Hand Ischemia after Radial Artery Cannulation

Critical hand ischaemia after transradial cardiac catheterisation: an uncommon complication of a common procedure

We describe a case of critical hand ischaemia after transradial cardiac catheterisation. The patient presented with hand ischaemia 5 days after transradial coronary angiography. Urgent angiography demonstrated radial artery occlusion with embolisation to the palmar arch and digital arteries. The ischaemia was refractory to an extensive thrombolytic regimen, and subsequently, the patient was referred to the vascular surgeon for urgent thrombectomy and patch angioplasty. The patient recovered slowly and no amputation was necessary, but complaints of right hand numbness and paresthesia of all digits remained.

Assessment of collateral circulation to the hand prior to radial artery harvest

Assessment of collateral circulation to the hand is required prior to invasive procedures or harvesting of the radial artery (RA). A modified Allen’s test (MAT) is commonly used to assess palmar arch collaterals. A variety of non-invasive methods including digital pressures, plethysmography, pulse oximetry and duplex ultrasonography are available to supplement physical examination. However, no consensus exists about the proper role of the MAT and the most appropriate non-invasive test (NIT) in this situation. Interpretation of the MAT and NIT findings are also controversial. This paper reviews the anatomy and the physiologic basis for the MAT and various NITs, the pros and cons of various NITs and recommendations for the assessment of collateral circulation to the hand prior to interventions directed at the RA.

Importance of Continuous Pulse Oximetry of the Ipsilateral Thumb/Index Finger during Transradial Angiography

We present a case of a 63-year-old male undergoing attempted basilar artery embolization using a right transradial artery approach in which continuous pulse oximetry of the ipsilateral thumb uncovered unanticipated hand ischemia during the procedure. A preprocedural evaluation using pulse oximetry of the right thumb demonstrated normal waveform and maintenance of normal oxygen saturation during manual compression of the right radial artery. This normal waveform and oxygen saturation was maintained after insertion of a 6Fr sheath into the radial artery. After insertion of a 6Fr guiding catheter into the right vertebral artery, near-complete dampening of the pulse oximetry waveform and precipitous decline in oxygen saturation were noted. Examination of the right hand demonstrated poor tissue perfusion. Immediate removal of the guiding catheter led to return of a normal waveform, oxygen saturation, and tissue perfusion. This case demonstrates the importance of continuous, intraprocedural monitoring of oxygenation of the ipsilateral hand during transradial angiography in order to avoid unanticipated perfusion abnormalities.

[Are there any contraindications to the transradial approach?]

The transradial approach is the most frequent access used in France for coronarography and percutaneous coronary intervention. This access permits a reduction of local complications in comparison with femoral access. There are very few real contraindications of transradial approach. The use of Allen's test before coronarography remains controversial in the transradial catheterization community. It remains a standard practice in some institutions, however many centers have stopped using Allen's test considering that there is no evidence supporting its use.

Reconstruction of the ischemic hand

Ischemia of the hand remains an uncommon condition, but problems with arterial perfusion of the hand can arise from trauma (open and closed), thrombosis, or arteriovascular disease. Certain identifiable patterns are seen with hand ischemia, usually discernable according to which one of the major arteries (radial or ulnar) are involved. This article discusses the origin and management of ischemic hand conditions, with an emphasis on recognizing the patterns of ischemia that are commonly seen.

Necrosis of the 4th and 5th digits after intra-articular injection of diazepam into the wrist

A 75-year-old woman presented with progressing pain, cyanosis, and hypaesthesia in her left hand after an intra-articular injection with diazepam into the wrist for osteoarthritis-related pain. Due to an iatrogenic intra-arterial injection, malperfusion of the ulnar digits developed. Angiography revealed blockage of perfusion of the 4th and 5th digits. Despite intra-arterial lysis, heparinisation, and vasodilatation, perfusion could not be reinstalled. Necrosis of the distal phalanges of the 4th and 5th digits developed, which had to be treated with amputation. The pathomechanism of tissue damage and the treatment options after intra-arterial injections are reviewed and discussed.

