Year : 2012  |  Volume : 15  |  Issue : 4  |  Page : 315--317

Transradial approach to interventional cardiology: Lessons for the anesthesiologist

Satyen Parida, Ramaiah Mahadeva Mohan Kumar, Pankaj Kundra 
 Department of Anesthesiology and Critical Care, JIPMER, Pondicherry, India

Correspondence Address:
Satyen Parida
Qr. No. D(II)18, JIPMER Campus, Dhanvantari Nagar, Pondicherry - 605 006

How to cite this article:
Parida S, Mohan Kumar RM, Kundra P. Transradial approach to interventional cardiology: Lessons for the anesthesiologist.Ann Card Anaesth 2012;15:315-317

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Parida S, Mohan Kumar RM, Kundra P. Transradial approach to interventional cardiology: Lessons for the anesthesiologist. Ann Card Anaesth [serial online] 2012 [cited 2021 Feb 27 ];15:315-317
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Full Text

The transradial approach (TRA) for coronary angiography was initiated by Dr. Lucein Campeau. [1] Later, Dr. Ferdinand Kiememeij developed tools necessary to extend the use of the radial artery (RA) to percutaneous coronary intervention (PCI). [2],[3] A meta analysis by Bertrand et al, comparing TRA and transfemoral approaches (TFA) for PCIs showed that TRA is associated with substantially less risks of bleeding and transfusions. [4] Another metaanalysis by Vorobcsuk et al. comparing TRA and trans femoral PCI in acute myocardial infarction also concluded that transradial PCI reduces the risk of peri-procedural major bleeding and major adverse events in the ST-Elevated Myocardial Infarction (STEMI) setting. [5] The TRA also finds favour among patients because they experience less discomfort, get mobilized earlier and have a better quality of life as compared to a femoral approach. [6] The RA is quite superficial, easily accessible and compressible, and has no major nerves or veins in its vicinity ensuring less risk of neuropathies, arterio-venous fistulas and major vascular complications. With technical enhancements, improved devices and greater clinician experience, the TRA has the potential for becoming the default vascular access route for diagnostic coronary procedures, elective angioplasties, primary PCIs in acute MI and in complex lesion PCI including chronic total occlusion (CTO) and bifurcating lesions. [7] In such a case, guidelines related to PCIs would require to be updated and global practice altered. The TRA for PCI has made rapid strides in the last 10-12 years. Despite a slight, but significant, increase in failure rate, compared to the femoral approach, [8],[9] the success rates of TRA are still of the order of 95% making it the preferred access site in patients with aorto-iliac disease. The incidence of bleeding complications with the TFA are around 3%. An occasional patient could end up with retroperitoneal bleeding, and the incidence of blood transfusions following TFA is around 1%. Painful hematomas, arterio-venous (AV) fistulas or pseudoaneurysms could also develop; however, these complications are extremely rare with TRA.

With a steady 25-30% rise in the number of coronary interventions in India every year, [10] the potential economic considerations of diagnostic and interventional access is huge. The commercial impact of such access could also extend to invasive radiology. The advantages of TRA stem from potentially lower direct costs, patient preference, fewer vascular complications and their subsequent costs, as well as earlier mobilization with decreased hospital stay. The use of TRA by the cardiologist has led to the RA being studied in great detail both under fluoroscopy and by ultrasonography including intravascular ultrasonography (IVUS). High origin of the RA, implying origin from the brachial artery above the level of the antecubital fossa or even from the axillary artery has been described quite frequently. [11] Origin of the RA from the medial and ulnar artery from the lateral side of the brachial artery have been reported, albeit rarely, as also, absence of RA with the anterior interosseous artery taking over its supply. Duplication of the RA in the forearm have also been infrequently reported. [11] The RA crossing over the brachial artery proceeding to the forearm in front of the bicipital aponeurosis or passing deep to the tendon of the biceps have been described. Tortuous radial and brachial arteries posing challenges for cannulation have been reported quite frequently. [11] Similarly, a superficial RA crossing into the anatomical snuffbox could also be encountered.

