10 van Leeuwen aimradial20170922 ACRA study
•Download as PPTX, PDF•
1 like•149 views
This document summarizes a study on the anatomy of the palmar arches and their relationship to outcomes after transradial catheterization. The study found: 1) The superficial palmar arch was incomplete in 46% of patients based on angiography, while the deep palmar arch was complete in all patients. 2) Non-invasive tests (MAT and Barbeau) to assess palmar arch patency had low diagnostic accuracy compared to angiography. 3) Incompleteness of the superficial palmar arch was associated with smaller vascular dimensions and more distal collateral flow but did not impact long-term hand function. 4) The study concludes non-invasive palmar arch tests should be abandoned
Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to 10 van Leeuwen aimradial20170922 ACRA study
Similar to 10 van Leeuwen aimradial20170922 ACRA study (20)
More from International Chair on Interventional Cardiology and Transradial Approach
More from International Chair on Interventional Cardiology and Transradial Approach (20)
Recently uploaded
Recently uploaded (20)
10 van Leeuwen aimradial20170922 ACRA study
- 1. ACRA Anatomy Study Maarten van Leeuwen Ínterventional cardiologist September 22, 2017 A comprehensive anatomic and functional assessment of the vasculature of the hand and relation to outcome after transradial catheterisation
- 2. I do not have any potential conflict of interest to report Potential conflicts of interest
- 3. Background • Palmar arches 1. Most important conduits for digital blood supply 2. Incompleteness may increase the risk for hand ischemia in case of RAO 3. Incompleteness in post-mortem studies highly variable 4. Anatomic studies in life patients are lacking Hamon, Eurointervention 2013 Brezezinski, Anesth Analg. 2009 Valgimigli, J Am Coll Cardiol. 2014 • MAT and Barbeau 1. Non-invasive patency testing of the palmar arches 2. Recommended to apply before radial access and harvest 3. Not related with acute ischemic complications of the hand
- 4. Methods Primary objective To determine the rate of palmar arch incompleteness and to compare this to the test results of the MAT and Barbeau Secondary objectives The effect of palmar arch incompleteness on digital vascular supply and upper extremity function
- 5. Demographic characteristics Age 63 (±11) Male 164 (76%) Length (cm) 175 (±8) Weight (kg) 85 (±17) Cardiovascular history Previous MI 46 (21%) Previous PCI 62 (29%) Previous CABG 2 (1%) Peripheral artery disease 10 (5%) Previous radial access 84 (39%) Previous femoral access 51 (24%) Cardiovascular risk factors Current smoking 38 (18%) Hypertension 112 (52%) Hypercholesterolemia 87 (41%) DM 45 (21%) BMI (kg/m2) 27 (24-30) Family history CVD 75 (36%) Procedure PCI 101 (47%) Procedural time (min) 34 (20-50) Procedural success 210 (98%) RA spasm 32 (15%) Pain score (VAS) 0 (0-3) Baseline characteristicsNon-invasive Invasive (angiograp n=234 n=215 MAT Palmar arch incomp Normal (0-5 s) 52% SPA Intermediate (6-10 s) 27% DPA Abnormal (>10 s) 22% SPA and DPA Barbeau Additional arterial c Type A 36% Interosseus collate Type B 51% Persistent median Type C 9% SPA-DPA anastom Type D 4% SPA-RA connectio
- 7. Palmar arch completeness Ruengsakulrach J Thorac Card Surg. 2001 54% 46% 0% 0%
- 8. Palmar arch completeness Ruengsakulrach J Thorac Card Surg. 2001 54% 46% 0% 0%
- 9. Palmar arch patency Non-invasive vs. invasive assessment Poor diagnostic accuracy (57- 62%)
- 10. SPA completeness Yes No p-value Vascular dimensions (mm) RA 2.51 (±0.4) 2.64 (±0.4) 0.017 UA 2.45 (±0.5) 2.23 (±0.4) 0.002 SPA 1.87 (±0.4) 1.66 (±0.4) <0.001 DPA 1.27 (±0.3) 1.32 (±0.3) 0.17 Collateral Flow (s) UA-Digit 1 3.8 (3.0-5.2) 4.6 (3.4-5.9) 0.08 RA-UA 1.1 (0.8-1.6) 1.3 (0.9-1.8) 0.22 Palmar arch patency Vascular and flow characteristics other characteristics Distal interosseus collaterals 44% 65% 0.002
- 11. SPA completeness Yes No p-value Vascular dimensions (mm) RA 2.51 (±0.4) 2.64 (±0.4) 0.017 UA 2.45 (±0.5) 2.23 (±0.4) 0.002 SPA 1.87 (±0.4) 1.66 (±0.4) <0.001 DPA 1.27 (±0.3) 1.32 (±0.3) 0.17 Collateral Flow (s) UA-Digit 1 3.8 (3.0-5.2) 4.6 (3.4-5.9) 0.08 RA-UA 1.1 (0.8-1.6) 1.3 (0.9-1.8) 0.22 Palmar arch patency Vascular and flow characteristics other characteristics Distal interosseus collaterals 44% 65% 0.002
- 12. Palmar arch incompleteness Long-term upper extremity dysfunction
- 13. Digital vascular supply is preserved in all patients by the palmar arches (DPA 100%, SPA 54%) MAT and Barbeau are related with SPA incompleteness, however diagnostic accuracy is low Loss of hand function is not related to palmar arch incompleteness at long-term follow-up Clinical message: MAT and Barbeau should be abandoned to prevent acute ischemia of the hand Conclusions Rademakers Neth Heart J 2012
- 14. ACRA Perfusion study - Digital perfusion and palmar arch incompleteness (LDPI) - Digital blood pressure and palmar arch incompleteness (Nexfin) Hirado study - Functional and ischemic stress testing in patients with RAO (TcPO2 and capillary lactate) Upcoming
Editor's Notes
- Glad to present the data of Gives to my opinion a better understanding of the anatomy of the vascular blood supply of the hand and previous publications that assessed the clinical relevance of non-invasive patency tests.
