Best Practices for the Prevention of Radial Artery Occlusion After Transradial Diagnostic Angiography and Intervention

Evaluation of Railway Sheathless Access System for Transradial Coronary and Peripheral Interventions

OBJECTIVE

Evaluate efficacy and safety of Railway Sheathless Access System™ (Railway) in the first 200 consecutive cases at our center.

BACKGROUND

Transradial Intervention (TRI) is limited by the frequent occurrence of spasm, radial artery occlusion (RAO) and inability to use larger guide catheters (GC). The small size of radial artery (RA) is the primary reason for these limitations. Railway allows downsizing by sheathless GC access with GC of any shape or brand.

METHODS

Procedural and clinical variables were recorded prospectively for every case with intended use of Railway in the medical records. Hospital wide documentation of arm pain, radial spasm and pre-discharge evaluation of RAO with reverse Barbeau's test was performed by nurses. We retrospectively reviewed the data of the first consecutive 200 cases with the intended use of the Railway.

RESULTS

Railway was used successfully to complete intended procedure in 199 (99.5%) of the 200 patients. Railway was used with a 6 Fr (171) or 7 Fr (29) GC of various shapes to achieve sheathless access in 197 patients and for tracking the GC through severe RA tortuosity or mitral paravalvular leak in the rest. Three patients (1.5%) had spasm and forearm pain, two (1%) patients had small (<5 cm) hematoma, while one (0.5%) patient required access switch over and subsequently had RAO.

CONCLUSION

Railway Sheathless Access System can be used routinely for TRI with high success rate and low complication rate.

Predictors of patent and occlusive hemostasis after transradial coronary procedures

OBJECTIVES

To assess the independent predictors of patent and occlusive hemostasis (PH and OH, respectively) during radial hemostasis after coronary procedures.

BACKGROUND

Radial artery occlusion (RAO) is a thrombotic complication of transradial catheterization that can lead to permanent occlusion of the radial artery. Sheath-vessel diameter ratio, postprocedure compression time, occlusive hemostasis, inadequate, and excessive anticoagulation are all predictors of RAO.

METHODS

As a part of a previously published study investigating the relationship between residual anticoagulation and risk of RAO, 837 patients undergoing transradial diagnostic coronary angiography or percutaneous coronary interventions were enrolled. Cumulative heparin dose used during the procedure and ACT measured before sheath removal were recorded. PH with reverse Barbeau test was attempted in all patients (NCT02762344).

RESULTS

PH was less frequently obtained for increasing cumulative heparin dose and ACT values (p < .0001 and p = .0034, respectively). At logistic regression analysis both cumulative heparin dose and ACT values were independent predictors of OH (OR 1.017, 95% IC 1.011-1.023 p < .0001 and OR 1.004, 95% IC 1.001-1.006, p = .0004) while adjusted probability for RAO showed exponential relationship with both parameters.

CONCLUSIONS

The level of anticoagulation is strongly related to the incidence of RAO, and should be taken into account when choosing hemostasis protocol.

Vascular access and radiation exposure during percutaneous coronary procedures

In the cardiology community, the use of transradial access for percutaneous coronary procedures is progressively increasing all around the world overtaking the use of transfemoral access. The advantages of the transradial access are based on a significant reduction in bleeding and vascular events compared to the femoral access and on a reduction in mortality in the setting of acute coronary syndromes. However, in recent years a slight but significant increase in radiation exposure for patients and operators associated with the radial approach has been detected, increasing concerns about possible long term increased stochastic risk. In particular interventional cardiologists are among physicians performing interventional procedures using X-rays, those exposed to the highest radiation dose during their activity and this exposure is not without possible long-term clinical consequences in term of deterministic and stochastic effects. All the operators should be aware of these risks and manage to reduce their radiation exposure. In this review we analysed the differences in term of radiation exposure comparing the radial and the femoral access for percutaneous coronary procedures. Then, we discussed the possible clinical consequences of these differences and finally we showed the available tools aimed to reduce the operator radiation exposure. In particular the use of adjunctive protective drapes placed on the patient might reduce operator radiation exposure in up to 81% of the dose.

Short Durations of Radial Hemostatic Device After Diagnostic Transradial Cardiac Catheterization: The PRACTICAL-2 Randomized Trial

BACKGROUND

Radial artery occlusion (RAO) is the most common complication following transradial approach (TRA) for cardiac catheterisation. Our aim was to assess if decreasing radial hemostatic device (RHD) time reduces the risk of RAO among individuals receiving small sheath sizes with no adjunctive heparin.

METHODS

We randomised 450 individuals undergoing diagnostic cardiac catheterization via TRA to 3 durations of RHD time: 10, 20, or 30 minutes. After these time periods, the RHD was gradually released over 20 minutes. The primary efficacy end point was forearm hematoma grade ≥ 2 (5-10 cm) and the primary safety end point was RAO (as determined by Doppler ultrasound) 1 hour after RHD removal (before discharge).

RESULTS

The mean age was 66 years and 64% were male. Five-French sheaths were used in all patients. Hematoma grade ≥ 2 occurred in only 1 patient, who was in the 20-minute group (P = 0.39). RAO occurred in 6.7% of patients in the 10-minute group, 10.7% in the 20-minute group and 6% in the 30-minute group (P = 0.26).

CONCLUSIONS

Among patients receiving small-caliber sheaths without adjunctive heparin, the incidence of forearm hematoma and RAO are low. Shorter durations of RHD time did not further reduce the risk of these complications.

[Radial artery occlusion ofter coronarography: is it really a problem?]

The use of transradial access for cardiac procedures has increased worldwide over the past two decades. Despite the many advantages this technique offers, there remains some concern that radial artery occlusion, a potential complication of radial cannulation, might lead to significant ischemic sequelae in the hand. This paper reviews the major causes, its possible consequences and the strategies for its prevention and treatment. It appears however from multiple studies that there is little or no correlation between radial occlusion and symptomatic hand ischemia.