Distal Transradial Access For Cardiac Catheterization in Patients Undergoing Hemodialysis

Abstract

Objectives. Although a distal radial artery (DRA) approach has recently been used in patients undergoing cardiac catheterization, no studies have so far investigated the safety and feasibility of DRA in patients undergoing hemodialysis (HD). We aimed to investigate the incidence of conventional radial artery (CRA) occlusion and puncture site complications after DRA puncture in patients undergoing HD. Methods. We retrospectively analyzed the data of 117 consecutive patients with HD who underwent coronary angiography or percutaneous coronary intervention via a DRA approach at our institution from September 2017 to December 2019. The primary endpoint was the incidence of CRA occlusion after DRA puncture, as assessed via vascular ultrasonography. Secondary endpoints included difficulty achieving hemostasis, DRA occlusion, aneurysm, arteriovenous shunt, and acute ischemia. Results. The DRA puncture was successful in 106 patients (success rate: 90.5%). Because 21 patients lacked postprocedural vascular ultrasonography data, the primary endpoint was evaluated in 85 patients. CRA occlusion occurred in three patients (3.5%) following DRA puncture. DRA occlusion and aneurysm occurred in five patients (5.9%) and one patient (1.2%), respectively. Conclusions. Catheterization through DRA is feasible in patients undergoing HD, with a clinically acceptable incidence of CRA and complications.

Keywords: coronary intervention, distal radial artery approach, angiography, conventional radial artery

The conventional radial artery (CRA) approach is recommended during coronary angiography (CAG) and percutaneous coronary intervention (PCI) because transfemoral interventions (TFIs) are commonly known to be associated with higher rates of bleeding than transradial interventions (TRIs).¹ CRA occlusion is a known major complication following TRIs, with an incidence ranging from 2% to 10%.² This problem is rarely seen as clinically significant sequelae because of the presence of adequate dual circulation via the radial and ulnar artery. However, in patients undergoing hemodialysis (HD) and those potentially needing the construction of a new arteriovenous fistula (AVF), CRA occlusion that may occur contralateral to the AVF is a serious complication. For most patient interventions in Japan, the average period for HD is more than 10 years.³ Consequently, incidences necessitating new AVFs in the contralateral arm are fairly common. Therefore, physicians tend to choose a femoral artery approach for catheterization in patients undergoing HD. However, the use of a femoral approach increases the risk of bleeding complications and mortality rates.¹ Due to the above reasons, we must investigate the approaches that decrease CRA occlusion without increasing bleeding events in HD patients.

Recently, Kiemeneij et al demonstrated the feasibility and safety of a DRA approach for cardiac catheterization. Subsequent reports of CRA occlusion following a DRA approach have been rare.^4-6 In addition, several previous studies have suggested that a DRA approach is associated with low rates of vascular complications.^4,6-9 Although we speculate that this approach may be beneficial for patients undergoing HD by avoiding CRA occlusion, no studies have so far provided data in the HD population. Hence, this study aimed to investigate the incidence of CRA occlusion and related events after DRA puncture in patients undergoing HD.

Methods

Study population. This study included 117 consecutive patients undergoing HD who had also undergone CAG or PCI via a DRA approach at our institution from September 2017 to December 2019. We used the DRA approach in patients with a palpable DRA contralateral to the AVF of the dialysis access point. Patients with either an unsuccessful puncture or no postprocedural vessel sonography were excluded. Puncture success was defined as the complete insertion of the catheter sheath via the DRA. The study protocol was approved by the Institutional Review Board of the Tokushukai Group Ethics Committee and conformed to the Declaration of Helsinki (Approval No: TGE01461-024).

Procedure. We attempted a puncture via the DRA contralateral to the AVF for dialysis. Following subcutaneous injection of lidocaine hydrochloride through a 27-G needle, the puncture was performed using a 20-G puncture needle. The decision to use ultrasound guidance was left to the surgeon. We used a 4-Fr or 5-Fr Glidesheath Slender Sheath (Terumo) for CAG and a 6-Fr Glidesheath Slender or 7-Fr Glidesheath Slender for PCI. Unfractionated heparin was administered intra-arterially following sheath insertion. The doses of unfractionated heparin were 2,000 U for all patients undergoing CAG, 5,000 U for female patients undergoing PCI, and 6,000 U for male patients undergoing PCI as an institutional regimen. After the procedure, hemostasis was achieved with Stepty (Nichiban Co) for 2 h. The same hemostasis procedure was repeated when bleeding could not be controlled after the initial 2 h of hemostasis. The procedure’s success was defined based on the ability to complete the procedure without changing the access site. Persistent bleeding for more than 4 h after the procedure was regarded as difficulty in achieving hemostasis.

