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Anterograde recanalisation of the radial artery followed by transradial angioplasty
Cardiovascular Revascularization Medicine 11 (2010) 266.e1 – 266.e4
Anterograde recanalisation of the radial artery followed by transradial angioplasty Zoltán Ruzsa a,⁎, László Pintér a , Ralf Kolvenbach b b
a Department of Radiology, Kálmán Pándy Hospital, Gyula, Hungary Department of Vascular Surgery, Augusta Hospital, Düsseldorf, Germany
Received 2 November 2009; received in revised form 8 January 2010; accepted 12 January 2010
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. © 2010 Elsevier Inc. All rights reserved.
Keywords:
Radial artery occlusion; Transradial angioplasty
1. Introduction The conventional way to access the coronary [1–3], carotid [4], and renal arteries [5] 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 [1–5]. 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 [6] and it does not have a clinical consequence if the hand collateral flow is good. Critical hand ischemia is an infrequent entity [7,8] and it is usually approached with open surgery [8], albeit few data are
⁎ Corresponding author. Department of Radiology, Kálmán Pándy Hospital, 5700 Gyula, Semmelweis utca 1, Hungary. E-mail address: [email protected] (Z. Ruzsa). 1553-8389/10/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.carrev.2010.01.007
available on treating this condition with balloon angioplasty (BA) [9,10,15]. 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. 1B). The distal radial artery was filled from the palmar arch, but the collateral was very small (Fig. 1A). 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. 2A). After a failed
266.e2
Z. Ruzsa et al. / Cardiovascular Revascularization Medicine 11 (2010) 266.e1–266.e4
occlusion. SIA has been around for 18 years but has become popular only in the last 2 to 3 years. After its initial successes in the femoropopliteal region, the technique has been extended to the infrapopliteal region. Transradial access for percutaneous intervention is widely used in interventional practice with high success and low complication rate [1–6]. Frequency of radial artery occlusion is relatively high during intervention procedures, but in most of the cases it has no clinical importance [6] if a double blood supply through the ulnar arch is present. Possible mechanisms involved in the occlusion of the radial artery can be thrombus formation due to prolonged cannulation of the radial artery, occlusive compression with pressure bandage [12], and iatrogenic radial artery dissection. Intraarterial administration of sodium heparin [11], short cannulation, immediate sheath removal, and noncompressive pressure bandage [12] can prevent radial artery
Fig. 1. (A, B) Right brachial angiography shows radial artery occlusion without sufficient collateral flow from the ulnar artery.
balloon advancement, the guidewire was advanced with a loop (Fig. 2B) 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. 3B). First, balloon dilatation was performed with a 3×40-mm Savvy balloon (Cordis) (Fig. 4A) 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. 4B). The final flow was patent and no flow-limiting dissection was visible (Fig. 5A and B). The patient was released from the hospital 3 days after the procedure and 2 months later he is asymptomatic. 3. Discussion In the present article, we report on a case with successful subintimal angioplasty (SIA) [13] of long radial artery
Fig. 2. (A) Radial artery recanalisation with balloon support. (B) Subintimal loop formation.
Z. Ruzsa et al. / Cardiovascular Revascularization Medicine 11 (2010) 266.e1–266.e4
266.e3
recently been proposed as an alternative approach in the therapy [9,10]. Pancholy [15] described the retrograde recanalisation technique in 14 patients. He has found that radial artery occlusion is very soft after the procedure due to thrombotic occlusion and the vessel can be recanalised with good angiographic results with direct radial artery puncture, using the Radifocus 0.021 guidewire (Terumo Corp, Tokyo, Japan) as an initial wire. Luminal recanalisation might be the standard in short occlusions [9,10]; however, in long occlusions subintimal recanalisation might be a method of choice. 4. Limitation The limitation of this technique is the lack of evidence of sustained patency of the recanalised segment.
Fig. 3. (A) Reentry in the distal segment of the radial artery. (B) Distal selective angiography confirmed good intraluminal position of the wire.
occlusion. The vascular anatomy of the hand is very complex and highly variable. At the level of the wrist, radial and ulnar arteries divide into two branches that join to form the deep and superficial palmar arches. If the palmar arch is developed, hand circulation is very resilient and the sequela of hand ischemia is at least a rare phenomenon. Some patients have incomplete palmar arches and might not have adequate communications between the ulnar and radial arteries [14]. In our case, the communication between the superficial and deep palmar arch was inadequate, despite the developed interosseous artery. In case of symptomatic radial artery occlusion, conservative and invasive treatment may be considered. The goal of conservative treatment in these patients is to improve quality of life, to prevent tissue necrosis, and to diminish hand pain. Revascularization has almost always been undertaken with an open surgical strategy [7,8]. However, the percutaneous intervention has
Fig. 4. (A) Balloon dilatation in the distal segment with a 3×40-mm Savvy balloon. (B) Balloon dilatation of the whole occluded segment with an Amphirion Deep 3-2.5×210-mm balloon.
