Radial artery patency after transradial catheterization

1. Radial Artery Patency After
Transradial Catheterization
Mark A Kotowycz,MD , MBA , FRCPC
Vladimir Dzavik , MD , FRCPC ,FAHA
Presented by Piti Niyomsirivanich , MD.
Cardiovascular Fellowship Maharat nakhonratchasima hospital

2. Introduction
• Transradial Catheterization
– Reduce major bleeding
– More QOL questionaires score
– Earlier ambulation
– Same day hospital discharge after PCI
– Decrease Cost

3. Radial artery occlusion
• 1-10% of cases
• Usually clinically silent due to dual blood supply
• And usually overlooked > 50% doesn’t routinely access
• But once the artery occluded cannot be used as
– access site for the future catheterization
– as an arterial conduit for bypass surgery

4. Pathophysiology
• Thrombotic process
– reduced with anticoagulant
– radial artery thrombus
• (vascular ultrasound , angiography )
• Local endothelial injury after sheath insertion
• Cessation of blood flow
• Tend to occure early after transradial catheterization
50% spontaneous recanalization within 1-3 months

5. Negative effects radial structural and function
• Structure
– 67% intimal tear
– 36% medial dissections immediately
– Small lumen area in repeated more than the 1st time
• Intimal hyperplasia
• Intima-media thickness
• Function
– Decrease response to NTG

6. Negative effects radial structural and
function
• Structure
– 67% intimal tear
– 36% medial dissections immediately
– Small lumen area in repeated more than the 1st time
• Intimal hyperplasia
• Intima-media thickness
• Function
– Decrease response to NTG
 repeated radial access site failure
 reduced graft patency in patient undergoing bypass
surgery with radial artery conduits.

7. Clinical Presentation
Usually Subclinical due to ulnar collateral circulation

8. • efficacy and safety
– transradial versus femoral approach
Radial % Femoral
%
HR 95% CI P
Major Vascular
Access site
Complications
1.4 3.7 0.37 0.27-0.52 < 0.0001
Other Definition of Major Bleeding
TIMI Non-
CABG Major
bleeding
0.5 0.5 1.0 0.53-1.09 1.00
Acuity Non-
CABG Major
bleeding
1.9 4.5 4.5 0.32-0.57 < 0.0001
The Lancet, Volume 377, Issue 9775, Pages 1409 - 1420, 23 April 2011
RIVAL Study

11. • efficacy and safety
– transradial versus femoral approach
Radial % Femoral
%
HR 95% CI P
Major Vascular
Access site
Complications
1.4 3.7 0.37 0.27-0.52 < 0.0001
Other Definition of Major Bleeding
TIMI Non-
CABG Major
bleeding
0.5 0.5 1.0 0.53-1.09 1.00
Acuity Non-
CABG Major
bleeding
1.9 4.5 4.5 0.32-0.57 < 0.0001
The Lancet, Volume 377, Issue 9775, Pages 1409 - 1420, 23 April 2011
RIVAL Study

12. In summary From RIVAL Study
• no difference in rates of composite
– Death.
– myocardial infarction.
– Stroke.
– major bleeding between access strategies.
• But
– radial access decreased major vascular
complications.
The Lancet, Volume 377, Issue 9775, Pages 1409 - 1420, 23 April 2011

13. Physical examination
• Weak or absent radial pulse.
• But may have a palpable pulse from collateral
ulnar (retrograde filling)
• Thus : Dx of RAO should not depend on
presence or absence pulse.

14. Natural History
71 % improved
20 % diffuse stenosis
60 % partial or complete
recanalization
Long term (3 months)
American Journal of Cardiology
Volume 83, Issue 2 , Pages 180-186, 15 January 1999
N=162 routine Ultrasound at Day 2 after transradial catheterization

15. Natural History
Catheterization and Cardiovascular Diagnosis
Volume 40, Issue 2, pages 156–158, February 1997
N=563 with a normal Allen test evaluate by U/S
RAO 5.3%
No complication
47% spontaneous
recanalization
follow-up (1 months)

16. Assessing Dual Hand Circulation
• Modified Allen Test

17. Assessing Dual Hand Circulation
• Plethysomography and pulse oximetry
(barbeau test)
No single case observed of hand ischemia in 7000 patients