Ultrasonography protocol. Before the procedure, blood flow and the inner diameter of the DRA and RA were assessed via vascular ultrasonography. DRA occlusion, CRA occlusion, and aneurysm at the puncture site were evaluated via vascular ultrasonography within 24 h after the procedure.

Endpoints. The primary endpoint of the study was CRA occlusion following DRA puncture, as assessed via vascular ultrasonography. Secondary endpoints included several puncture-related complications such as difficulty achieving hemostasis, DRA occlusion, aneurysm, arteriovenous shunt, and acute ischemia.

Statistical analyses. All data were retrospectively analyzed. Categorical variables are expressed as numbers and percentages. Continuous variables, including arterial diameter, are expressed as means with standard deviations. These were compared using paired t-tests, as appropriate. Statistical significance was defined as P<.05. All statistical analyses were performed using JMP version 14 (SAS Institute Inc.).

Results

The study flow chart is shown in Figure 1. We attempted DRA puncture in 117 patients undergoing HD. Successful puncture via the DRA was achieved in 106 of these patients (success rate, 90.5%). Twenty-one patients lacked postprocedural vascular ultrasonography data. Thus, the primary endpoint was evaluated in 85 patients.

Baseline characteristics are shown in Table 1. The average patient age was 68.8 years (range, 41-84 years). Sixty-three ­patients (74.1%) were male. Hypertension, diabetes, dyslipidemia, and smoking were present in 72.3%, 56.6%, 56.7%, and 55.3% of patients, respectively. Procedural characteristics are shown in Table 2. The procedure was successful in 81 patients (95.2%). CAG or PCI could not be completed via the DRA in the remaining four patients due to a tortuous subclavian artery. A right-sided approach was used in 75 patients (88.2%). The maximum sheath size was 7-Fr Glidesheath Slender, with an outer diameter of 2.79 mm. Vascular sonography was performed before the procedure in 65 patients (76.5%). The mean diameter of the DRA was significantly smaller than that of the CRA (1.92 ± 0.37 mm vs 2.12 ± 0.53 mm; P<.05). The ratio of the sheath outer diameter (SOD) to the DRA diameter was significantly smaller than the ratio to the CRA diameter (Figure 2). A SOD/CRA ratio ≥1 was noted in 22%, 27%, 49%, and 92% of cases in which 4-Fr, 5-Fr Glidesheath Slender, 6-Fr Glidesheath Slender, and 7-Fr Glidesheath Slender were used, respectively. A SOD/DRA ratio ≥ 1 was noted in 27%, 64%, 91%, and 96% of cases in which 4-Fr, 5-Fr, 6-Fr, and 7-Fr Glidesheath Slender were used, respectively.

Table 3 shows the primary and secondary endpoints assessed by ultrasonography after the procedure. CRA occlusion occurred in three patients (3.5%) following DRA puncture. DRA occlusion and aneurysm occurred in five patients (5.9%) and one patient (1.2%), respectively. Detailed information related to the three patients with CRA occlusion is presented in Table 4. All of these patients were female, and two of the three patients had SOD/CRA ratios > 1. Table 5 shows a comparison of features between patients with and without CRA occlusion. The CRA occlusion group included a large proportion of patients undergoing single platelet therapy with or without antithrombotic therapy than the non-CRA occlusion group. Although CRA occlusion was observed, the diameters of DRA and CRA were not significantly different between the CRA and non-CRA occlusion groups (DRA, 1.61 mm vs 1.95 mm [P=.13]; CRA, 1.83 mm vs 2.15 mm [P=.24]).

Discussion

The present study investigated the incidence of CRA occlusion and puncture site complications following a DRA approach in patients undergoing HD. Our findings indicated that DRA puncture was highly successful (90.7% success rate) in these patients. In addition, the incidence of CRA occlusion was very low, affecting only 3.5% of patients, and fewer cases of vascular complications were observed.

Previous studies have reported puncture success rates ranging from 89.0% to 99.6% for the DRA approach when applied in the general population.^4–7 Our results of puncture success rates in patients with HD are consistent with those in the general population. Another study reported a success rate of 98.4% for CRA puncture in patients undergoing HD.¹⁰ The DRA puncture success rate in our study is lower than the CRA puncture success rate from the previous report. We considered that puncture success rates might be related to the technical learning curve, small arterial diameter, and the study’s small population.

