Case Files by Dr. George

Radial and Ulnar Artery Occlusion Following Transradial and Transulnar Coronary Intervention Requiring Endovascular Revascularization

Mohammad N. Zabad, MD, Sean Janzer, MD, and Jon C. George, MD

Division of Cardiology, Interventional Cardiology and Endovascular Medicine,

Einstein Medical Center, Philadelphia, Pennsylvania

Mohammad N. Zabad, MD, Sean Janzer, MD, and Jon C. George, MD

Division of Cardiology, Interventional Cardiology and Endovascular Medicine,

Einstein Medical Center, Philadelphia, Pennsylvania

Abstract

Vascular complication at the site of catheter insertion is the most common complication following cardiac catheterization. Use of radial artery access has been shown to decrease frequency of vascular complications; however, arterial thrombosis and occlusion persist as a challenge with repeat procedures. Dual blood supply of the hand minimizes the clinical relevance of a vascular complication in the majority of cases. However, in the case presented herein, we discuss a patient who presented with right hand weakness and paresthesia following multiple previous coronary interventions using radial and ulnar arteries. She was found to have occlusion of both arteries, requiring intervention.

Case Report

A 40-year-old female presented with right hand paresthesia and weakness 48 hours post discharge following a diagnostic left heart catheterization and coronary angiography via a right ulnar artery approach. The patient had a history of extensive coronary artery disease in the setting of multiple cardiovascular risk factors including hypertension, uncontrolled type II diabetes mellitus, hyperlipidemia, ongoing tobacco use, positive family history for coronary artery disease, and noncompliance with a medical regimen comprised of dual antiplatelet therapy and antianginal medications. She underwent multiple coronary interventions with drug-eluting stents for multivessel disease, including:

  • Ostial left anterior descending (LAD) coronary artery stenting two years prior (right radial artery access);
  • Left main to left circumflex stent 9 months prior (right femoral artery access);
  • Proximal right coronary artery (RCA) stent 3 months prior (right ulnar artery access).

Her most recent presentation was 2 days ago, with chest pain and a mildly elevated troponin of 0.07 after she stopped taking all her medications for two months. She underwent diagnostic coronary angiography (via right ulnar access) that revealed an 80% in-stent restenosis of the proximal LAD stent, for which she was referred to cardiothoracic surgery with a plan to arrange for outpatient coronary artery bypass grafting (CABG). However, she presented 48 hours later with right arm numbness and tingling, mostly involving her thumb and index finger, along with weakness described as difficulty holding a pen without restriction of gross motor function. She stated that symptoms started and persisted following her most recent catheterization procedure.

On physical exam, the right brachial artery was palpable with +2 pulses, but weak on right radial and ulnar sites, with faint Doppler signals. Neurological exam revealed decreased sensation in the first 4 digits, with 3/5 strength on right hand grip compared to 5/5 on the left. Her right hand felt cooler to touch compared to the left, with no pallor or cyanosis, and good capillary refill. Social history was notable for active tobacco use (1 pack per day for >20 years), but no alcohol or drug abuse. Labs were notable for elevated hemoglobin A1C of 10.3, and mild microcytic anemia with hemoglobin of 11.4 and mean corpuscular volume (MCV) of 76.

Imaging with Doppler arterial ultrasound of the right upper extremity revealed complete thrombosis of the right radial artery in the mid to distal forearm, with distal reconstitution and high-grade narrowing of the ulnar artery at the wrist from acute thrombus but also with distal reconstitution.

During hospitalization, the patient was started on intravenous heparin and brought to the catheterization laboratory for peripheral angiography of her right upper extremity. Access was obtained in the right common femoral artery. Angiography of the right brachial artery with runoff revealed a right ulnar artery occlusion with reconstitution of the superficial and deep palmar arches and a concomitant right radial artery occlusion (Figure 1). A support catheter and wire was advanced through the ulnar artery to traverse the occlusion into the distal palmar arch. Selective angiography through the catheter confirmed intraluminal position and filling of the palmar arch (Figure 2). Laser atherectomy and balloon angioplasty of the right ulnar artery was performed with significant improvement in flow (Figure 3). To cross the radial artery occlusion, a retrograde approach through the ulnar artery across the deep palmar arch into the cap of the occlusion of the right radial artery was used (Figure 4). Balloon angioplasty via an antegrade approach was performed with good expansion and excellent angiographic results, which demonstrated brisk flow and filling of the entire palmar arch (Figure 5). The patient was subsequently discharged on dual antiplatelet therapy and one week of rivaroxaban with outpatient follow-up in the cardiology and cardiothoracic surgery clinic.

