Abstract
We report a patient with critical hand ischemia after transradial coronary angioplasty. The radial artery occlusion was confirmed by angiography. The report discusses the role of angioplasty for the treatment of symptomatic radial artery occlusion.
1
Introduction
The conventional way to access the coronary , carotid , and renal arteries during endovascular interventions is through the femoral artery; however, this approach is not always possible because of vessel pathology or aberrant anatomy in the iliofemoral arteries and the aortic arch. A trans-brachial or transradial (TR) artery approach can be employed as an alternative when femoral access is not possible . The rationale for the TR approach has been to attempt to reduce the incidence of bleeding complications at the vascular access site and the necessity for prolonged bed rest. Being able to avoid local complications of TR coronary angioplasty is mainly determined by the favourable anatomic relations of the radial artery to its surrounding structures. Radial artery occlusion is a rare complication (1–5%) after TR angioplasty and it does not have a clinical consequence if the hand collateral flow is good. Critical hand ischemia is an infrequent entity and it is usually approached with open surgery , albeit few data are available on treating this condition with balloon angioplasty (BA) .
2
Case report
A 49-year-old man presented with rest pain of the right hand 4 weeks after right coronary angioplasty. The patient’s history was notable for smoking, hypertension, and coronary artery disease. On examination, the right hand was considerably colder than the left, and all fingers showed cyanosis which was most marked at the thumb. A right subclavian angiogram was performed where the right subclavian, axillary, and brachial arteries were patent. There was no atherosclerotic disease within the brachial artery. The brachial artery demonstrated filling of the ulnar and interosseous arteries, but the radial artery was occluded in the proximal part ( Fig. 1 B ). The distal radial artery was filled from the palmar arch, but the collateral was very small ( Fig. 1 A). In an effort to prevent tissue necrosis and to improve patient comfort a BA was carried out. Angioplasty was performed from anterograde brachial access with a 5F 11-cm-long hydrophil sheath (Cordis Co., Bridgewater, NJ, USA). A Choice ES 300-cm, 0.014-in. wire (Boston Scientific, Inc., Natick, MA, USA) was advanced in the radial artery. After a failed guidewire passage, balloon support was used ( Fig. 2 A ). After a failed balloon advancement, the guidewire was advanced with a loop ( Fig. 2 B) until the distal end of the occlusion. A selective angiogram was performed via the over-the-wire balloon to clear out the intraluminal position ( Fig. 3 B ). First, balloon dilatation was performed with a 3×40-mm Savvy balloon (Cordis) ( Fig. 4 A ) and afterwards the whole segment was postdilated with an Amphirion Deep 3-2.5×210-mm-long, below-the-knee balloon (Invatec, Co., Brescia Area, Italy) for 5 min due to flow-limiting dissection ( Fig. 4 B). The final flow was patent and no flow-limiting dissection was visible ( Fig. 5 A and B). The patient was released from the hospital 3 days after the procedure and 2 months later he is asymptomatic.
2
Case report
A 49-year-old man presented with rest pain of the right hand 4 weeks after right coronary angioplasty. The patient’s history was notable for smoking, hypertension, and coronary artery disease. On examination, the right hand was considerably colder than the left, and all fingers showed cyanosis which was most marked at the thumb. A right subclavian angiogram was performed where the right subclavian, axillary, and brachial arteries were patent. There was no atherosclerotic disease within the brachial artery. The brachial artery demonstrated filling of the ulnar and interosseous arteries, but the radial artery was occluded in the proximal part ( Fig. 1 B ). The distal radial artery was filled from the palmar arch, but the collateral was very small ( Fig. 1 A). In an effort to prevent tissue necrosis and to improve patient comfort a BA was carried out. Angioplasty was performed from anterograde brachial access with a 5F 11-cm-long hydrophil sheath (Cordis Co., Bridgewater, NJ, USA). A Choice ES 300-cm, 0.014-in. wire (Boston Scientific, Inc., Natick, MA, USA) was advanced in the radial artery. After a failed guidewire passage, balloon support was used ( Fig. 2 A ). After a failed balloon advancement, the guidewire was advanced with a loop ( Fig. 2 B) until the distal end of the occlusion. A selective angiogram was performed via the over-the-wire balloon to clear out the intraluminal position ( Fig. 3 B ). First, balloon dilatation was performed with a 3×40-mm Savvy balloon (Cordis) ( Fig. 4 A ) and afterwards the whole segment was postdilated with an Amphirion Deep 3-2.5×210-mm-long, below-the-knee balloon (Invatec, Co., Brescia Area, Italy) for 5 min due to flow-limiting dissection ( Fig. 4 B). The final flow was patent and no flow-limiting dissection was visible ( Fig. 5 A and B). The patient was released from the hospital 3 days after the procedure and 2 months later he is asymptomatic.