- Before I go to the results, short introduction about the anatomy of the vascular supply of the hand.. The radial artery (RA) and ulnar artery (UA) provide most blood supply to the hand and the palmar arches serve as most important conduits for digital blood supply. In case of obstruction or damage to the RA, incompleteness of these arches puts patients at an increased risk for hand ischemia, espcially the first digit because of its radial dependency. Most anatomic knowledge regarding the palmar arches comes from post-mortem studes, using different visulization techniques and classification methods, describing highly variable incompleteness rates. In life patients, patency of the palmar arch is frequently assessed with the the MAT and Barbeau test and has been recommended before TR procedure and Radial harvest (before cabg or reconstructive surgery). However, ischemic complications have not been associated with the results of both tests, including markers for ischemia (published Dr Valgimigli). We therefore initiated a prospective study….
- With 234 participants scheduled for elective corany angio or intervention. In all patients the modified Allen test (MAT) and Barbeau test was performed before radial acces. And the vascular anatomy of the hand was documented by angiography, considered as the gold standard (analysable in 92%), to determine the rate of palmar arch incompleteness. We also aimed to: Determine the association with the MAT and Barbeau. And the effect of palmar arch incompleteness on digital blood supply and upper extremity function, with the validated QuickDASH and CISS score
- These are the baseline chararctirstics of our study population…with representative demographics, CV history and risk factors. PCI was performd in 50% and RA spasm occured in 15% of TR procedures
- This is an example how we performed angiography by means of retrograde contrast injection into the radial artery.... with antegrade filling of the collateral system, including the UA and palmar aches Ruengsakulrach P, Eizenberg N, Fahrer C, Fahrer M and Buxton BF. Surgical implications of variations in hand collateral circulation: anatomy revisited. J Thorac Cardiovasc Surg. 2001
- Completeness of the palmar arches was based on a previous anatomic publication that determined the safety of radial artery harvest11. The SPA was defined as complete when it directly supplied all digits, including the ulnar side of the thumb. The DPA was defined as complete when the distal part of the deep palmar branch of the RA was connected with the deep palmar branch of the UA11. So what is association with the test results of the Barbeau and modified allen test??
- Completeness of the palmar arches was based on a previous anatomic publication that determined the safety of radial artery harvest11. The SPA was defined as complete when it directly supplied all digits, including the ulnar side of the thumb. The DPA was defined as complete when the distal part of the deep palmar branch of the RA was connected with the deep palmar branch of the UA11. So what is association with the test results of the Barbeau and modified allen test??
- In this figure you clealrly see an association between the test results…with the highest prevalence of SPA incompleteness in patients with an abnormal MAT and type D barbeau test. However, if we implement our data in an ROC curve….we may appreciate that both tests have a poor ability to detect SPA incompleteness. The MAT had a 33% sensitivity and 86% specificity for SPA incompleteness with a cut-off value of >10 s and a 59% sensitivity and 60% specificity with a cut-off value of >5 s. The Barbeau test had a 7% sensitivity and 98% specificity for a type D and a 21% sensitivity and 93% specificity for type C and D combined
- So, if look at the other charatceristics of the handcirculation, we clealrly see that patients with palmar arch completeness have a larger collateral circulation (UA and SPA), that results in a trend for delayed perfusion of the first digit. In addition, arteriel collaterals between the IA and the distal were more often observed in patients with SPA incompleteness, probalby to optimize the digital perfusion.
- So, if look at the other charatceristics of the handcirculation, we clealrly see that patients with palmar arch completeness have a larger collateral circulation (UA and SPA), that results in a trend for delayed perfusion of the first digit. In addition, arteriel collaterals between the IA and the distal were more often observed in patients with SPA incompleteness, probalby to optimize the digital perfusion.
- Yesterday my colleaguw Dr van Royen gave a compresive overview of upper extremity dysfunction after TR access the potential causes, including the collateral reserve. In this study we assessed upper extremity function at 2 years follow-up ans observed that loss of hand function, as asses with quickdash, was not didderent between patients with and without palmar arch incompletenss.
- Both tests will only lead to false exclusion from TR procedures and sub sequentially to more access related bleeding complications when femoral access is used as alternative Thrombo-embolic phenomena to the digital arteries or palmar arch circulation is probably the main underlying mechanism of acute hand ischemia