Although HD patients are known to exhibit heavy calcification in various vessels, our data suggest that catheter access via the DRA is possible in these patients. Notably, we observed a few cases of CRA occlusion following DRA puncture. CRA patency is critical in patients undergoing HD because the CRA may be used for a new, alternative AVF in the future. Therefore, physicians tend to choose a femoral artery approach for catheterization in patients undergoing HD. However, the use of a femoral approach increases the risk of bleeding complications and mortality rates.¹ Moreover, research has indicated that patients undergoing HD attract a high risk of bleeding, and those who experience bleeding events exhibit high mortality.¹¹

Several reports have documented CRA occlusion rates ranging from 0% to 1.7% following DRA puncture in the general population.^4,5,7,9 Although the CRA occlusion rate was higher in our HD cohort than in the general population, another previous study reported a CRA occlusion rate of 6.5% following CRA puncture in patients undergoing HD.¹⁰ Comparing the CRA occlusion rate of this report, the rates observed in this study are lower. Therefore, our findings indicate that DRA puncture is safe and feasible in these patients. The factors leading to CRA occlusion after DRA puncture remain unclear. Some studies have reported that the use of low-dose heparin or an SOD/CRA ratio >1 is associated with CRA occlusion after CRA puncture.¹² However, no studies have suggested that SOD/CRA diameter is an independent predictor of CRA occlusion after DRA puncture. Although only three CRA occlusion cases were observed in the present study, two of the affected patients had an SOD/CRA ratio > 1. Inserting a sheath with a large diameter into a vessel with a relatively small diameter may have led to CRA occlusion in these patients. Further studies are required to determine whether the ratio can be considered an independent predictor of CRA occlusion following a DRA approach.

Moreover, all patients with CRA occlusion in our study were female. Although there is no evidence that sex differences influence the risk of CRA occlusion after DRA puncture, there may be a relationship between sex and CRA occlusion rate. One study reported that female patients have a significantly smaller DRA diameter than male patients, and the success rate of the DRA approach tends to be higher in men than in women.¹³ In this study, DRA diameters were similar for male and female patients (DRA diameter; male vs. female: 1.97 ±1.34 mm vs. 1.83 ± 0.44, P=.185). In addition, we showed that low-dose heparin was used in all three patients with CRA occlusion. Previous studies have indicated that a high dose of heparin can decrease the risk of CRA occlusion.^14,15 Considering their findings, there might have been no CRA occlusion cases in the intervention group if high dose heparin was utilized in our study. Moreover, our results indicated that CRA occlusion occurred only in patients with single platelet therapy or without antithrombotic therapy. Because there were only a few patients with CRA occlusion, this result has relatively low power. However, strong antithrombotic therapy may reduce the risk of CRA occlusion. Further studies are required to elucidate the relationships between sex differences and CRA occlusion rate and predictors of CRA occlusion.

Aneurysm after DRA puncture was observed in one patient (1.1%) in this study. This result is inconsistent with previous findings indicating an association between DRA puncture and vascular complications in 5.0% of cases.^4–9,16 Given the high risk of bleeding, our data suggest that DRA puncture can be advantageous for patients undergoing HD.¹⁷ In particular, DRA puncture for catheterization may be associated with lower CRA occlusion rates than CRA puncture in these patients. Further evidence from appropriately randomized trials is required to determine whether DRA puncture reduces CRA occlusion rates. In this study, the catheter procedure could not be completed in four patients (4.7%), all of whom had a severely tortuous subclavian artery. The approach site was adjusted in these patients due to difficulties in controlling the catheter. Although this issue can also arise with the CRA approach, caution should be exercised when using the DRA approach, especially during emergency procedures.

This study had some limitations, including its non-randomized and observational design and the fact that patient selection and puncture success rate depended on the physician. However, almost all physicians in our department had previously performed these procedures. In addition, post-procedure ultrasonography was performed within 24 h after the procedure. Thus, our study lacked long-term follow-up data. Given our small study population, we were also unable to investigate CRA occlusion predictors, which occurred in three patients. Lastly, we noted several cases in which CRA flow recovered after the end of long-term follow-up. Thus, the optimal timing of follow-up ultrasonography remains to be determined.

Conclusion

A DRA approach for cardiac catheterization may be feasible in patients undergoing HD and may help avoid CRA occlusion and puncture site complications. DRA puncture is associated with low rates of CRA occlusion and puncture site complications in patients undergoing HD and coronary interventions. This approach may be more appropriate for cardiac catheterization than that via the CRA.

Affiliations and Disclosures

From Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan.

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 accepted December 11, 2021.