[Ultrasound guided radial artery cannulation: procedure description and literature review]

Arterial catheterization is the second most common invasive procedure performed in critical care units. These devices are essential in certain types of patients (the hemodinamically unstable or those who require regular evaluation of the gasometric values). Complications related to arterial cannulation are relatively scarce. However, there are no reliable indicators to predict the occurrence of radial artery occlusions or ischemic lesions in the hand after a radial cannulation procedure has been performed. Ultrasound-guided catheter insertion has been used for years to guide central venous cannulation in critical care, but its use has been more limited for arterial catheterization. This paper aims to describe the technique of ultrasound-guided radial artery catheterization and reviews the most important research papers that have evaluated the safety and efficacy of this procedure in the adult population.

Complications related to less-invasive haemodynamic monitoring

BACKGROUND

The aim of this study was to evaluate the type and incidence of complications during insertion, maintenance, and withdrawal of central arterial catheters used for transpulmonary thermodilution haemodynamic monitoring (PiCCO™).

METHODS

We conducted a prospective, observational, multicentre study in 14 European intensive care units (six countries). A total of 514 consecutive patients in whom haemodynamic monitoring by PiCCO™ was indicated were studied.

RESULTS

Five hundred and fourteen PiCCO catheters (475 in femoral, 26 in radial, nine in axillary, and four in brachial arteries) were inserted. Arterial access was obtained on the first attempt in 86.4% of the patients. Minor problems such as oozing after insertion (3.3%) or removal of the catheter (3.5%) were observed, but no episodes of serious bleeding (more than 50 ml) were recorded. Small local haematomas were observed after insertion (4.5%) and after removal (1.2%) of the catheter. These complications were not more frequent in patients with coagulation abnormalities. The incidence of site inflammation and catheter-related infection was 2% and 0.78%, respectively. Other complications such as ischaemia (0.4%), pulse loss (0.4%), or femoral artery thrombosis (0.2%) were rare, transient, and all resolved with catheter removal or embolectomy, respectively.

CONCLUSIONS

In this series of patients, central arterial catheters used for PiCCO™ monitoring were demonstrated to be a safe alternative for advanced haemodynamic monitoring.

Hand gangrene following unsuccessful cannulation of the internal jugular vein: a case report and literature review

Hand gangrene following vascular cannula placement is uncommon and is usually the result of thrombotic occlusion of an artery. We describe a case of hand gangrene resulting in wrist disarticulation, following multiple unsuccessful attempts at internal jugular vein cannulation in a critically ill patient.

The Accuracy of the Central Venous Blood Gas for Acid-Base Monitoring

Background: Routine use of central venous blood gases (VBGs) may reduce complications from prolonged arterial cannulation. We investigated the reliability of the VBG as a substitute for arterial blood gas (ABG) in multiple care settings. Methods: We developed a VBG adjustment rule of ABG pH = VBG pH + 0.05, ABG CO2 = VBG PCO2 -5 mm Hg from prior studies and validated this relationship with simultaneous venous and arterial blood obtained from 187 medical/surgical intensive care, cardiac catheterization laboratory, and coronary care unit patients with central venous access. Results: The overall accuracy of a normal adjusted VBG (aVBG) to predict a normal ABG was 90%. After adjustment, the mean systematic difference (bias) between ABG and VBG pH decreased from 0.035 ± 0.02 to -0.015 ± 0.02 and PCO2 bias decreased from -4.5 ± 3.5 to 0.5 ± 3.5. Intraclass correlation coefficients for agreement improved after applying the adjustment rule to venous pH (from 0.84 to 0.93, P < .001) and PCO2 (from 0.66 to 0.84, P < .001). Overall diagnostic accuracy of VBG improved from 45% to 74% after adjustment. Multiple logistic regression demonstrated that the factor independently associated with discrepancy between VBG and ABG diagnoses was an abnormal aVBG (OR 6.8, 95% CI 2.8-16.5). Conclusions: Because of the high agreement between a normal aVBG with a normal ABG and the small bias between these tests, we recommend use of the adjusted central VBG.

Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations

Consistent anatomic accessibility, ease of cannulation, and a low rate of complications have made the radial artery the preferred site for arterial cannulation. Radial artery catheterization is a relatively safe procedure with an incidence of permanent ischemic complications of 0.09%. Although its anatomy in the forearm and the hand is variable, adequate collateral flow in the event of radial artery thrombosis is present in most patients. Harvesting of the radial artery as a conduit for coronary artery bypass grafting, advances in plastic and reconstructive surgery of the hand, and its use as an entry site for cardiac catheterization has provided new insight into the collateral blood flow to the hand and the impact of radial arterial instrumentation. The Modified Allen's Test has been the most frequently used method to clinically assess adequacy of ulnar artery collateral flow despite the lack of evidence that it can predict ischemic complications in the setting of radial artery occlusion. Doppler ultrasound can be used to evaluate collateral hand perfusion in an effort to stratify risk of potential ischemic injury from cannulation. Limited research has demonstrated a beneficial effect of heparinized flush solutions on arterial catheter patency but only in patients with prolonged monitoring (>24 h). Conservative management may be equally as effective as surgical intervention in treating ischemic complications resulting from radial artery cannulation. Limited clinical experience with the ultrasound-guided arterial cannulation method suggests that this technique is associated with increased success of cannulation with fewer attempts. Whether use of the latter technique is associated with a decrease in complications has not yet been verified in prospective studies. Research is needed to assess the safety of using the ulnar artery as an alternative to radial artery cannulation because the proximity and attachments of the ulnar artery to the ulnar nerve may potentially expose it to a higher risk of injury.

Tracking hypotension and dynamic changes in arterial blood pressure with brachial cuff measurements

BACKGROUND

Arterial cannulation is strongly recommended during shock. Nevertheless, this procedure is associated with significant risks and may delay other emergent procedures. We assessed the discriminative power of brachial cuff oscillometric noninvasive blood pressure (NIBP) for identifying patients with an invasive mean arterial blood pressure (MAP) below 65 mm Hg or increasing their invasive MAP after cardiovascular interventions.

METHODS

This prospective study, conducted in three intensive care units, included adults in circulatory failure who underwent 45 degrees passive leg raising, 300 mL fluid loading, and additional 200 mL fluid loading. The collected data were four invasive and noninvasive MAP measurements at each study phase.

RESULTS

Among 111 patients (50 septic, 15 cardiogenic, and 46 other source of shock), when averaging measurements of each study phase, NIBP measurements accurately predicted an invasive MAP lower than 65 mm Hg: area under the receiver operating characteristic curve 0.90 (95% CI: 0.71-1), positive and negative likelihood ratios 7.7 (95% CI: 5.4-11) and 0.31 (95% CI: 0.22-0.44) (cutoff 65 mm Hg). For identifying patients increasing their invasive MAP by more than 10%, the area under the receiver operating characteristic curve was 0.95 (95% CI: 0.92-0.96); positive and negative likelihood ratios (cutoff 10%) were 25.7 (95% CI: 10.8-61.4) and 0.26 (95% CI: 0.2-0.34).

CONCLUSIONS

NIBP measurements have a good discriminative power for identifying hypotensive patients and performed even better in tracking MAP changes, provided that one averages four NIBP measurements.

Three-Digit Allen’s Test

Hand ischemia after radial artery intervention remains a rare but serious complication. Allen's test is widely used to assess the adequacy of ulnar collateral circulation to the hand. There have been documented cases of hand ischemia after radial artery intervention even with a negative test. We describe a modification of Allen's test based on the anatomy of the radial artery branches that could potentially decrease the number of false negative tests.