18. Assessing Dual Hand Circulation
• Duplex ultrasounography (most accurate way)

19. Predictors of RAO
• Diameter of the sheath
• Postprocedure compression time
• Presence of anterograde flow during
hemostasis
• Use of anticoagulation

20. Sheath size
• Oversized of Sheath
–  vascular remodeling
– Thrombosis
250 patients
under going PCI
Pretreated
with NO
Journal of the Society for Cardiac Angiography & Interventions [1999, 46(2):173-178]
6F or larger inserted
S-A ratio > 1  RAO 13%
S-A ratio < 1  RAO 4%
(P=0.01)

21. Sheath size
171 patients
under going PCI
6 F Sheath
5 F Sheath
RAO 1.1% in 5F group
RAO 5.9% in 6F group
NAUSICA trial (Ongoing)
patients under
going PCI
Randomized
4F Sheath
6F Sheath
RAO
1-month follow-up
Catheterization and Cardiovascular Interventions
Volume 57, Issue 2, pages 172–176, October 2002
P = 0.08
NCT00815997

22. Predict radial artery size ??
• Associations between radial artery diameter
– BW , Ht. Surface area  weak correlation and
less predictable
J INVASIVE CARDIOL 2013;25(7):353-357

24. Options to minimized the risks of RAO
• 5F system can be used in most patients.
• New Sheathless hydrophillic guiding catheters
– (external diameter of 5F sheath while 6.5F internal
diameter)
• Larger guides with an external diameter of 6F
sheath that have and internal diameter
equivalent to a 7F guide

25. Patent Hemostasis
• Compressible
• But too aggressive compression
–  no flow state  thrombosis
• Predictor of RAO
– Absence of anterograde flow during hemostasis

26. Patent Hemostasis
• Conventional pressure application
– Versus
– PHOPHET trial
• Pulse oxymeter guided (HemoBand)
• (less RAO at 24 hrs) 5% vs 12%,p<0.05)
– RACOMAP trial
• Mean artery pressure guided (TR Band)
• (less RAO) (1.2% vs 12%,p=0.0001)
Catheter Cardiovasc Interv. 2008 Sep 1;72(3):335-40
Enferm Clin. 2009 Jul-Aug;19(4):199-205

27. TR Band

28. Anticoagulation
• Minimize the risk of the RAO
• Based on observational data because of no
RCT.
• Heparin (Current practice 2000-5000 U of
heparin)

29. Anticoagulant
0
10
20
30
40
50
60
70
80
Spaulding et al. (p<0.05)
N=415
Bernad et al. (p = 0.17)
N=465
no anticoagulant
2000 U heparin
5000 U heparin
71%
24%
4.3% 4.9%
2.9%
Cathet Cardiovasc Diagn. 1996 Dec;39(4):365-70.
Am J Cardiol. 2011 Jun 1;107(11):1698-701

30. Date of download:
6/10/2014
Copyright © The American College of Cardiology.
All rights reserved.
Observations From a Transradial Registry: Our Remedies Oft in Ourselves Do Lie⁎
J Am Coll Cardiol Intv. 2012;5(1):44-46. doi:10.1016/j.jcin.2011.10.005
Rates of RAO in Previously Published Studies According to RAO-Avoidance Strategies Used
Early = 7 days post-procedure in Sanmartin et al. study (8); hospital discharge in Rathore et al. study (9); 24 h post-procedure in Pancholy et al. study
(11); 24 to 72 h post-procedure in Cubero et al. study (12); and 4 to 5 h post-procedure in Bernat et al. study (13). Late = 4 to 6 months post-procedure
in Rathore et al. study (9); 4 to 8 weeks in Plante et al. study (10); and 1 month post-procedure in Pancholy et al. study (11). RAO = radial artery
occlusion; UFH = unfractionated heparin.
Figure Legend:
Whether angioplasty was required or not

31. • But Heparin add on Bivalirudin remains
unclear. (need further investigation)

32. Treatment
• Relatively asymptomatic.
• Observation
• Recanalization
– relieve ischemic symptoms
– to save the artery for future procedure
– Anterograde or Retrograde
• Aspiration after wiring

33. Conclusions
• Occurs in 1-10%
• Mechanism : Thrombosis
• Strategies for minimized RAO
– Small Sheaths or Sheathless
– Non occlusive hemostasis
– anticoagulation

34. Thankyou