Abstract
The aim of this article is to focus on the utilization of forearm approach for cardiac catheterization in challenging groups of patients. Radial and ulnar approaches have gained significant popularity among the majority of interventional cardiologists. Multiple studies have demonstrated the feasibility, safety and efficacy of forearm route for cardiac catheterization and have highlighted the significant reduction in bleeding complications by avoiding the puncture of the groin. In this review we present the strategies need to be followed in order to apply the forearm approach in challenging group of patients.
Highlights
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Forearm approach is associated with reduced access site complications.
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Being familiar with the use of ulnar approach increases the chance of procedural success and reduces the need for crossover to femoral route.
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Forearm approach should be preferred for the category of critically ill patients, if the operator is experienced enough and confident, in order to reduce access site complications and all-cause mortality.
1
Introduction
Forearm approach for cardiac catheterization constitutes a safe and feasible alternative to the traditional femoral route. Avoiding femoral puncture leads to reduced rates of access site complications [ ], reduced mortality in high risk patients with ST segment elevation myocardial infarction [ ] and increased patient comfort due to faster mobilization or even same-day hospital discharge, thus resulting in decreased medical expenses [ ]. Unfortunately, the forearm approach use varies among different countries, different centers in the same country and different operators in the same center. Surprisingly, low prevalence of forearm approach is reported in USA, since 16% of cardiac catheterizations are performed from radial route [ ].
The dual blood supply of each forearm, the ulnar and the radial artery, anastomosing across the hand in the superficial and deep palmar arches, limits the possibility of limb- threating ischemia. Both of these arteries are suitable sites for puncture during a cardiac catheterization. The radial artery is superficial, lying just under the skin and without any proximal nerves or veins that are possible to be damaged. On the contrary, the ulnar artery is situated deeply, without a bone support beneath and lies in proximity to the ulnar nerve. The radial approach is more widely used compared to the ulnar approach, but being familiar with the use of ulnar approach as an access site option increases the chance of procedural success and reduces the need for crossover to femoral route.
2
Studies demonstrating feasibility and safety of radial and ulnar approach
Since the first radial approach for coronary angiography in 1989 by Campeau and the first coronary angioplasty three years later by Kiemeneij [ ], percutaneous interventions through forearm approach have gained acceptance and operator preference. In patients with acute coronary syndromes, the MATRIX and the RIFLE-STEACS trials showed that radial access, as compared to femoral access, reduced the occurrence of adverse clinical events [ , ]. On the other hand, the RIVAL study reported that the radial and femoral approaches were both safe and effective for PCI [ ]. Transradial approach has been compared with transfemoral route in both observational studies and randomized trials and has consistently demonstrated statistically significant reduction in bleeding and access site complications. As far as ulnar artery is concerned, the AJULAR (Ajmer Ulnar Artery) study tried to use ulnar artery access as an alternative to radial route and found that transulnar access is an excellent alternative and non-inferior to transradial approach, if performed by an experienced operator [ ].
2
Studies demonstrating feasibility and safety of radial and ulnar approach
Since the first radial approach for coronary angiography in 1989 by Campeau and the first coronary angioplasty three years later by Kiemeneij [ ], percutaneous interventions through forearm approach have gained acceptance and operator preference. In patients with acute coronary syndromes, the MATRIX and the RIFLE-STEACS trials showed that radial access, as compared to femoral access, reduced the occurrence of adverse clinical events [ , ]. On the other hand, the RIVAL study reported that the radial and femoral approaches were both safe and effective for PCI [ ]. Transradial approach has been compared with transfemoral route in both observational studies and randomized trials and has consistently demonstrated statistically significant reduction in bleeding and access site complications. As far as ulnar artery is concerned, the AJULAR (Ajmer Ulnar Artery) study tried to use ulnar artery access as an alternative to radial route and found that transulnar access is an excellent alternative and non-inferior to transradial approach, if performed by an experienced operator [ ].
3
The importance of an alternative access site after initial access site failure
Most operators utilize the radial approach when they want to perform the catheterization from the forearm route. Given that all procedures cannot be performed successfully from the radial approach, knowing when to stop and switch to another approach maybe the most important characteristic of an experienced forearm operator. Alternatively, another forearm artery can be used after initial transradial access failure in order to avoid puncturing the groin.
