1 Keele Cardiovascular Research GroupMinimizing Radial Injury – The Unmet Need 3rd Cyprus transradial course Dr Muhammad Rashid Keele Cardiovascular Research Group Keele University UK
2 Disclosures None
3 Why Bother
4 Radial Artery Very small artery compared to femoral artery.Average size is 2.44 ± 0.60mm in Caucasians. Trans-radial intervention results in significant injury to vessel wall. Precludes future use of radial artery for TRI and suitability for consideration of CABG.
5 Injuries to Radial arteryFunctional changes in endothelium Radial occlusion Structural damage to intima and media
6 Functional Injury to radial arteryReduction in FMD ; Flow-mediated dilatation (FMD) is an in vivo bioassay of NO-mediated endothelial function used as surrogate for endothelial function. Impaired vasodilatory response of vascular smooth muscles. Endothelial layer damage which provides the substrate for RAO
7 Figure 1. Mean radial artery diameter at baseline in the cannulated versus noncannulated arm before the procedure, immediately after the procedure, and 9 weeks after the procedure. *p <0.05. This study provide insight into the patterns of injury to radial artery during radial intervention. Mean radial artery diameter at baseline in the cannulated versus non-cannulated arm before the procedure, immediately after the procedure, and 9 weeks after the procedure Burstein et al Impact of Radial Artery Cannulation for Coronary Angiography and Angioplasty on Radial Artery Function, The American Journal of Cardiology, Volume 99, Issue 4, 2007, 457–459
8 Figure 2. Radial artery response to FMD in the cannulated versus noncannulated arm before the procedure, immediately after the procedure, and 9 weeks after the procedure. *p <0.01. Radial artery response to FMD in the cannulated versus noncannulated arm before the procedure, immediately after the procedure, and 9 weeks after the procedure Burstein et al Impact of Radial Artery Cannulation for Coronary Angiography and Angioplasty on Radial Artery Function, The American Journal of Cardiology, Volume 99, Issue 4, 2007, 457–459
9 Structural Injuries Intimal Tears Medial dissections
10 Radial artery Intimal hyperplasiaRepresentative cases of intimal hyperplasia observed by optical coherence tomography in the first-transradial coronary intervention group and the repeat-transradial coronary intervention group. (A) Representative optical coherence tomography image of the distal radial artery from the first-transradial coronary intervention group (58-year-old male). (B) Representative optical coherence tomography image of the distal radial artery from the repeat-transradial coronary intervention group (65-year-old male).
11 Causes of intimal and medial injuriesMainly occur when there is a artery internal diameter and sheath outer diameter mismatch. Intimal tears are frequent in the distal portion of the RA. Aggressive manipulation and instrumentation Catheter manipulation and Sheath removal particularly in an event of RAS. Particularly if sheath to artery diameter ratio is >1. The intimal tear usually occur at the distal portion of the artery which suggest that when we manipulate the catheters or wires
12 Patterns of radial injuriesTaishi Yonetsu et al. Eur Heart J 2010;eurheartj.ehq102
13 And there is more to it Medial calcification Adventitial inflammationAdventitial necrosis Radial artery spasm Radial artery occlusion
14 Radial artery Spasm Incidence is as high as 12% without use of any pharmacological agents* RAS leads to patient discomfort, increased risk of vascular complications, radial artery occlusion and procedure failure rate. Various pharmacological agents such nitroglycerine, verapamil, nicardipine etc are used to minimise RAS Use of hydrophilic sheath reduces RAS * *Kwok C et al Cardiovascular Revascularization Medicine 16 (2015) 484–490 – Rathore et al JACC 2010 May;3(5):
15 Radial artery Spasm verapamil at a dose of 5 mg (4% RAS ) or verapamil in combination with nitroglycerine (2%) are the best combinations to reduce RAS
16 Radial artery occlusionLoss of radial pulse on palpation subsequently confirmed by Doppler ultrasonography or plethysmography. Achilles's heel of TRI. Incidence varies depending on timing and method of assessment but typically around 7%- 8% within 24 hours.
17 Mechanism
18 Mediators of RAO Equipment / procedure related Catheter size/ exchangeSheath Size Use of anti coagulation Patent hemostasis Compression time
19 Catheter size and RAO Rashid et al Radial Artery Occlusion in Transradial Interventions JAHA 2016;5:e002686
20 How to reduce catheter sizeSheath less guides may help to reduce the Fr size. Glide sheath slender (GSS) system has hydrophilic coated outer thin wall with an external diameter approximately one Fr smaller than the corresponding conventional system and offering the same internal diameter. Sheathless trans radial cardiac catheterization using conventional catheters and balloon assisted tracking; a new approach to downsizing.
