The ulnar artery: A site suitable for arterial cannulation in pediatric patients

BACKGROUND

Historically, the ulnar artery has rarely been considered for arterial cannulation as it is less easily palpated than the radial artery. With the current routine use of ultrasound in pediatric patients, the ulnar is as accessible as the radial and could be viewed as an equivalent site for cannulation.

AIMS

The purpose of this study was to compare ulnar and radial artery suitability for arterial cannulation in pediatric patients using 2-dimensional ultrasound.

METHODS

We examined the ulnar and radial arteries of pediatric patients aged birth to 6 years who were scheduled to undergo general anesthesia. Following anesthesia induction, the investigators positioned the patient's wrist to 30-45 degrees of extension and obtained images of the ulnar and radial arteries in the transverse and longitudinal planes. Assessments of the arteries' anterior-posterior diameter, cross-sectional area and depth were made by visual inspection at the time of image acquisition and by electronic caliper measurement of recorded images.

RESULTS

In 108 patients, mean anterior-posterior diameter of the ulnar artery was larger than the radial artery in the transverse view, longitudinal view, and cross-sectional area in 63.6%, 59.4%, and 60.4% of patients (p = .002, .004, and .006, respectively). Mean ulnar artery size was, on average, larger than the radial artery by 7.7%, 8.1%, and 12.9% in the transverse AP diameter, longitudinal AP diameter, and cross-sectional area (95% CI 3.1-12.4%; 3.2-13.0%; 4.4-21.5%). The investigator's visual evaluation of vessel size at the bedside showed substantial agreement with the measured cross-sectional area (linear-weighted kappa of 0.73). In a subset of 13 patients age <24 months, the mean depth of the ulnar artery was 2.13 mm compared to 1.65 mm for the radial artery (difference -0.48 mm 95% CI 1.08-0.12).

CONCLUSIONS

The ulnar artery was larger than the radial artery in 60% of pediatric patients thus may offer an arterial cannulation site advantage due to its larger size. The use of 2-dimensional ultrasound examination allows accurate assessment of upper extremity distal arteries in order to optimize site selection for arterial cannulation in pediatric patients.

Comparison of long-term radial artery occlusion following trans-radial coronary intervention using 6-french versus 7-french sheaths

BACKGROUND

The aim of this study was to explore the impact of 6-Fr and 7-Fr sheaths on the incidence of long-term radial artery occlusion (RAO) after trans-radial coronary intervention (TRI).

METHODS

From September 2013 to January 2016, patients with ischemic heart disease including acute myocardial infarction and true bifurcation lesions were randomly assigned to 6-Fr group and 7-Fr group immediately after coronary angiography in a 1:1 ratio. The radial artery diameters were observed by ultrasound examination one day prior to TRI as well as at 30 days and 1 year after TRI. The primary endpoint was the incidence of RAO at 1-year after TRI. The secondary endpoints were the incidence of local vascular complications during hospitalization and changes of radial artery diameters within 1-year after TRI between the two groups. Additionally, multivariate logistic regression analysis was used to explore potential factors related to the incidence of long-term RAO after TRI.

RESULTS

A total of 214 patients were enrolled and randomly assigned to 6-Fr group (n = 105) or 7-Fr group (n = 109). There was no significant difference in the incidence of RAO at 1-year after TRI (8.57% vs. 12.84%, p = 0.313). Moreover, no significant difference was observed in the incidence of local vascular complications during hospitalization (20% vs. 24.77%, p = 0.403). After 1-year follow-up, no significant difference was found in radial artery diameters (2.63 ± 0.31 mm vs. 2.64 ± 0.27 mm, p = 0.802). Multivariate logistic analysis revealed that repeated TRI was an independent risk factor of long-term RAO 1 year after TRI (OR = 10.316, 95% CI 2.928-36.351, p = 0.001).

CONCLUSIONS

Compared to 6-Fr sheath, 7-Fr sheath did not increase short-term or long-term incidence of RAO after TRI.

Altered Hand Temperatures Following Transradial Cardiac Catheterization: A Thermography Study

BACKGROUND

There is concern about potential detrimental effects of transradial access (TRA) on radial artery structure, endothelial and hand function. This thermography study evaluated TRA impact on hand microvascular perfusion.

