Abstract
Background
Patients’ intra and post procedural comfort, quick recovery, as well as procedure success, are key elements for choosing the right arterial access site. Radial artery access has been of increasing interest since it was first described. Advanced treatments of coronary lesions, from primary percutaneous interventions during ST elevation myocardial infarction cases to chronic total occlusion cases, have been increasingly done through the radial access. Distal left trans radial artery (dlTRA) is a new technique first described by Kiemineij. We report the first documented US experience of the left distal radial artery access for coronary angiography and interventions.
Methods
dlTRA was attempted on 22 consecutive patients, consented for a cardiac catheterization. 7 patients underwent percutaneous coronary intervention. The left hand is prepped in the usual fashion, exposing the anatomical snuff box. Under ultrasound guidance, the artery is punctured and the sheath is inserted carefully. The cardiac catheterization is completed using standard diagnostic and guiding catheters, that are typically chosen for femoral artery access. Hemostasis was achieved with a radial band. Patients had the ability to use the right hand as well as bend their left wrist post procedure.
Results
dlTRA was successful in all 22 patients. 7 patients underwent PCI through this approach. Two patients required a multivessel complex PCI with multiple stents and additional equipment. There were no conversions to the right radial or femoral approach. All patients had excellent hemostasis with a radial band, with no complications. Pre discharge radial pulses were intact in the wrist as well as in the anatomical snuff box.
Conclusion
Distal left trans radial access is feasible and safe in patients that are carefully selected and are deemed good candidates. There is a learning curve for developing such program, as is the case with conventional radial access.
Highlights
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Radial artery access has been of increasing interest since it has been first described.
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The use of the left radial artery allows coronary catheter placement similar to the femoral artery approach and direct access to the internal mammary artery.
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Distal left trans radial access is feasible and safe in patients that are carefully selected and are deemed good candidates.
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Improved operator’s ergonomics and patients comfort during and after the procedure when compared to conventional radial artery access.
1
Introduction
Radial artery access has been of increasing interest since it was first described by Campeau [ ] in 1989 for diagnostic coronary angiography and its evolution by Kiemeneij and Laarman [ ] in 1995 to be used in percutaneous coronary intervention (PCI). Patients’ intra and post procedural comfort, quick recovery, as well as procedure success, are key elements for choosing the right arterial access site. Radial artery access has matured in the United States of America (USA) to be the default and preferred access site in many centers, especially primary PCI for ST segment elevation myocardial infarctions, or as complex as chronic total occlusion (CTO) cases and bifurcation percutaneous intervention cases. Several small studies have been conducted in Europe and USA comparing femoral vs radial approach for cardiac catheterization [ , ]. Each arterial access site has its advantages and disadvantages. An advantage of femoral access is the ability to use large bore devices, for example when mechanical support is indicated. The disadvantage of a femoral approach has been increased risk of bleeding complication and patient discomfort.
The use of the left radial artery allows catheter placement similar to the femoral artery approach and provides direct access to the left internal mammary artery for angiography in patients with previous coronary artery bypass grafts. The right radial artery has also been criticized for higher radiation as compared to femoral and left radial approach [ ]. Provided the absence of significant subclavian disease and tortuosity, good spasmolytic premedication of the artery, and the use of hydrophilic sheaths, completing the cardiac catheterization from the radial artery is successful. The major disadvantage of utilizing the left radial is the lack of good ergonomics to the operator, given the need to bend over the patient. Also, the discomfort that may be caused to the patient given their supinated arm across their body during the case.
Recently, Kiemeneij described Left distal transradial angiography (ldTRA) and interventions (ldTRI) using the anatomical snuff box [ ]. It has the advantage of being left sided with the patient’s arm is in a more natural position during the procedure, hence improved ergonomics. We sought to report the first case series in our institution to evaluate the feasibility of ldTRA access. We report the first documented cases series in the USA of the left distal radial artery access for coronary angiography and interventions.
2
Case report
2.1
Patient preparation
As with any procedure, planning is very important. The left radial artery is palpated in the anatomical snuff box to confirm adequate vessel size. The anatomical snuff box is a triangle on the dorsum of the hand, at the base of the thumb, bordered by the extensor pollicis longis tendon, the extensor pollicis brevis tendon and the styloid process of the radius bone ( Fig. 1 .A ). The scaphoid bone serves as the floor beneath the snuff box contents. The radial artery is one of the contents of the hand’s anatomical snuff box. An ultrasound can be used to evaluate the size of the vessel prior to the procedure, as well as at the time of the arterial puncture ( Fig. 1 .B and C). The patient is placed on the cardiac catheterization table in the usual manner. The left arm is slightly extended out on a conventional radial board, with the hand in a midway position between being supinated and pronated, with the thumb facing upwards. A radial drape is placed over the hand after it is prepped, exposing the anatomical snuff box. A wrist restraint can be placed on the patient’s forearm, just below the elbow, with a strap across the patient’s body. The strap can then be tied to the right side of the catheterization table once access is obtained and the arm can be positioned across the patient’s body.