Discussion

The transradial approach to cardiac catheterization has many advantages and is increasingly being used for both diagnostic coronary angiography and percutaneous coronary intervention (PCI).1 Fewer vascular access complications, reduced major bleeding, improved patient satisfaction, earlier ambulation, and decreased length of stay favor a radial approach compared to a femoral approach.2-5 Although rarely utilized, the ulnar artery might be a feasible access site for catheterization. Data suggest similar outcomes, and no difference in procedure and fluoroscopy times compared to radial access when performed by skilled operators.6,7

Radial artery thrombosis is a known complication of transradial catheterization that can lead to permanent occlusion of the radial artery.8 Variable rates of this complication have been reported in different studies and it is estimated to occur in 5-19% of cases.9,10 Because of the dual blood supply to the hand, palmar perfusion is usually maintained by increasing flow in the ulnar circulation.11,12 Thus, radial artery occlusion is usually a clinically silent event and often underdiagnosed.13 However, when radial artery occlusion is suspected, accessing the ulnar artery carries an increased risk for complications, including hand ischemia. The pathophysiology of this process is thought to be due to local endothelial injury resulting from sheath and catheter insertion, and subsequent thrombosis with cessation of blood flow.14 One study found that 67% of radial arteries had intimal tears immediately following transradial PCI.1 Other studies have shown smaller lumen diameter and area with repeat use of radial artery for access as compared to the index access.15 Radial artery occlusion appears to occur early after transradial catheterization, and roughly 50% of patients have spontaneous recanalization of the artery within 1–3 months.14 A study of 162 patients who had an ultrasound following transradial catheterization on day 2 and 3 months showed that 9% of patients had no flow in the radial artery on an initial ultrasound.16 However, 60% of those patients were found to have recanalization of the artery at 3 months. A larger study of 560 patients demonstrated similar findings, with a 5% rate of radial artery occlusions noted on hospital discharge and spontaneous recanalization noted in 47% of occluded radial artery patients at 1-month follow-up.17 Rates of radial artery occlusion appear to be higher with prolonged cannulation time, although this can be reduced by use of anticoagulation intra procedure.7 Repetitive cannulations of the same artery also appear to be associated with higher rates of radial artery occlusion. Progressive narrowing of the artery with each procedure is believed to be the etiology behind a difficulty in cannulation on subsequent procedures.13 Other independent factors predicting radial artery occlusion include sheath diameter, size of the radial artery, diagnostic vs interventional procedure, preexisting peripheral vascular disease and diabetes, and finally, post-procedure compression time.7-13

Radial artery occlusion is not always benign. Hand ischemia and other complications have been reported. Moreover, once the artery is occluded, it cannot be used as an access site for future procedures or as an arterial conduit for bypass surgery. Furthermore, radial artery occlusion also limits the use of the ipsilateral ulnar artery, since the use of that artery would further increase the risk of hand ischemia.

Due to the dual blood supply of the hand, with its extensive collateral flow between the radial and ulnar arteries, symptomatic radial occlusion requiring medical attention appears to be extremely rare. In one study, hand ischemia occurred in only 0.2% of patients5, while another study reported a 2% incidence of an absent radial pulse early after transradial catheterization while 9% had undetectable radial flow by color Doppler17. Most cases of radial occlusion were incidental findings during follow-up visits or repeat procedures, without clinical sequelae. On exam, patients may have a weak or absent radial pulse with compromised flow, while other patients with a palpable pulse may have complete occlusion with retrograde filling of the radial artery through collaterals. Thus, the diagnosis of radial artery occlusion should not depend on exam alone and should be confirmed by other diagnostic imaging studies such as duplex ultrasonography.1

Several measures can be taken to help minimize the risk of radial artery occlusion. Use of a reliable and reproducible method of assessing the collateral circulation prior to radial artery cannulation, such as the Allen and Barbeau tests, may be beneficial.11,12-19 However, the most accurate way of assessing dual hand circulation is with duplex ultrasonography, although this is not routinely used in practice.

Conclusion

Radial artery occlusion is a relatively common though rarely clinically significant event in patients undergoing transradial catheterization. The primary mechanism appears to be arterial thrombosis, superimposed on a background of vascular injury from sheath insertion. Strategies for minimizing radial artery occlusion include use of smaller sheaths, non-occlusive hemostasis, and appropriate anticoagulation. In the case presented herein, the patient experienced sensory and motor deficits in her right hand subsequent to both radial and ulnar artery access for cardiac catheterization. She was found to have acute thrombosis of her distal right ulnar artery along with chronic occlusion of her distal right radial artery, and underwent endovascular intervention resulting in the successful reperfusion of both arteries. 

