 week later, he underwent elective transfemoral PCI with rotational atherectomy for a calcified proximal left anterior descending coronary artery stenosis. The patient did not experience any adverse events during the follow-up period.

Hospitalization was 3.9 ± 2.6 days for the femoral group and 1.4 ± 2.1 days for the forearm group (P=.02). Twenty-nine patients (23.4%) were discharged the same day after catheterization (27 from the forearm group and 2 from the femoral group; P<.001).

Endpoints. Major access-site complications are presented in Table 3. Major access-site complications were recorded in 5 cases (4.0%), all from the femoral group (5/44 [11.4%] vs 0/80 [0.0%]; P<.01); 4 patients had access-site bleeding with hemoglobin drop between 3-5 g/dL (BARC class 3a), which required transfusion in 1 patient, while the fifth patient had worsening of preexisting limb ischemia and prolonged hospitalization, but without needing intervention. 

Forearm artery occlusion was documented in 3 cases after forearm catheterization (all right radial cases). However, the occlusion was asymptomatic in all cases.

Two patients died during the index hospitalization due to myocardial infarction complicated by heart failure and cardiogenic shock, although they underwent a successful revascularization (1 patient from the femoral group and 1 patient from the forearm group).

One patient (treated transfemorally) suffered a periprocedural myocardial infarction complicated by cardiogenic shock due to an unsuccessful PCI of the right coronary artery.

Thirty-day outcomes. Data were obtained from all patients or their relatives by telephone contact or physical visit. One patient from the forearm group died suddenly 3 days after PCI due to probable stent thrombosis. There were no patients who experienced stroke, new myocardial infarction, definite stent thrombosis, new amputation, or new AV fistula formation during the 30-day follow-up.

Long-term follow-up. Telephone contact was attempted in all patients in August 2016. We obtained information from 106 of the participating patients or their relatives (97.2%). Median follow-up period was 11 months (first quartile 8 months, third quartile 17 months). 

Sixteen patients died during follow-up; 7 patients (15.9%) died from the femoral group and 9 patients (11.3%) died from the forearm group (P=.42). The causes of death were worsening of preexisting heart failure (5 patients), stroke (3 patients), sepsis (2 patients), internal bleeding (2 patients), probable stent thrombosis (2 patients), death during car accident (1 patient), and death during transcatheter aortic valve replacement procedure (1 patient). Six patients experienced stroke (2 from the femoral group and 4 from the forearm group). Two patients experienced new myocardial infarction (1 from each group) and no patients had definite stent thrombosis. 

Five patients (4.6%) had problems with their hemodialysis access-site function (1 patient from the femoral group and 4 patients from the forearm group). All had a left-hand AV fistula and needed a new hemodialysis access site. The new access sites were right-arm AV fistula (3 patients), left-arm AV fistula (1 patient), and CVC (1 patient).

Three patients underwent a new lower-limb amputation during long-term follow-up (2 patients from the forearm group and 1 patient from the femoral group).

Discussion

This retrospective analysis shows that forearm access in ESRD patients is feasible and is associated with fewer access-site complications than the femoral approach. Moreover, forearm artery catheterization shows low occlusion rates and significantly shorter hospitalization times, with a high rate of same-day discharge. These findings should be evaluated in a randomized, prospective trial, but are nonetheless important, since access-site complications are associated with increased mortality. 

The access-site complication rate was high in femoral cases compared to forearm cases in our study cohort (11.4% vs 0.0%, respectively). Patients with access-site bleeding complications carry a greater risk for death (relative risk, 1.71; 95% confidence interval, 1.37-2.13).¹⁴ 

Longevity of AV fistulas has recently improved due to better nursing care and new treatments, such as balloon angioplasty.⁹ The rate of hemodialysis access-site dysfunction was low in our study (only 5 patients had dysfunction and needed a new hemodialysis access site during a median 11-month follow-up period). If this occurs and patients have a postcatheterization occluded forearm artery (3.75% in our study population), other possible sites for AV fistula or AV graft must be examined. A proximal AV fistula (brachiocephalic or brachiobasilic) can be created. Alternatively, a loop or straight AV graft can be constructed. In patients with no upper-limb vascular access site, other options should be examined, such as creating an AV fistula in the patient’s lower extremity or performing dialysis through a permanent CVC. However, the risk of death due to this complication is extremely low. 

Forearm artery occlusion, which occurs in 1%-10% of patients after forearm catheterization,¹⁵ may prohibit the use of this site for new AV fistula creation if the contralateral AV fistula is not functional. For that reason, better practices to maintain forearm artery patency after catheterization are needed. Material miniaturization using small-diameter radial sheaths (for example, 4 Fr),¹⁶ sheaths with a reduced outer diameter for a given inner diameter (Glidesheath Slender; Terumo),⁷ or sheathless guiding catheters¹⁷ may reduce the incidence of forearm artery occlusion. Newer hemostatic techniques, such as patent hemostasis¹⁰ or the ULTRA technique,⁵ may further reduce the incidence of this complication.

Patient age is another parameter that must be taken into consideration before applying the forearm approach in ESRD patients. Younger patients are more likely to live many years and experience hemodialysis access-site failure, needing a new AV fistula; on the other hand, they have reduced access-site complication rates when treated transfemorally.¹⁸ This is why the concept of forearm approach for cardiac catheterization is even more attractive in older ESRD patients undergoing cardiac catheterization.

It is true that the forearm approach is associated with better outcomes in patients undergoing cardiac catheterization. However, many patients who should derive the maximum benefit from the forearm approach are often excluded (eg, the elderly, women, those with previous coronary artery bypass graft surgery).¹⁹ The cornerstone of achieving the maximum benefit from the forearm approach is to apply it to those who would benefit most, and these are the most fragile of our patients, such as those with ESRD.

Study limitations. This study has the inherent limitations of a retrospective analysis. Moreover, the number of patients studied is relatively small. Despite these limitations, the present study is the first to evaluate catheterization site and accompanied complications in ESRD patients, and the data presented should be considered hypothesis generating. 

Conclusion

The forearm approach is feasible and associated with lower access-site complications in ESRD patients undergoing cardiac catheterization. Further randomized studies are needed in order to evaluate these findings.

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From the ¹Second Cardiology Department, Red Cross General Hospital, Athens, Greece; ²Vascular Surgery Department, “Attikon” University Hospital, Athens, Greece; ³Cardiology Department, “Konstantopoulio” General Hospital, Athens, Greece; ⁴Cardiology Department, University Hospital of Heraklion, Crete, Greece; and ⁵Medifil Hemodialysis Center, Peristeri, Greece.

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 January 2, 2017, provisional acceptance given March 29, 2017, final version accepted June 7, 2017.

Address for correspondence: Michael Koutouzis, MD, PhD, Red Cross General Hospital, 11526, Athens, Greece. Email: koutouzismike@yahoo.gr