Do we still need Allen or oximetry prior to radial approach?

1. Do We Still Need Allen or Oximetry
Prior to Radial Approach?
Ian C Gilchrist, MD, FACC, FSCAI
Professor of Medicine
Penn State’s Hershey Medical Center
Heart & Vascular Institute
Hershey, PA
USA

2. The Myth
20th U.S. edition of Gray's Anatomy of the Human Body, Gray plate
1237:1918 (public domain)
Circulation 2006;113;e6-e7
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3. Ritual
ritual rit·u·al (rĭch'ōō-əl) n. A
detailed act or series of acts
carried out by an individual
(doctor) to relieve anxiety or
to forestall the development
of anxiety.
The American Heritage® Stedman's Medical Dictionary
Copyright © 2002, 2001, 1995 by Houghton Mifflin Company. Published by Houghton Mifflin Company.Mayan Mural image of a Mayan Warrior and a captive. Licensed: Vital
Imagery Ltd
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4. Reality
Permission: Gunther von Hagens' BODY WORLDS, Institute for Plastination,
Heidelberg, Germany, www.bodyworlds.com
Permission: Ian Gilchrist 2013
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5. J Trauma. 2006;61:468–470.
Allen’s Test & Arterial Lines
No Class I evidence
No randomized data for meta-analysis
No standard definition of abnormal
Significance of abnormal is unclear
No predictive value
…performance of an Allen test before radial artery cannulation
should not be considered a “standard of care”.
CONCLUSION
Visuals unlimited
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6. Transradial Allen’s Test
Built on assumption of predictability
Refined with oximetry
Touted as a ritual at many courses
Labeled standard of care without data
Not used by many long standing operators
Ischemic complications remain rare & not related
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7. J Am Coll Cardiol 2014;63:1833–41
203
Normal: 83
Intermediate:80
Abnormal: 60
Allen’s Test
Thumb capillary lactate
Thumb plethysmography
Ulnar frame count
Handgrip strength test
Discomfort ratings
Testing
Baseline
1 Day
1 Month
1 Year
Follow Up
Conclusion: No differences between the groups to suggest a risk
from an abnormal Allen’s Test
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8. RADAR Results
Handgrip
Discomfort
Lactate
J Am Coll Cardiol 2014;63:1833–41
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9. Allen’s/Barbeau Association
Abnormal Allen’s
Normal Allen’s
J Am Coll Cardiol 2014;63:1833–41
DC
BA Intermediate Allen’s
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10. Is there a Role for Collateral Testing?
Image from: http://www.pcronline.com/eurointervention/tools-and-techniques/radial-approach-for-percutaneous-coronary-intervention/
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11. Risk, Benefits & Alternatives
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12. Practice Recommendations
There is no evidence to support utility to Testing for Dual
Circulation for pre-procedural triage for transradial
catheterization to prevent ischemic complications.
We need to refocus our attention on the use of oximetry-
plethysmography & other techniques to guide patent
hemostasis once the transradial procedure is completed to
minimize radial artery occlusion.
Bertrand OF, Carey PC, Gilchrist IC. Allen or no Allen: that is the question!
J Am Coll Cardiol. 2014;63(18):1842-4.
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13. Thank you
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