266.e4
Z. Ruzsa et al. / Cardiovascular Revascularization Medicine 11 (2010) 266.e1–266.e4
References
Fig. 5. Final angiography showed good flow with typical subintimal pattern.
5. Conclusion SIA is an effective percutaneous technique for the revascularization of patients with upper extremity ischemia due to arterial occlusions involving the radial artery. However, further randomized studies are needed to evaluate the effectiveness of percutaneous intervention in the subgroup of patients with radial occlusion following coronary angioplasty.
[1] Kiemeneij F, Laarman GJ, de Melker E. Transradial artery coronary angioplasty. Am Heart J 1995;129:1–7. [2] Cantor WJ, Puley G, Natarajan MK, Dzavik V, Madan M, Fry A, Kim HH, Velianou JL, Pirani N, Strauss BH, Chisholm RJ. Radial versus femoral access for emergent percutaneous coronary intervention with adjunct glycoprotein IIb/IIIa inhibition in acute myocardial infarction— the RADIAL-AMI pilot randomized trial. Am Heart J 2005;150:543–9. [3] Ruzsa Z, Ungi I, Horváth T, Sepp R, Zimmermann Z, Thury A, Jambrik Z, Sasi V, Tóth G, Forster T, Nemes A. Five-year experience with transradial coronary angioplasty in ST-segment-elevation myocardial infarction. Cardiovasc Revasc Med 2009;10(2):73–9. [4] Pinter L, Cagiannos C, Ruzsa Z, Bakoyiannis C, Kolvenbach R. Report on initial experience with transradial access for carotid artery stenting. J Vasc Surg 2007;45(6):1136–41. [5] Galli M, Tarantino F, Mameli S, Zerboni S, Butti E, Sagone A, Passerini F, Cappucci A, Ferrari G. Transradial approach for renal percutaneous transluminal angioplasty and stenting: a feasibility pilot study. J Invasive Cardiol 2002;14(7):386–90. [6] Stella PR, Odekerken D, Kiemeneij F, Laarman GJ, Slagboom T, van der Wieken R. Incidence and outcome of radial artery occlusion following transradial coronary angioplasty. Cathet Cardiovasc Diagn 1997;40:156–8. [7] Chang BB, Roddy SP, Darling RC, Maharaj D, Paty PS, Kreienberg PB, et al. Upper extremity bypass grafting for limb salvage in end-stage renal failure. J Vasc Surg 2003;38:1313–5. [8] Namdari S, Weiss AP, Carney WI. Palmar bypass for digital ischemia. J Hand Surg [Am] 2007;32:1251–8. [9] Ferraresi R, Ferlini M, Sozzi F, Pomidossi G, Caravaggi C, Danzi GB. Images in cardiovascular medicine. Percutaneous transluminal angioplasty for treatment of critical hand ischemia. Circulation 2006;114: e232e4. [10] Dineen S, Smith S, Arko FR. Successful percutaneous angioplasty and stenting of the radial artery in a patient with chronic upper extremity ischemia and digital gangrene. J Endovasc Ther 2007;14:426–8. [11] Lefevre T, Thebault B, Spaulding C, Funck F, Chaveau M, Guillard N, Chalet Y, Bellorini M, Guerin F. Radial artery patency after percutaneous left radial artery approach for coronary angiography. The role of heparin. Eur Heart J 1995;16:293. [12] Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of radial artery occlusion–patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv 2008;72(3):335–40. [13] Scott EC, Biuckians A, Light RE, Burgess J, Meier III GH, Panneton JM. Subintimal angioplasty: our experience in the treatment of 506 infrainguinal arterial occlusions. J Vasc Surg 2008;48(4):878–84. [14] Greenwood MJ, Della-Siega AJ, Fretz EB, Kinloch D, Klinke P, Mildenberger R, Williams MB, Hilton D. Vascular communications of the hand in patients being considered for transradial coronary angiography: is the Allen's test accurate? J Am Coll Cardiol 2005;46 (11):2013–7. [15] Pancholy SB. Transradial access in an occluded radial artery: new technique. J Invasive Cardiol 2007;19(12):541–4.
