Transradial approach for percutaneous transluminal angioplasty and stenting in the treatment of chronic mesenteric ischemia

Analysis of Subjective and Objective Screening Techniques as Predictors of Safety for Radial Artery Intervention

BACKGROUND

There is no currently accepted standard in safety evaluation for radial artery intervention. We sought to compare the accuracy of various subjective and objective screening techniques in predicting safety for radial artery intervention.

METHODS

Fifty-four patients in a prospective cohort study at a single institution underwent subjective Allen's test, objective Barbeau test, and several objective hand ultrasound techniques to assess safety for radial artery intervention. These results were then compared to the gold standard of conventional hand angiography to document complete palmar arch. Statistical analysis including sensitivity, specificity, positive predictive values, negative predictive values, and accuracy were calculated.

RESULTS

Compared to hand angiography, the subjective Allen's test and the objective Princeps Pollicis Artery ultrasound demonstrated the comparable levels of sensitivity (100% vs. 96.7%, respectively), specificity (100% vs. 100%, respectively), and accuracy (97.2% vs. 97.1%, respectively). The objective Barbeau test demonstrated similar results (sensitivity of 100%, accuracy of 98.2%) with the exception of a lower specificity (50%).

CONCLUSIONS

There is no currently accepted standard in safety evaluation for radial artery intervention. However, preliminary data suggest that certain subjective and objective techniques such as Allen's testing, Princeps Pollicis artery ultrasound, and Barbeau testing are comparable options in predicting palmar arch patency.

The use of an upper extremity hemodialysis access site for stenting of the superior mesenteric artery for chronic mesenteric ischemia

We report the use of an upper extremity hemodialysis access site to facilitate endovascular treatment of the superior mesenteric artery in the setting of chronic mesenteric ischemia. A 64-year-old woman with end-stage renal disease on hemodialysis presented with worsening symptoms associated with chronic mesenteric ischemia. Her left upper extremity interposition graft within the fistula access site was selected to avoid a hostile aortoiliac system and in consideration of the potential benefits it provided over transfemoral, transbrachial, and transradial sites. The procedure was technically successful without complication. Hemodialysis access sites, such as the interposition graft within the fistula of this patient, are a potential route of upper extremity access for mesenteric interventions in patients with end-stage renal disease on hemodialysis.

Transradial interventions in contemporary vascular surgery practice

OBJECTIVES

Upper extremity arterial access is often required for endovascular procedures, especially for antegrade access to the visceral aortic branches. Radial arterial access has been shown previously to have low complication rates, and patients tolerate the procedure well and are able to recover quickly. However, transradial access remains relatively uncommon amongst vascular surgeons.

METHODS

The radial artery was evaluated by ultrasound to evaluate for adequate caliber, and to identify any aberrant anatomy or arterial loops. A modified Barbeau test was performed to ensure sufficient collateral circulation. A cocktail of nitroglycerin, verapamil and heparin was administered intra-arterially to combat vasospasm. Sheaths up to 6 French were utilized for interventions. On completion of the procedure, a compression band was used for hemostasis in all cases.

RESULTS

Twenty-five interventions were performed in 24 patients. The left radial artery was used in 23/25 cases (92.0%). Procedures included visceral and renal artery interventions; stent graft repair of a renal artery aneurysm; embolization of splenic, pancreaticoduodenal and internal mammary aneurysms; embolization of bilateral hypogastric arteries following blunt pelvic trauma; interventions for peripheral arterial disease; delivery of a renal snorkel graft during endovascular aortic aneurysm repair, and access for diagnostic catheters during thoracic endovascular aortic aneurysm repair. Technical success was 92.0%. There was one post-operative radial artery occlusion (4.3%) which led to paresthesias but resolved with anticoagulation. There were no instances of arterial rupture, hematoma, or hand ischemia requiring intervention.

CONCLUSIONS

Using the transradial approach, we have demonstrated a high technical success rate over a range of clinical contexts with minimal morbidity and no significant complications such as bleeding or hand ischemia. The safety profile compares favorably to historical complication rates from brachial access. Radial access is a safe and useful skill for vascular surgeons to master.

Acute mesenteric ischemia: primary percutaneous therapy

INTRODUCTION

Management of acute mesenteric ischemia is still a matter of concern for physicians. This disorder has been associated to an increased mortality mainly because of a late diagnosis and controversial treatment options.

METHODS AND RESULTS

We describe the case of a multidisciplinary approach to a cardiogenic thrombotic occlusion of superior mesenteric artery resulting in acute mesenteric ischemia. After rapid diagnosis with Duplex scan, we brought the patient to our catheterization laboratory and managed it with the common tools used for primary percutaneous coronary intervention. Among the specific issues of this case report, we observed some of the common complications of the acute myocardial infarction managed in the catheterization laboratory and treated them with the same tools used in the "myocardial area."

CONCLUSIONS

We showed how an "interventional cardiologist's" approach to acute mesenteric ischemia was effective in restoring superior mesenteric artery patency and in aborting a mesenteric infarction.