METHODS AND RESULTS

We prospectively measured hand thermography, radial and ulnar artery size and blood flow velocities in both catheterization and non-catheterization hands at baseline and 30-days after TRA in 158 patients. There were no differences in radial or ulnar arterial diameters or velocities pre- and post-TRA in catheterization and non-catheterization hands (p = NS). The absolute total hand thermography values post-TRA were increased in both catheterization and non-catheterization hand (pre-TRA 30.4 ± 2.9 vs. post-TRA 31.6 ± 2.6 p < 0.01; pre-TRA 30.2 ± 2.9, post-TRA 31.6 ± 2.6 p < 0.01, respectively). After ulnar artery occlusion, hand temperatures decreased in both catheterization and non-catheterization hands, both pre- and post-TRA and were similar in the catheterization and non-catheterization hands (p = NS). Total hand temperature decreased with ulnar artery occlusion and was significantly attenuated post-TRA (p < 0.001 both catheterization and non-catheterization hands).

CONCLUSIONS

TRA is associated with temperature changes in both catheterization and non-catheterization hands at one month after the index procedure. These changes likely represent a systemic response to local TRA stimulus.

Long-term endothelial dysfunction after trans-radial catheterization: A meta-analytic approach

BACKGROUND

Following cardiac catheterization using radial artery (RA) access, persistent endothelial dysfunction may limit the use of RA as a conduit during coronary artery bypass graft (CABG) surgery. We reviewed published literature to investigate the effects of transradial coronary catheterization on RA endothelial function.

METHODS

We searched PubMed from inception to April 2017 for published studies assessing RA endothelial function late (≥1 month) after coronary catheterization. A total of 12 eligible published studies (n = 490 patients) were included in the final quantitative synthesis. Statistical heterogeneity among studies was assessed by the I² . A random effects model was used to calculate the pooled estimate for standardized mean difference (SMD). Meta-regression analysis was used to explore predictors of change in RA endothelial function following catheterization.

RESULTS

In all studies, a significant reduction in endothelium dependent response was observed post-catheterization (SMD = -0.53, 95% confidence interval [CI]: -0.93 to -0.13, P = 0.01) and a marginal, non-significant, reduction in endothelium independent response (SMD = -0.38, 95%CI: -0.77, 0.01, P < 0.059). In controlled studies, using the contralateral RA as a control, a significant impairment in endothelial function was confirmed (SMD = -6.26, 95%CI: -9.71 to -2.81, P < 0.0001), while the change in endothelium-independent response was not significant (SMD = -4.46, 95%CI: -13.3 to 4.37, P = 0.32). In meta-regression analysis male gender (z = 2.36, P = 0.018) and increasing time following catheterization (z = 2.62, P = 0.009) were associated with less RA endothelial dysfunction.

CONCLUSIONS

Transradial catheterization impairs endothelium dependent vasodilatory properties of the cannulated RA, which do not recover even several months post-catheterization. Non-recovery of vasomotor function of cannulated RAs may limit their use as arterial grafts during CABG surgery.

Radial artery neointimal hyperplasia after transradial PCI-Serial optical coherence tomography volumetric study

Aims

Transradial catheterization (TRC) is a dominant access site for coronary catheterization and percutaneous coronary interventions (PCI) in many centers. Previous studies reported higher intimal thickness of the radial artery (RA) wall in patients with a previous history of TRC. In this investigation the aim was to assess the intimal changes of RA using the optical coherence tomography (OCT) intravascular imaging in a serial manner.

Methods and results

100 patients with the diagnosis of non-ST-elevation myocardial infarction (nSTEMI) treated by PCI were enrolled (6 patients were excluded from this analysis because of occluded RA at follow-up [2 patients] and insufficient quality of OCT images [4 patients]). An 54mm long OCT run of the RA was performed immediately after the index PCI and repeated 9 months later. Volumetric analyses of the intimal layer and lumen changes were conducted. Median intimal volume at baseline versus 9 months was 33.9mm³ (19.0; 69.4) versus 39.0mm³ (21.7; 72.6) (p<0.001); and median arterial lumen volume was 356.3mm³ (227.8; 645.3) versus 304.7mm³ (186.1; 582.7) (p<0.001). There was no significant difference in the effect of any clinical factor on the RA volume changes.

Conclusions

OCT volumetric analyses at baseline and 9 months showed a significant increase in the radial artery intimal layer volume and a decrease in lumen volume after transradial PCI. No significant factors affecting this process were identified.

Is the Complication Rate of Ulnar and Radial Approaches for Coronary Artery Intervention the Same?