2.2
Access
Using a small gage needle, carefully, a local anesthetic is injected subcutaneously in the snuff box. Care should be taken not to inject deep to avoid pain caused by irritating the periosteum of the styloid process of the radius bone. The artery is then accessed using the typical radial artery needle. The most critical part of obtaining access in the snuff box, is threading the wire through the needle in the vessel in a retrograde fashion. Extreme care should be used, with good radial expertise; tactile feedback should be used to guide the wire advancement. This is because the artery may be tortuous as it leaves the anatomical snuffbox to enter the wrist. A small skin incision may be required prior to introducing the sheath. Once the sheath is inserted over the wire, the dilator and wire can be removed in the usual fashion ( Fig. 2 .B ). Should there be any resistance in passing the wire further in the forearm, wire advancement should be stopped, and further imaging with fluoroscopy should be done, and angiography can be done with a partially inserted radial sheath before full advancement.
A spasmolytic cocktail can be administered, blood pressure permitting (200 μg of Nitroglycerin and 2.5 mg of Verapamil). The arm is then moved across the patient’s body and with the patient’s left palm on the right groin ( Fig. 3 .B ). The wrist restrain may be tied across the body to the right side of the catheterization table to help stabilize the patient’s arm comfortably. The operator then takes the usual position during cardiac catheterization. Heparin (5000 IU) should be administered to reduce the incidence of radial artery occlusion (RAO) [ ].
The procedure is then continued in the usual fashion. Should there be difficulty in passing the 0.035 wire on which the catheter runs, at the elbow, a different wire can be used, as a soft tip guidewire (e.g. Versicore) or a hydrophilic guidewire (e.g. Glidewire), with extreme care. Should there be difficulty be encountered in advancing the wire, angiography can be done to evaluate for radial artery loops and anatomic variables. A long exchange length 0.035 J tip wire can be used for catheter exchanges.
2.3
Hemostasis
After the procedure is completed, the sheath is flushed, and blood pressure permitting, extra vasodilators may be given, to reduce the discomfort on sheath removal, should there be any and to reduce the incidence of radial artery occlusion (RAO) [ ]. The sheath is then retrieved partially, with a radial band then applied at the site ( Fig. 5 .B). A larger sized radial band is used at times due to the larger girth of the hand at the anatomic snuff box. Patent hemostasis is the goal, to prevent RAO [ ]. Another device that can be used for hemostasis is a band with air bladder (SafeGuard), as proposed by Kiemneij, which does not need to be around the whole hand. The band is then removed in 2–3 h following the usual radial band removal protocol. The arteriotomy site is then covered with a small gauze covered by clear dressing ( Fig. 6 ). Prior to discharge, distal radial pulses in the wrist and at the arteriotomy site should be palpated.
2.4
Experience
As an experienced radial center, and a “radial ready” cardiac catheterization lab, we decided to attempt this innovative arterial access. We sought to evaluate the feasibility and success of completing procedures from the anatomic snuff box. Most importantly, patients’ feedback on comfort was imperative in deciding on continuing to use such access. We have attempted 22 cases, with 100% success rate in obtaining access as well as cannulating the artery and completing the procedure without converting to right radial or femoral with 7 procedures proceeding to percutaneous interventions. The first 2 cases, were done, using a 5 FR radial sheath and standard 5 FR Judkins catheters, with excellent coronary cannulation, with no additional catheters needed. We used ultrasound to confirm adequate radial artery sizing, despite palpating a sizable radial artery in the anatomical snuff box. The other diagnostic cases were completed successfully using 6 FR radial sheaths and standard 5 FR Judkins diagnostic catheters.
As for the PCI cases, one case was a multivessel PCI of the obtuse marginal artery branch as well as the ramus artery ( Fig. 4 .C ). This was a complex case requiring additional equipment including a guide extension cathter to deliver equipment in tortuous arteries. The guide support was excellent, coming in from the left radial artery. The case being long, the patient remained comfortable during the case. Post intervention hemostasis of the arteriotomy site was achieved successfully by a conventional radial band and was later covered with a clear dressing (See Fig. 7 .)