Feasibility of trans-radial approach in percutaneous intervention for upper arm dialysis access

BACKGROUND

This retrospective study evaluated the feasibility and efficacy of trans-radial intervention for upper arm dialysis access.

METHODS

This study retrospectively reviewed 165 trans-radial interventions performed for upper arm dialysis access in 101 patients. Sixty-nine patients had arteriovenous graft (AVG), and 32 had arteriovenous fistula (AVF). Balloon angioplasty was performed in 66 stenotic dialysis accesses and 99 thrombosed dialysis accesses. Thrombosed dialysis access was further managed by additional balloon thrombectomy with or without urokinase injection.

RESULTS

Procedural time was 46.7 +/- 25.5 minutes. Anatomic and clinical success rates were 89.7% and 84.2%, respectively. The rate of complications, most of which involved lesion rupture with contrast-media extravasation and distal embolism, was 9.7%. Pretreatment stenosis was more severe (p = 0.01) and the prevalence of total occlusion was higher (p < 0.01) in the AVG group than the AVF group. The success rate and complication rate did not statistically differ (p = 0.59). Additionally, the thrombosed group had a lower success rate (p = 0.02), a higher complication rate (p < 0.01) and a longer procedural time (p < 0.01) than the stenotic group.

CONCLUSIONS

Comparison with previous studies employing the traditional approach reveals that trans-radial intervention has a comparable success rate, procedural time and complication rate for upper arm dialysis access. Therefore, trans-radial intervention is a safe and feasible technique for upper arm dialysis access.

Transradial approach for noncoronary angiography and interventions

PURPOSE

The purpose of this study was to retrospectively evaluate the feasibility and safety of a transradial approach for non-coronary angiography and interventions.

BACKGROUND

Generally, the transradial approach is used for coronary angiography and intervention around the world, and experiences have been widely reported. However, few large studies have examined the transradial approach for vessels other than the coronary or cerebral artery.

METHODS

Subjects comprised 329 patients who underwent a total of 400 procedures (285 abdomens, 68 pelvises, and 47 lower limbs) with transradial angiography and interventions between January 1999 and June 2006. Normal Allen test results were confirmed before all procedures. A 130- or 150-cm long 4F catheter modified to our own design was used for angiography and interventions such as transarterial embolization or transarterial chemotherapy.

RESULTS

Radial artery access was unachievable in 19 of the 400 procedures (4.8%). The radial artery was injured during 1 procedure (0.2%). In the remaining 380 procedures, sufficient angiography was obtained to grasp the condition of indispensable vessels for diagnosis and interventions scheduled in advance succeeded. Total transradial technical success rate in the series was 95%. Frequency of complications such as radial injury or radial spasm was 1.8%. No cases of local hematoma, hand ischemia, or cerebral infarction were encountered.

CONCLUSION

The transradial approach was useful for non-coronary angiography and interventions and offers the advantages of low risk and reduced stress on patients.

Percutaneous Treatment of Dysfunctional Brescia-Cimino Fistulae Through a Radial Arterial Approach

BACKGROUND

Dysfunctional Brescia-Cimino fistulae contribute to significant morbidity in hemodialysis patients. These fistulae normally are treated through a retrograde venous approach. There are no data regarding a transradial approach. Furthermore, measurement of pressure reduction in the radial artery appears to be useful.

METHODS

We retrospectively examined 50 interventions to treat 49 patients (17 men, 32 women; mean age, 61.8 +/- 10.6 years) with Brescia-Cimino fistulae. Inclusion criteria were patients with palpable radial arteries and dysfunctional end-to-side Brescia-Cimino fistulae. Patients with infected fistulae, contrast allergy, upper-arm/synthetic graft/central-vein stenosis, and end-to-end Brescia-Cimino fistulae were excluded from the study. Radial arterial pressures before and after angioplasty were compared as a surrogate of stenosis relief. Anatomic and clinical success rates were calculated.

RESULTS

Sixty-five stenoses and 4 total occlusions were treated through radial access. All radial punctures were successful, except in 1 patient. Most lesions were located in the cephalic vein (87%). Mean length of treated lesions was 4.1 +/- 2.8 cm. Mean pretreatment diameter of lesion stenoses was 76.7% +/- 12.1%. Mean posttreatment diameter stenosis was 22.6% +/- 8.2% (P < 0.001). Systolic, diastolic, and mean blood pressures recorded from the radial artery decreased from 130 +/- 40, 60 +/- 18, and 87 +/- 27 to 88 +/- 40, 43 +/- 18, and 60 +/- 26 mm Hg (P < 0.001, P < 0.001, and P < 0.001), respectively. The anatomic success rate of the transradial approach was 91.3%. The clinical success rate of the transradial approach was 96%.

CONCLUSION

The transradial approach is a feasible and highly effective approach to treat dysfunctional Brescia-Cimino fistulae. Measuring blood pressure reduction through the radial artery appears promising as a hemodynamic evaluation method.