There are several alternatives according to the clinical scenario. If the reason for switching is the inability for successful radial cannulation, then the most reasonable and less time consuming alternative is the ipsilateral ulnar artery. For this reason it is important to simultaneously sterilize the region of the ulnar artery, even if the radial artery is chosen as first access site. The ipsilatelar ulnar artery can also be chosen after successful radial artery cannulation, in case of anatomical complexities and variations of the arm vasculature, like a 360 loop of the radial artery at the level of the elbow that makes radial catheterization impossible [ ]. In this case, the ipsilateral ulnar artery is a continuity of the brachial artery and transulnar catheterization can be performed usually without problems. In this scenario, the patient has two sheaths in the same forearm, one in the radial and one in the ulnar artery, but this is not a clinical problem according to the existing experience ( Fig. 1 ) [ ]. Besides, Kedev et al. showed that the transulnar approach is safe, even in patients with documented previously occluded radial artery [ ]. Lately, the distal radial artery, in the anatomical snuffbox has been demonstrated as an alternative access site for cardiac catheterization ( Fig. 2 ). Although there are no randomized trials comparing the distal to the traditional radial access, it seems a feasible option, having the advantage of faster haemostasis [ ]. If the difficulty is identified proximally to the elbow level (brachial artery, aortic arch or ascending aorta) then the next access site should be at the contralateral forearm. The above mentioned algorithm is followed in our Department and resulted in a very low rate of femoral artery utilization [ ].
4
Post-coronary artery bypass graft surgery patients
Patients with previous coronary artery bypass graft operation remain a very challenging and heterogenous group for cardiac catheterization from the forearm approach. These patients represent the 18% of non-ST-elevation acute coronary syndrome patients, they are usually old and have high prevalence of diabetes or severe peripheral artery disease, factors that multiply the risk of femoral complications and make the forearm approach quite an intriguing option. According to the grafts used, they should be treated with a different strategy.
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Patients with only vein grafts: Although it could be challenging and time consuming to engage the vein grafts from the forearm approach, this can be done with safety by experienced forearm operators. Angiography wires and guiding catheters are the same used from the femoral approach. Guide extension catheters like Guidezilla (Boston Scientific, USA) and Guideliner (xxx, USA) can be extremely helpful tools for selective visualization of the grafts providing the necessary support for performing a PCI [ ].
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Patients with in situ LIMA implantation: These patients should be catheterized from the left forearm, where the LIMA can be easily and selectively engaged, since its ostium is on the way of the catheter pathway. The procedure can be performed without significant increase in the procedure time or radiation exposure [ ].
- c.
Patients with in situ LIMA and RIMA implantation: These patients should be treated initially from the right forearm, where the RIMA, which presents difficulties in its visualization even from the femoral approach, can be comfortably engaged on the way to the ascending aorta. The left subclavian engagement from the right forearm approach can be challenging due to the need of complex catheter manipulations at aortic arch level, but it is feasible in the majority of the cases in the hands of experienced operators [ ]. In the minority of patients that it is not feasible, a left forearm artery catheterization, which leads in the combined cannulation of both forearms, may be necessary in order to complete the procedure.
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Patients with extracted left radial artery: These patients represent a very challenging group for catheterization. A right forearm approach should be the initial choice. In case of failure of successful forearm artery catheterization or if the procedure cannot be completed from the right forearm approach, then the left ulnar artery can be a feasible alternative, if performed by a skilled operator [ ].
5
Patients with chronic kidney disease and end stage renal disease
The prevalence of chronic kidney disease (CKD) is increased among patients with coronary artery disease and renal failure is associated with adverse cardiovascular outcomes. Patients with CKD are prone to bleeding disorders due to the reduced clearance of antithrombotic agents and to increased arterial stiffness and calcification [ ]. Furthermore, cardiac catheterization is strongly associated with kidney injury in a multifactorial way and this complication is correlated with long term hospital stay and increased morbidity and mortality as well [ ]. People with CKD are at risk to develop end stage renal disease after cardiac catheterization due to direct injury from iodinated contrast and to atheroemboli from aortic atherosclerosis as well [ ]. Vora et all showed that radial approach should be preferred in patients with CKD, as it is associated with lower risk of blood transfusion 48 h after the procedure and with lower risk of progression to end stage renal disease [ ].
On the other hand, patients with end stage renal disease (ESRD) represent a very challenging group for cardiac catheterization. The altered calcium metabolism leads to increased calcium deposition in the coronary vasculature and the peripheral arteries as well. This extensive atherosclerotic disease, in combination with low hemoglobin due to the lack of erythropoietin, increases the risk of bleeding complications. Additionally, the excessive calcium load in the coronary arteries influences PCI complexity in these patients, increasing the use of plaque modification devices, like rotational or orbital atherectomy. Previously, end stage renal disease was considered as a contraindication for forearm approach in order to preserve the forearm arteries for future hemodialysis access site formation [ ].
It has been demonstrated that forearm approach is safe in patients with ESRD and is associated with less access site bleeding complications compared to femoral approach, without observed increase in complications related to hemodialysis access site formation [ ].
However, forearm approach in these patients should be performed from the upper extremity that has a functional arteriovenous fistula. Among patients who have both arms used for AV fistula formation, the forearm with the non-functioning AV fistula may be used for catheterization ( Fig. 3 ).