Address for correspondence: Koki Shishido, MD, Department of Cardiology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa 247-8533, Japan. Email: koki10192002@yahoo.co.jp

References

1. Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Intv. 2008;1:379–386. doi:10.1016/j.jcin.2008.05.007

2. Pancholy SB, Patel TM. Effect of duration of hemostatic compression on radial artery occlusion after transradial access. Catheter Cardiovasc Interv. 2012;79:78-81. Epub 2011 May 16. doi:10.1002/ccd.22963

3. Ohya M, Iwashita Y, Kunimoto S, et al. An analysis of medication adherence and patient preference in long-term stable maintenance hemodialysis patients in Japan. Intern Med. 2019;58:2595-2603. Epub 2019 Jun 7. doi:10.2169/internalmedicine.2676-19

4. Kiemeneij F. Left distal transradial access in the anatomical snuffbox for coronary angiography (ldTRA) and interventions (ldTRI). EuroIntervention. 2017;13:851-857. doi:10.4244/EIJ-D-17-00079

5. Yu W, Hu P, Wang S, et al. Distal radial artery access in the anatomical snuffbox for coronary angiography and intervention: a single center experience. Medicine. 2020;99:e18330. doi:10.1097/MD.0000000000018330

6. Kim Y, Ahn Y, Kim I, et al. Feasibility of coronary angiography and percutaneous coronary intervention via left snuffbox approach. Korean Circ J. 2018;48(12):1120-1130. Epub 2018 Aug 6. doi:10.4070/kcj.2018.0181

7. Mizuguchi Y, Izumikawa T, Hashimoto S, et al. Efficacy and safety of the distal transradial approach in coronary angiography and percutaneous coronary intervention: a Japanese multicenter experience. Cardiovasc Interv Ther. 2020;35(2):162-167. Epub 2019 May 24. doi:10.1007/s12928-019-00590-0.

8. Valsecchi O, Vassileva A, Cereda AF, et al. Early clinical experience with right and left distal transradial access in the anatomical snuffbox in 52 consecutive patients. J Invasive Cardiol. 2018;30(6):218-223. Epub 2018 Mar 15.

9. Norimatsu K, Kusumoto T, Yoshimoto K, et al. Importance of measurement of the diameter of the distal radial artery in a distal radial approach from the anatomical snuffbox before coronary catheterization. Heart Vessels. 2019;34(10):1615-1620. Epub 2019 Apr 10. doi:10.1007/s00380-019-01404-2

10. Kuno T, Hirano K, Imaeda S, et al. A transradial approach of cardiac catheterization for patients on dialysis. J Invasive Cardiol. 2018;30(6):212-217.

11. Hayashi T, Shishido K, Yokota S, et al. Impact of bleeding events after percutaneous coronary intervention in patients on hemodialysis. Heart Vessels. 2020;35(10):1323-1330. Epub 2020 Apr 16. doi:10.1007/s00380-020-01605-0

12. Buturak A, Gorgulu S, Norgaz T, et al. The long-term incidence and predictors of radial artery occlusion following a transradial coronary procedure. Cardiol J. 2014;21(4):350-356. Epub 2013 Oct 21. doi:10.5603/CJ.a2013.0128

13. Kim Y, Ahn Y, Kim MC, et al. Gender differences in the distal radial artery diameter for the snuffbox approach. Cardiol J. 2018;25(5):639-641. doi:10.5603/CJ.2018.0128

14. Hahalis GN, Leopoulou M, Tsigkas G, et al. Multicenter randomized evaluation of high versus standard heparin dose on incident radial arterial occlusion after transradial coronary angiography: the SPIRIT OF ARTEMIS Study. JACC Cardiovasc Intv. 2018;11(22):2241-2250. Epub 2018 Nov 1. doi:10.1016/j.jcin.2018.08.009

15. Feyzullah B, Fatih G, Tanriverdi Z, et al. The high dose unfractionated heparin is related to less radial artery occlusion rates after diagnostic catheterization: a single centre experience. Acta Cardiol. 2021;76(2):168-174. Epub 2019 Dec 23. doi:10.1080/00015385.2019.1705584 2019:1–7

16. Roh JW, Kim Y, Kim HY, Ahn Y, Jeong MH. Comparison of 4-French versus 5-French sheaths for diagnostic coronary angiography via the snuffbox approach. Cardiol J. 2021;28(4):528-533. Epub 2020 Jan 21. doi:10.5603/CJ.a2020.0003

17. Numasawa Y, Kohsaka S, Miyata H, et al. Impact of body mass index on in-hospital complications in patients undergoing percutaneous coronary intervention in a Japanese real-world multicenter registry. PLoS One. 2015;10(4):e0124399. doi:10.1371/journal.pone.0124399