Minimising Radial Artery Injury

1. Session III: Advance concepts in Transradial PCI
Minimising Radial Artery Injury
Dr Sudhir Rathore MD, MRCP(UK), FACC
Consultant Cardiologist
Fortis Escorts Hospital and Research Centre,
New Delhi, India
Visiting Cardiologist St Georges Hospital, London

2. I, Dr Sudhir Rathore, DO NOT have a financial
interest/arrangement or affiliation with one or
more organizations that could be perceived as a
real or apparent conflict of interest in the
context of the subject of this presentation.

3. Background
 Recently Transradial access has become alternative and
preferred vascular access site.
 Radial artery is medium sized muscular artery.
 Repeated coronary procedures needs patent and
healthy radial artery.
 Radial artery is being used increasingly as a conduit for
coronary revascularisation.
 Transradial access potentially results in injury to radial
artery and can range from endothelial dysfunction to RA
occlusion.
 All efforts must be made to minimise radial artery injury
following TRA.

4. Extent of Injury- Contemporary practice
 Radial artery Occlusion: 4-10% (Early), 2-6%
(Late) during contemporary practice.
 Non-occlusive radial artery injury: Reported in
around 50% of the RA in the form of neo-intimal
hyperplasia, radial artery stenosis etc.
 Vascular function reduced in RA in majority of
the cases.
 RA size, sheath to artery ratio, DM, number of
catheters used, use of heparin, female gender
are shown to be predictors of injury.

5. Acute Injury
Intimal tears: 32%
Medial dissect.:16%
Thombi: 20%
Chronic Injury
Higher neo-intimal
thickness in patients
with repeated
procedures
Taishi Yonetsu et al. EHJ, April 22, 2010

6. Histopathological study- Distal and
Proximal RA
Staniloe CS, et al. Vasc. Health and management, June 2009

7. Prophet Study- Patent Haemostasis
Pancholy S. CCI, 72:335-340, 2008

8. ROCOMAP
Cubero JM. CCI, 73: 467-472, 2009

9. Radial artery Occlusion: Role of heparin
and ulnar artery compression
Bernat, I, Bertrand, O et al. AM Journal Cardiology, 2011

11. Predictors of Radial artery Occlusion
Variables Odds 95% C.I P value
Ratio
Male sex 0.61 0.29-1.28 0.194
Younger age 1.02 1.00-1.04 0.036
Smaller wrist size 1.39 1.06-1.80 0.014
No operator RAS 0.53 0.31-0.90 0.021
No Heparin usage 7.12 3.75-13.52 <0.001

16. Results-1-
Coated sheath-FMD(PRE-POST)
Figure 1. Changes in FMD (%) in the catheterized and non-catheterized arms
pre and post-procedure. Data is presented as mean ± SD. *, significantly
different from pre P<0.05

17. Uncoated sheath-FMD(PRE-POST)
Figure 2. Changes in FMD (%) in the catheterized and non-catheterized
arms pre and post-procedure. Data is presented as mean ± SD. *,
significantly different from pre P<0.05

18. Coated- FMD (POST-RECOV)
Figure 5. Changes in FMD (%) in the catheterized and non-catheterized
arms post and recov. Data is presented as mean ± SD. *, significantly
different from pre P<0.05

19. Uncoated-FMD(POST-RECOV)
Figure 6. Changes in FMD (%) in the catheterized and non-catheterized
arms post and recov. Data is presented as mean ± SD. *, significantly
different from pre P<0.05

20. Comparison between coated and
uncoated sheaths
 FMD in the catheterized arm decreased significantly
from 10.3±3.8 to 5.3±3.3% and from 8.1±2.4 to
5.2±3.7% in the coated and uncoated groups,
respectively.
 These values returned towards baseline levels ~3
months later (6.4±1.4 and 9.4±4.1, coated and uncoated,
respectively).
 GTN decreased significantly from 14.8±7.2 to 9.5±4.1%
in the coated group and from 12.2±4.6 to 7.5±4.2% in
the uncoated group.
 Values returned to baseline at ~3mths (16.6±5.6% and
12.1±3.9%, coated and uncoated respectively).

21. Vascular function- Impact of Artery to
sheath ratio

22. FMD: Impact of no. of catheters and smoking
Heiss. C et al. JACC Interv. 2:1067-1073, 2009

23. Impact of Sheath size: 4Fr vs 6Fr
Lei H, Dong WY, at al. Chinese Medical Journal, 123: 1373-1376, 2010

24. Take Home Message 1
 Radial artery injury is common after TRA.
 RA occlusion rates could be significantly reduced
by adopting routine patent haemostasis and use
of Heparin (5000 Units or more).
 Compression devices should be removed early
and in timely fashion.
 Radial artery spasm should be avoided and
treated promptly using vasodilators and other
measures to reduce radial artery injury and
occlusion.
 Predictors of RA injury should be identified and
adequate measures taken.

25. Take Home Message 2
 RA endothelial function (FMD) and GTN
mediated function are significantly impaired after
TRA.
 Vascular functions recover to baseline in three
months time.
 RA to sheath ratio (<1), smoking and higher
number of catheter exchanges seems to result in
higher extent of injury.
 Less injury with smaller diameter catheters (4-
5Fr vs. 6Fr).
 Secondary prevention of risk factors could
potentially reduce vascular injury.
 Role of Prehab. Or Isometric exercise of forearm
? Reduce vascular injury (Work in progress)