Anterograde recanalisation of the radial artery followed by transradial angioplasty Zoltán Ruzsa a,⁎, László Pintér a , Ralf Kolvenbach b b
a Department of Radiology, Kálmán Pándy Hospital, Gyula, Hungary Department of Vascular Surgery, Augusta Hospital, Düsseldorf, Germany
Received 2 November 2009; received in revised form 8 January 2010; accepted 12 January 2010
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. © 2010 Elsevier Inc. All rights reserved.
Keywords:
Radial artery occlusion; Transradial angioplasty
1. Introduction The conventional way to access the coronary [1–3], carotid [4], and renal arteries [5] 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 [1–5]. 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 [6] and it does not have a clinical consequence if the hand collateral flow is good. Critical hand ischemia is an infrequent entity [7,8] and it is usually approached with open surgery [8], albeit few data are
⁎ Corresponding author. Department of Radiology, Kálmán Pándy Hospital, 5700 Gyula, Semmelweis utca 1, Hungary. E-mail address: [email protected] (Z. Ruzsa). 1553-8389/10/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.carrev.2010.01.007
available on treating this condition with balloon angioplasty (BA) [9,10,15]. 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. 1B). The distal radial artery was filled from the palmar arch, but the collateral was very small (Fig. 1A). 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. 2A). After a failed
266.e2
Z. Ruzsa et al. / Cardiovascular Revascularization Medicine 11 (2010) 266.e1–266.e4
occlusion. SIA has been around for 18 years but has become popular only in the last 2 to 3 years. After its initial successes in the femoropopliteal region, the technique has been extended to the infrapopliteal region. Transradial access for percutaneous intervention is widely used in interventional practice with high success and low complication rate [1–6]. Frequency of radial artery occlusion is relatively high during intervention procedures, but in most of the cases it has no clinical importance [6] if a double blood supply through the ulnar arch is present. Possible mechanisms involved in the occlusion of the radial artery can be thrombus formation due to prolonged cannulation of the radial artery, occlusive compression with pressure bandage [12], and iatrogenic radial artery dissection. Intraarterial administration of sodium heparin [11], short cannulation, immediate sheath removal, and noncompressive pressure bandage [12] can prevent radial artery
Fig. 1. (A, B) Right brachial angiography shows radial artery occlusion without sufficient collateral flow from the ulnar artery.
balloon advancement, the guidewire was advanced with a loop (Fig. 2B) 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. 3B). First, balloon dilatation was performed with a 3×40-mm Savvy balloon (Cordis) (Fig. 4A) 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. 4B). The final flow was patent and no flow-limiting dissection was visible (Fig. 5A and B). The patient was released from the hospital 3 days after the procedure and 2 months later he is asymptomatic. 3. Discussion In the present article, we report on a case with successful subintimal angioplasty (SIA) [13] of long radial artery
Fig. 2. (A) Radial artery recanalisation with balloon support. (B) Subintimal loop formation.
Z. Ruzsa et al. / Cardiovascular Revascularization Medicine 11 (2010) 266.e1–266.e4
266.e3
recently been proposed as an alternative approach in the therapy [9,10]. Pancholy [15] described the retrograde recanalisation technique in 14 patients. He has found that radial artery occlusion is very soft after the procedure due to thrombotic occlusion and the vessel can be recanalised with good angiographic results with direct radial artery puncture, using the Radifocus 0.021 guidewire (Terumo Corp, Tokyo, Japan) as an initial wire. Luminal recanalisation might be the standard in short occlusions [9,10]; however, in long occlusions subintimal recanalisation might be a method of choice. 4. Limitation The limitation of this technique is the lack of evidence of sustained patency of the recanalised segment.
Fig. 3. (A) Reentry in the distal segment of the radial artery. (B) Distal selective angiography confirmed good intraluminal position of the wire.
occlusion. The vascular anatomy of the hand is very complex and highly variable. At the level of the wrist, radial and ulnar arteries divide into two branches that join to form the deep and superficial palmar arches. If the palmar arch is developed, hand circulation is very resilient and the sequela of hand ischemia is at least a rare phenomenon. Some patients have incomplete palmar arches and might not have adequate communications between the ulnar and radial arteries [14]. In our case, the communication between the superficial and deep palmar arch was inadequate, despite the developed interosseous artery. In case of symptomatic radial artery occlusion, conservative and invasive treatment may be considered. The goal of conservative treatment in these patients is to improve quality of life, to prevent tissue necrosis, and to diminish hand pain. Revascularization has almost always been undertaken with an open surgical strategy [7,8]. However, the percutaneous intervention has
Fig. 4. (A) Balloon dilatation in the distal segment with a 3×40-mm Savvy balloon. (B) Balloon dilatation of the whole occluded segment with an Amphirion Deep 3-2.5×210-mm balloon.
