Minimising radial artery injury during procedures using transradial approach
19/02/2017
BCS Editorial
By: Dr Maria Dwornik
Introduction
Transradial access (TRA) is currently an evidence-based (class 1, level of evidence A) recommendation for most diagnostic cardiac catheterisation studies and percutaneous coronary interventions1. Compared to transfemoral approach, transradial access was associated with better outcome (reduction in mortality and adverse cardiac events following PCI2–4, reduction in major bleeding and access-site related vascular complications5), improved patient comfort and cost effectiveness6,7. With the increasing rates of TRA use worldwide8,9, preservation of radial artery patency becomes an important aspect of patient care overall. Significant radial artery injury can be permanent and preclude it’s future use as a conduit for cardiac catheterisation, intervention, coronary graft, haemodialysis or invasive monitoring in high dependency unit.
Incidence of radial artery injury and methods of assessment
From the recent systematic review, radial artery occlusion (RAO) complicating TRA-based procedures vary depending on the time of assessment with the range of 7.7% if assessed within first 24 h, 9.5% within the first week and 5.8% after one week up to a month post procedure10.
It is also important to note that objective assessment of RA patency with Doppler- or plethysmographic-based (“reverse Barbeau test”) flow determination is required11. In some instances appreciable pulsation may just represent a radial artery distal stump and presence of palpable pulse alone was shown to significantly underestimate RAO incidence12.
Furthermore, non occlusive injury may occur resulting in potentially permanent structural and functional changes, albeit with a preserved RA patency and pulse13. Studies analysing RA injury based on histological and flow-mediated dilatation analysis found non occlusive injury rates are higher and persist longer14.
Pathophysiology
Direct trauma from the introducer sheath and guide catheters used during the procedure results in an acute RA injury. It was shown that acute RA trauma at the distal part of the vessel with a 6F sheath results in intimal tear and medial dissection, the incidence of which is reported as high as 43% and 23% respectively when assessed using OCT15. Flow mediated dilatation, a surrogate marker of endothelial function, was found to be reduced in 50-70% shortly after TRA-based procedure with a full or partial recovery at long term follow up16–18.
Natural history of reduction in the incidence of RAO almost by 50% within the first month is hypothesised to be due to a spontaneous recanalization19. In some instances however, chronic endothelial dysfunction, thrombus formation and intimal hyperplasia may occur resulting in a chronic asymptomatic RAO despite the preservation of a palpable pulse, as shown in studies using in vivo OCT15 or IVUS20 or histological analysis of harvested radial artery used for grafting21.
Strategies minimising radial artery injury
Several factors were shown to influence RAO rates such as age, sex, body mass index, sheath size, use of anticoagulation and duration of haemostasis, but the most consistent predictors of reduced RAO incidence are use of high dose heparin during procedure and shorter compression time post procedure.
Sheath and guide catheter characteristics
RAO incidence increases with the increase in sheath size13 and is estimated at 0% with 4 Fr, 1-
7% with 5 Fr, 6-11% with 6 Fr, 11% with 8 Fr introducer sheath systems and 2% with a 6.5 Fr
sheathless guide. Sheath length (13 vs 23 cm) and coating (hydrophilic coating vs non
coated) have no influence on the RAO incidence22. Similarly, smaller diameter guide catheters may
reduce injury23. However, the choice of sheath and guide catheter needs to be balanced and
consider not only RA preservation but also importance of back up support from the guide and
anticipated procedure complexity.
Radial cocktail
Administration of a so called “radial cocktail” consisting of 2.5 mg of verapamil (with or without 200 mg of nitroglycerin) into the radial sheath before the advancement of catheters was shown to produces an increase in vascular volume based on IVUS analysis and became a common practice thought to minimise RA spasm24. Also, RAO incidence was shown to decline if radial cocktail was administered before and after procedure just before the sheath removal25.
Anticoagulation
Paradoxically, incidence of RAO is higher (8.8%) following a diagnostic catheterisation compared to PCI (4.5%), likely due to a lower use of antithrombotics and anticoagulants in the former instance. Use of anticoagulation is one of the most important strategies minimising RAO incidence during TRA-based procedures. In the metaanalysis, intra-arterial administration of unfractionated heparin at a higher dose (5000 IU) during procedure was shown to significantly reduce the incidence of RAO (RR 0.36; 95% CI 0.17– 0.76) compared to lower doses (2000-3000 IU)10 and was not associated with an increase in bleeding complications. Similar effects to high dose heparin on the incidence of RAO were observed with bivalirudin, although this option is more expensive26.
Haemostasis
Shorter compression times (15 minutes vs 2 h) during haemostasis was shown to significantly reduce RAO incidence (RR 0.28; 95% CI 0.05–1.50). However, this benefit may be offset by higher rates of bleeding complications27. In terms of haemostatic device, TR band was shown to be associated with a lower risk of RAO compared with Haemoband28 and Radistop29.
In addition, some centres use prophylactic ipsilateral ulnar artery compression during patent haemostasis of RA as it was shown to significantly reduce the 30-day RAO incidence (0.9% vs 3.0%, p < 0.0001) compared to a patent haemostasis alone30.
Management of acute radial artery occlusion
Acute RAO is often asymptomatic and very rarely leads to acute hand ischaemia31,32 with around 0.2% incidence5. This is due to a fail-safe mechanism of dual arterial supply to a hand with hand perfusion maintained by the arterial supply from ulnar artery, deep and superficial palmar arches and interosseus collaterals. Hence, RAO diagnosis requires objective assessment of arterial flow.
If acute RAO diagnosed sufficiently early, several strategies have been described to help recanalisation of the artery. Percutaneous antegrade31,32 (from brachial artery) or retrograde33,34 (from radial collaterals) recanalization, ipsilateral ulnar artery compression for 1 hour35,36 or treatment with LMWH for 4 weeks post procedure37 have all been described in single case reports, case series or non randomised studies. To date there is no sufficient evidence to advocate routine use of any of the above strategies.
Conclusion
Radial artery occlusion is a relatively rare complication of TRA-based procedures and often asymptomatic. However, radial artery injury on microvascular level is common and can be permanent despite preserved radial pulse. Preservation of radial artery patency and functional integrity becomes an important aspect of care, influencing future use of radial artery as a viable conduit for coronary grafting or intervention. Avoiding sheath-to-artery mismatch, use of 5000 IU intra-arterial or intravenous UFH during the procedure and shorter compression time during haemostasis were all shown to reduce RAO incidence. Administration of drugs reducing radial artery spasm may also reduce risk of RAO.
Integrating objective assessment of RA patency within the pre- and post-procedural checklist with Doppler- or plethysmographic-based assessment of flow (“reverse Barbeau test”) may improve identification and prevention of permanent vascular injury. Randomised trials are however required to delineate treatment strategies for acute RA occlusion.
References
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