21 Anticoagulation and compression time
22 Patent haemostasis Patent haemostasis ; just enough pressure to compress the artery whilst allowing the antegrade flow through the artery. Reduces RAO by almost three folds*. Also reduces compression time *PROPHET STUDY CCI 2008;72:
23 Anticoagulation Acute RAO is thrombotic phenomenon.Anticoagulation is essential to minimize the risk of RAO Recommended Dose is IU Haparin. Spaulding C et al Left radial approach for coronary angiography: results of a prospective study Cathet Cardiovasc Diagn Dec;39(4):365-70
24 Patient Factors influencing RAORadial artery diameter. Sheath to artery diameter ratio. (A/S diameter ratio >1 is desired). Female gender. Patient body weight (BMI). Wrist circumference
25 Treatment of RAO by compression of ulnar arteryTechnique of ulnar compression. TR band inflated with maximum 18 ml of air placed directly on ulnar artery. Note, normal coloration of hand. Oxymetry-plethysmography of thumb showed typical pulse wave with normal oxygen saturation. Minimal red coloration seen at radial puncture site
26 Treatment of RAO Compressions of ulnar artery improves retrograde flow through the radial artery and help in re-canalising the acute occlusion. American Journal of Cardiology , DOI: ( /j.amjcard RAO before and after 1-hour ulnar artery compression. RAO was greater after initial hemostasis and remained significantly greater in 2,000-IU heparin group after transient ulnar artery compression.
27 Treatment of RAO Other options include s/c LMWH for four week*.Successful wiring of chronic occlusion is been reported by retro / ante grade approach…..watch out for thrombus embolization and high risk of perforation…!!!
28 Radial access and hand InjuryWould I do radial procedure to a pianist?
29 Hand Function Hand function includes several important physiological capabilities mainly Anatomical integrity, including blood and lymph circulation Muscle strength Range Of Motion (ROM), Coordination, and sensory functions, including proprioception and touch sensibility.
30 Hand Injury & TRI Hand injury is complex cascade of events.May result from nerve damage, tissue hypoxia, soft tissue injury, or swelling. Various tools such as DASH,QDASH, VAS scale, BCTQ score, Cold Intolerance Symptom Severity (CISS) are validated to assess the upper limb function. Visual Analogue Scale (VAS) [30], and the Boston Carpal Tunnel Questionnaire (BCTQ)
31 Hand injury & TRI Assessment of hand function is not a routine clinical practice. It may be particular concern for patients form specific occupation such as pianist, vascular surgeons etc. Only handful of studies have evaluated hand function after TRI.
32 The Effect of Transradial Coronary Catheterization on Upper Limb Function(A) Upper limb function as assessed with the QuickDASH score over time. Box plots show the change of the QuickDASH score between baseline and 30-day follow-up for transradial (TR)- and transfemoral (TF)-treated patients. Whiskers represent 5th to 95th percentiles, and p values were calculated with Wilcoxon signed rank test (p < 0.05 was considered statistically significant). A higher QuickDASH score indicates worse upper limb function or symptoms. (B) Cold intolerance of the upper extremity as assessed with the CISS (Cold Intolerance Symptom Severity) score over time. Box plots show the change of the CISS score between baseline and 30-day follow-up for TR- and TF-treated patients. Whiskers represent 5th to 95th percentiles, and p values were calculated with Wilcoxon signed rank test (p < 0.05 was considered statistically significant). J Am Coll Cardiol Intv. 2015;8(4): doi: /j.jcin
33 The Effect of Trans-radial Coronary Catheterization on Upper Limb FunctionProcedure-related extremity problems were equally reported by patients with TR and TF access (19.6% vs. 17.3%, respectively; p = 0.70). Extremity problems that persisted during 30-day follow-up were also not different between both access groups (TR 10.5%, TF 11.5%; p = 0.82) (A) Procedure-related upper extremity complaints after transradial access. A pie chart highlighting the numerical proportions of patients with temporary and persisting upper extremity complaints after transradial access. (B) Type of procedure-related upper extremity complaints that persisted during 30-day follow-up after transradial access. A pie chart summarizing the numerical proportions of different types of persisting extremity complaints after transradial access. J Am Coll Cardiol Intv. 2015;8(4): doi: /j.jcin
34 Hand dysfunction Fourteen articles described upper extremity dysfunction, with an incidence of up to 1.7%. Upper extremity dysfunction was rarely investigated, hardly ever as primary endpoint, and if investigated not thoroughly enough
35 ARCUS study
36 ARCUS results
37 Summary Serious complications are rare from TRA.Radial artery spasm and occlusion are most commonly encountered complications. Trauma to the vascular endothelium and subsequent changes in endothelial cell function may contribute to patterns of injury such as radial artery occlusion and intimal hyperplasia that are known to limit the success of future transradial procedures. Appropriate patient selection, procedure planning and equipment handling are as important as use of pharmacological agents ( Heparin), shorter compression time and smaller catheter size.
38 Prevention is better than Cure…..!!!!!Summary Hand dysfunction may occur after TRA but event rate is incredibly low. Current literature presents conflicting data on hand injury post TRA. More trial evidence will add further strength to existing data. Prevention is better than Cure…..!!!!!
39 Thank You