266.e4
Z. Ruzsa et al. / Cardiovascular Revascularization Medicine 11 (2010) 266.e1–266.e4
References
Fig. 5. Final angiography showed good flow with typical subintimal pattern.
5. Conclusion SIA is an effective percutaneous technique for the revascularization of patients with upper extremity ischemia due to arterial occlusions involving the radial artery. However, further randomized studies are needed to evaluate the effectiveness of percutaneous intervention in the subgroup of patients with radial occlusion following coronary angioplasty.
[1] Kiemeneij F, Laarman GJ, de Melker E. Transradial artery coronary angioplasty. Am Heart J 1995;129:1–7. [2] Cantor WJ, Puley G, Natarajan MK, Dzavik V, Madan M, Fry A, Kim HH, Velianou JL, Pirani N, Strauss BH, Chisholm RJ. Radial versus femoral access for emergent percutaneous coronary intervention with adjunct glycoprotein IIb/IIIa inhibition in acute myocardial infarction— the RADIAL-AMI pilot randomized trial. Am Heart J 2005;150:543–9. [3] Ruzsa Z, Ungi I, Horváth T, Sepp R, Zimmermann Z, Thury A, Jambrik Z, Sasi V, Tóth G, Forster T, Nemes A. Five-year experience with transradial coronary angioplasty in ST-segment-elevation myocardial infarction. Cardiovasc Revasc Med 2009;10(2):73–9. [4] Pinter L, Cagiannos C, Ruzsa Z, Bakoyiannis C, Kolvenbach R. Report on initial experience with transradial access for carotid artery stenting. J Vasc Surg 2007;45(6):1136–41. [5] Galli M, Tarantino F, Mameli S, Zerboni S, Butti E, Sagone A, Passerini F, Cappucci A, Ferrari G. Transradial approach for renal percutaneous transluminal angioplasty and stenting: a feasibility pilot study. J Invasive Cardiol 2002;14(7):386–90. [6] Stella PR, Odekerken D, Kiemeneij F, Laarman GJ, Slagboom T, van der Wieken R. Incidence and outcome of radial artery occlusion following transradial coronary angioplasty. Cathet Cardiovasc Diagn 1997;40:156–8. [7] Chang BB, Roddy SP, Darling RC, Maharaj D, Paty PS, Kreienberg PB, et al. Upper extremity bypass grafting for limb salvage in end-stage renal failure. J Vasc Surg 2003;38:1313–5. [8] Namdari S, Weiss AP, Carney WI. Palmar bypass for digital ischemia. J Hand Surg [Am] 2007;32:1251–8. [9] Ferraresi R, Ferlini M, Sozzi F, Pomidossi G, Caravaggi C, Danzi GB. Images in cardiovascular medicine. Percutaneous transluminal angioplasty for treatment of critical hand ischemia. Circulation 2006;114: e232e4. [10] Dineen S, Smith S, Arko FR. Successful percutaneous angioplasty and stenting of the radial artery in a patient with chronic upper extremity ischemia and digital gangrene. J Endovasc Ther 2007;14:426–8. [11] Lefevre T, Thebault B, Spaulding C, Funck F, Chaveau M, Guillard N, Chalet Y, Bellorini M, Guerin F. Radial artery patency after percutaneous left radial artery approach for coronary angiography. The role of heparin. Eur Heart J 1995;16:293. [12] Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of radial artery occlusion–patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv 2008;72(3):335–40. [13] Scott EC, Biuckians A, Light RE, Burgess J, Meier III GH, Panneton JM. Subintimal angioplasty: our experience in the treatment of 506 infrainguinal arterial occlusions. J Vasc Surg 2008;48(4):878–84. [14] Greenwood MJ, Della-Siega AJ, Fretz EB, Kinloch D, Klinke P, Mildenberger R, Williams MB, Hilton D. Vascular communications of the hand in patients being considered for transradial coronary angiography: is the Allen's test accurate? J Am Coll Cardiol 2005;46 (11):2013–7. [15] Pancholy SB. Transradial access in an occluded radial artery: new technique. J Invasive Cardiol 2007;19(12):541–4.