Abstract
Background
Angioplasty on the radial artery have been performed with good success rates in patients with critical hand ischemia. We sought to assess the feasibility and safety of radial angioplasty on complex radial access in patients undergoing coronary angiography.
Methods/Material
A prospective series of procedures with complex radial/ulnar access to which radial-ulnar angioplasty (RU-A) was performed. We set goals of efficacy and safety that included the success rate of the procedure (need for ¨Crossover femoral¨) and the existence of radial pulse at one month.
Results
18 cases of RU-A out of 11,500 procedures from March 2010 to July 2016 (0.15%) were included. The majority of the patients were men with a variety of cardiovascular risk factors (age 71 ± 9; 94% Hypertensive, 56% Diabetic, 18% chronic kidney disease). The most common indication for radial/ulnar angioplasty was severe arteriosclerotic stenosis. Angioplasty was performed with different types of over the wire peripheral balloons (Mean diameter 4,3 ± 1 and mean length 42 ± 15 mm), in one case a stent implantation was needed. The success rate was 100% without vascular complications at 1-month clinical and vascular doppler follow-up.
Conclusions
Radial/ulnar artery angioplasty is feasible and safe in selected patients undergoing elective angiography or percutaneous coronary intervention using complex forearm approach.
Highlights
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Transradial approach (TRA) in coronary angiography and percutaneous coronary intervention (PCI) has become a viable and attractive alternative for the femoral approach.
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There are still complex cases where the radial/ulnar access is not possible due to severe atherosclerotic disease and a different access can not be performed neither due to different reasons like arteriovenus fistulas, severe atherosclerotic stenosis, amputated patients, etc.
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Radial/ulnar artery angioplasty could be feasible and safe in selected patients to seal an iatrogenic dissection or facilitate catheterization/PCI when no other possible upper extremity access was available.
In recent years, the percentage of coronary angiography/intervention by radial/ulnar access has increased exponentially. Although it requires a greater learning curve, this growth is due to a reduction in mortality and major adverse cardiovascular events (MACE), improving safety with a reduction in the rate of major bleeding and vascular complications across the spectrum of patients with coronary disease . Arteriosclerotic disease, repeated procedures, iatrogenic dissection or the need for larger diameter catheters are causes that frequently involve femoral crossover or conversion . Angioplasty on the radial artery is an alternative in complex radial access, reducing the abandonment rate and recovering the radial system for future procedures. These procedures have been performed with good success rates in patients with critical hand ischemia , although their use in patients undergoing coronary angiography//percutaneous coronary intervention (PCI) is unknown.
1
Methods
We present a retrospective study of a clinical experience where radial-ulnar angioplasty (RU-A) were performed to seal an iatrogenic dissection or facilitate catheterization/PCI when no other possible upper extremity access was available. In this manuscript, the data, management, steps, are focused on RU-A to facilitate catheterization/PCI. Complex access was defined as that in which calcification, obstruction, tortuosity or some other reason did not allow advancement of the material to perform catheterization. We set goals of efficacy and safety that included the success rate of the procedure (need for ¨Crossover femoral¨) and the existence of radial pulse at one month. At our centre, when a radial/ulnar fixed obstructive disease is present, other upper extremity accesses are tried (left radial/ulnar) and if the patient is not on anticoagulation we move to femoral access as last choice. Before performing the RU-A other strategies like sheathless catheter, 4-5F catheters, pigtail-assisted tracking or balloon-assisted tracking were tried without success. All patients were on double antiplatelet therapy and immediately after the arterial cannulation, cocktail was administered through the introducer with 5000 IU of unfractionated heparin and 200 mcgr of nitroglycerin. In cases of suspicion of vasospasm, boluses with later nitroglycerin and sedatives were administered.
There were 18 cases of RU-A out of 11,500 procedures from March 2010 to July 2016 (0.15%). Here are the steps:
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Channelling the radial/ulnar route and advancing the 6F introducer sufficiently to progress the guide through the artery.
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Proceed with hydrophilic 0.035″guidewire through the introducer or, if this is not possible, a 0.014″ angioplasty guidewire.
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Progress the peripheral over the wire (OTW) balloons by dilating the diseased segment at low pressure and distally to the introducer ( Fig. 1 ). Avoid contrast injections after radial angioplasty.
Fig. 1
Radial angioplasty.
A Angiogram showing a severe and diffuse radial calcified stenosis, in the distal segment (white arrow). B-C Angiogram of dilatation with peripheral balloon 4 × 80 mm at proximal and distal segments over a 0,014″ wire. D Angiogram after the procedure showing radial patency without complications (white arrow).
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Carry out the coronary procedure. During the procedure if there are any dissections at the radial level, its sealing is usually achieved.
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Perform control injection at the end of the procedure from the radial introducer to assess possible complications resulting from radial angioplasty ( Fig. 1 ).
At he end of the procedure a pneumatic band (TR band, Terumo) was used for radial/ulnar hemostasis for 2–4 h. A non-occlusive/patent hemostasis was performed.
2
Results
The majority of the patients were men with a variety of cardiovascular risk factors and the most common indication for radial/ulnar angioplasty was severe arteriosclerotic stenosis ( Table 1 ).
| Age (years) | 71 ± 9 |
|---|---|
| Male | 78% (n = 14) |
| Smoker (active) | 33% (n = 6) |
| Hypertensive | 94% (n = 17) |
| Diabetes Mellitus | 56% (n = 10) |
| Hyperlipidemic | 83% (n = 15) |
| Peripheral artery disease | 28% (n = 5) |
| Prior ischemic heart disease | 28% (n = 5) |
| Previous coronary intervention by the same approach | 28% (n = 5) |
| Chronic kidney disease (FGe <30 ml/1,73 m2) | 18% (n = 3) |
| Radial approach | 89% (n = 16) |
| Ulnar approach | 11% (n = 2) |
| Multivessel disease | 67% (n = 22) |
| Radial angioplasty indication | |
| – Severe atherosclerotic disease | 78% (n = 14) |
| – Iatrogenic dissection | 22% (n = 4) |
| Angiographic severe calcification | 67% (n = 12) |
| Wires used | |
| – 0,014″ | 56% (n = 10) |
| – 0,035″ | 44% (n = 8) |
| Peripheral balloon used: | |
| – Admiral Xtreme | 44% (n = 8) |
| – Amphyrium Deep | 11% (n = 2) |
| – Passeo | 44% (n = 8) |
| Mean balloon diameter (mm) | 4,3 ± 1 |
| Mean balloon length (mm) | 42 ± 15 |
| Mean inflate pressure (atm) | 5,9 ± 0,7 |
| Vascular complication | 0% |
| Stent needed | 6% (n = 1) |
| Coronary PCI | 61% (n = 11) |
| N° vessel | |
| – 1 vessel | 33% (n = 4) |
| – 2 vessel | 58% (n = 7) |
| – 3 vessel | 8% (n = 1) |
| Catheter used: | |
| – Medtronic therapeutic | 56% (n = 10) |
| – Sheathless (Asahi) | 6% (n = 1) |
| – Diagnostic | 39% (n = 7) |
| Long sheath 90 cm (Terumo) | 6% (n = 1) |
| Diameter of catheter | |
| – 5F | 39% (n = 7) |
| – 6F | 56% (n = 10) |
| – 7F | 6% (n = 1) |
| Coronary debulking | 6% (n = 1) |
| Success PCI | 94% (n = 17) |
| Radial/ulnar patency at 1 month (palpation and vascular doppler) | 100% (n = 18) |
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