Ultrasonic quizzing of the RA, including IVUS following RA catheterization has provided interesting insights into how the invasive procedure could affect the artery. Indwelling RA catheters induce local injury. Even 6 hours of cannulation has been shown to induce arterial wall scarring. Significant long-term structural changes have been reported after TRA for cardiac catheterization procedures, [12] including marked decrease in RA diameter, [13] stenosis or even total occlusion. [14],[15] Incidence of RA occlusions following coronary angioplasties, assessed 1 month after the procedure, has been found to be 2.8%. The TRA has its own share of complications, which are minor and localized if recognized and dealt with early. These include post-procedural RA thrombosis, non occlusive RA injury, forearm hematoma, RA eversion or rupture, axillary, infraclavicular or even mediastinal hematomas, late rebleeding, pseudoaneurysms, arterio-venous fistula, causalgia, residual pain and chronic regional pain syndrome have been described at the whole arm level.

Ghuran et al, [16] stated that using Modified Allen's Test when the RA is well felt is not necessary; the observation is based on their series of 630 patients who underwent 662 transradial coronary interventions without reporting any ischemic events, despite not employing the test for any of them. Furthermore, ischemia of the hand had developed after radial cannulation, even when the Modified Allen's Test was normal prior to intervention. A normal Modified Allen's Test seems good enough to screen patients for RA harvest for coronary artery bypass grafting (CABG). The accuracy of the Modified Allen's Test may be improved by employing pulse oximetry and plethysmography. Barbeau [17] studied 1010 consecutive patients presenting for transradial catheterization, they noted that 80% of the abnormal Allen's test group had satisfactory plethysmography and pulse oximetry responses to RA compression. This decreased the potential 'RA rejection' rate from 6.4% based on the Allen's test to 1.5%.

Radial Artery Spasm Radial artery spasm is common during attempts at cannulation and apart from causing pain and discomfort to the patient, also hamper smooth performance of the procedure. Temporary spasm occur in up to 57% of radial arteries immediately after cannula insertion. [18] While the long-term clinical significance of RA spasm is not clear, there is some suggestion that a higher incidence of persistent RA occlusion might occur in patients who develop vasospasm during the cannulation. [19] RA spasm could be an important cause of failure of the TRA in the catheterization lab and failure of cannulation or damping of the arterial trace in the operating theatre. Vasospasm after an initial unsuccessful cannulation attempt could be reversed by subcutaneous nitroglycerine, infiltrated alone, or in combination with lignocaine. In this regard, we have adopted our cardiologists' practice of adding 0.5 mg of nitroglycerine to 5 mL of 2% lidocaine in cases where multiple attempts at RA cannulation were required. Intra-arterial cocktails of verapamil (5 mg) and nitroglycerine (200 μg) in 10 mL of normal saline have also been used to overcome vasospasm during cardiac catheterization. Other pharmacological agents such as nicorandil (4 mg) or magnesium sulfate (150 mg) could be used instead. Hydrophilic coating of introducer sheaths [19] and nitric oxide-coated sheaths [20] have also been reported to reduce incidence of vasospastic and occlusive sequelae and could have implications for design of arterial cannulas.

While RA catheterization provides an attractive approach to the coronaries, it does complicate issues for the anesthesiologist when the patient presents for a CABG following an angiography. The right RA is generally preferred by the cardiologist, because access through the left RA requires marked adduction of the arm to retain a routine laboratory setup with positioning of the cardiologist on the patient's right side. Furthermore, cardiac surgeons favor harvesting the RA conduit for CABG from the patient's non dominant hand, which most commonly is the left. Additionally, catheterization is associated with intimal thickening and endothelial dysfunction, [21] making these arteries, less than ideal as conduits for CABG. A retrospective study has shown a reduced early graft patency (77% versus 98%, P = 0.017) in patients who had experienced a previous radial procedure before RA grafting but without early clinical impact. [21] This leaves the anesthesiologist with the options of either using the same artery that the cardiologist had cannulated, for hemodynamic monitoring, which could be technically daunting, or opt for an alternate site for cannulation, such as the femoral artery. If the former is opted for, aids to RA cannulation such as the guide wire-assisted technique, the pressure curve directed technique, ultrasound or Doppler guidance may have to be explored by the anesthesiologist. Other modified techniques such as cannulating the artery in the dorsum of the hand, where it emerges from the anatomical snuffbox, accessing the artery at more proximal locations under ultrasound imaging and antegrade RA cannulation after the cut down approach have also been described. The last technique actually measures the pressure in the ulnar artery through the palmar arch. Such antegrade arterial cannulation can be used when radial arteries are obstructed and retrograde blood flow is still observed during failed cut down attempts at standard retrograde arterial cannulation. The observed blood flow would be from the ulnar artery via patent palmar arches.


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