We compared the clinical outcomes of patients who underwent coronary artery intervention by the transulnar and transradial artery approaches. In this 1 year, single-center study, patients were randomized to either a radial artery (RA) or ulnar artery (UA) group. Of 538 patients, the primary outcome, arterial occlusion of a forearm artery, occurred in 21 of 225 patients in the RA group compared to 6 of 220 patients in the UA group (9.3% vs 2.7%, P = .007). The rate of arterial occlusion was significantly lower following ulnar access compared to radial (odds ratio [OR] = 3.85, P = .006). A higher risk of occlusion was associated with repeated procedures rather than a single procedure (OR = 5.14, P = .003), smoking (OR = 2.39, P = .04), and arterial to sheath diameter ratio of ≤1 (OR = 2.62, P = .03). However, the disadvantage of UA was an increase of incidence of hematomas (13.2% vs 5.8%, P = .01) and symptoms of discomfort (15.5% vs 5.8%, P = .002). In conclusion, the transulnar strategy proved to be noninferior to the transradial approach for coronary procedures ( ClinicalTrials.gov Identifier: NCT01979627).

Overexpression of Jagged1 Ameliorates Aged Rat-Derived Endothelial Progenitor Cell Functions and Improves Its Transfusion Efficiency for Rat Balloon-Induced Arterial Injury

BACKGROUND

Endothelial progenitor cell (EPC) has significant age-dependent alterations in properties, but the role of Jagged1 in aging-induced decline of EPC functions remains unclear.

METHODS

2- and 20-month old healthy male Sprague-Dawley rats were used in present study. Jagged1 gene transfection was performed in EPC isolated from aged (AEPC) and young rats (YEPC), respectively. Experiments were divided into 4 groups: (1) pIRES2-EGFP (PE) group, (2) PE-combined N-[N-(3, 5-difluoro-phenacetyl)-1- alany1]-S-phenyglycine t-butyl ester (DAPT) (PE + D) group, (3) pIRES2 EGFP-Jagged1 (PEJ) group, and (4) PEJ combined DAPT (PEJ + D) group. Notch molecules were detected by real-time quantitative polymerase chain reaction or Western blotting. CD34, CD133, CD45, and KDR markers were detected by flow cytometry. EPC migration and proliferation were detected with a modified Boyden chamber and 3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide assay, respectively; the tube formation ability was assayed by in vitro angiogenesis kit; EPC transfusion after Jagged1 gene transfection was performed in rat carotid artery injury models.

RESULTS

Jagged1 gene transfection effectively activates notch-signaling pathway. Compared with PE groups, overexpression of Jagged1 significantly promoted AEPC functions including proliferation, migration, the tube formation ability, and cell differentiation, these effects could be reasonably diminished by DAPT. In vivo study demonstrated that Jagged1 overexpressing also significantly promoted AEPC homing to the vascular injury sites and decreases the neointima formation after vascular injury.

CONCLUSIONS

Overexpression of Jagged1 ameliorates aged rat-derived EPC functions and increases its transfusion efficiency for balloon-induced rat arterial injury.

Effect of Long-Term Administration of Nicorandil on Endothelial Function of the Radial Artery in Patients With Angina Undergoing Transradial Percutaneous Coronary Intervention

We evaluated the effect of long-term administration of nicorandil on endothelial function of the radial artery in patients with angina undergoing elective transradial coronary intervention (TRI). A total of 127 patients were randomly assigned to nicorandil (standard medication plus nicorandil 5 mg twice daily, n = 64) or control group (standard medication except nicorandil, n = 63) immediately after TRI procedure. Radial artery diameter (RAD), flow-mediated dilation (FMD), and nitroglycerin-mediated dilation (NMD) of radial artery were measured 1 day before TRI as well as 1 day and 3 months after TRI by Ultrasound-Doppler. No significant difference was observed in the baseline RAD, FMD, and NMD between the 2 groups (all P > .05). In cannulated arm, at 3-month follow-up, RAD in nicorandil group was much larger than that in the control group (2.78 ± 0.27 mm vs 2.61 ± 0.30 mm, P = .001). Besides, FMD and NMD were much higher in nicorandil group than those in the control group (10.38% ± 2.43% vs 6.81% ± 1.86%; 15.94% ± 6.28% vs 10.46% ± 5.37%, respectively, all Ps < .001). In conclusion, long-term administration of nicorandil after TRI could improve the endothelial function of the cannulated radial artery.