The authors can be contacted via Jon C. George, MD, at jcgeorgemd@gmail.com.

References
  1. Kotowycz MA, Dzavík V. Radial artery patency after transradial catheterization. Circ Cardiovasc Interv. 2012 Feb 1; 5(1): 127-133.
  2. Jolly SS, Yusuf S, Cairns J, et al; RIVAL trial group. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011 Apr 23; 377(9775): 1409-1420.
  3. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol. 2012 Dec 18; 60(24): 2481-2489.
  4. Bernat I, Horak D, Stasek J, et al. ST-segment elevation myocardial infarction treated by radial or femoral approach in a multicenter randomized clinical trial: the STEMI-RADIAL trial. J Am Coll Cardiol. 2014 Mar 18; 63(10): 964-972.
  5. Ferrante G, Rao SV, Jüni P, et al. Radial versus femoral access for coronary interventions across the entire spectrum of patients with coronary artery disease: a meta-analysis of randomized trials. JACC Cardiovasc Interv. 2016 Jul 25; 9(14): 1419-1434.
  6. Gokhroo R, Bisht D, Padmanabhan D, et al. Feasibility of ulnar artery for cardiac catheterization: AJmer ULnar ARtery (AJULAR) catheterization study. Catheter Cardiovasc Interv. 2015 Jul; 86(1): 42-48.
  7. Hahalis G, Aznaouridis K, Tsigkas G, et al. Radial artery and ulnar artery occlusions following coronary procedures and the impact of anticoagulation: ARTEMIS (Radial and Ulnar ARTEry Occlusion Meta-AnalysIS) systematic review and meta-analysis. J Am Heart Assoc. 2017 Aug 23; 6(8). pii: e005430.
  8. Pancholy S, Coppola J, Patel T, et al. 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 Sep 1; 72(3): 335-340.
  9. Cubero JM, Lombardo J, Pedrosa C, et al. Radial compression guided by mean artery pressure versus standard compression with a pneumatic device (RACOMAP). Catheter Cardiovasc Interv. 2009 Mar 1; 73(4): 467-472.
  10. Muller DW, Shamir KJ, Ellis SG, Topol EJ. Peripheral vascular complications after conventional and complex percutaneous coronary interventional procedures. Am J Cardiol. 1992 Jan 1; 69(1): 63-68.
  11. Benit E, Vranckx P, Jaspers L, et al. Frequency of a positive modified Allen’s test in 1,000 consecutive patients undergoing cardiac catheterization. Cathet Cardiovasc Diagn. 1996 Aug; 38(4): 352-354.
  12. Greenwood MJ, Della-Siega AJ, Fretz EB, et al. Vascular communications of the hand in patients being considered for transradial coronary angiography: is the Allen’s test accurate? J Am Coll Cardiol. 2005 Dec 6; 46(11): 2013-2017.
  13. Sinha SK, Jha MJ, Mishra V, et al. Radial artery occlusion - incidence, predictors and long-term outcome after TRAnsradial Catheterization: clinico-Doppler ultrasound-based study (RAIL-TRAC study). Acta Cardiol. 2017 Jun; 72(3): 318-327.
  14. Rademakers LM, Laarman GJ. Critical hand ischaemia after transradial cardiac catheterisation: an uncommon complication of a common procedure. Neth Heart J. 2012; 20: 372-375.
  15. Costa F, van Leeuwen MA, Daemen J, et al. The Rotterdam radial access research: ultrasound-based radial artery evaluation for diagnostic and therapeutic coronary procedures. Circ Cardiovasc Interv. 2016 Feb; 9(2): e003129.
  16. Pancholy SB. Comparison of the effect of intra-arterial versus intravenous heparin on radial artery occlusion after transradial catheterization. Am J Cardiol. 2009; 104: 1083-1085.
  17. Stella PR, Kiemeneij F, Laarman GJ, et al. Incidence and outcome of radial artery occlusion following transradial artery coronary angioplasty. Cathet Cardiovasc Diagn. 1997; 40: 156-158.
  18. Nagai S, Abe S, Sato T, et al. Ultrasonic assessment of vascular complications in coronary angiography and angioplasty after transradial approach. Am J Cardiol. 1999; 83: 180-186.
  19. Barbeau GR, Arsenault F, Dugas L, et al. Evaluation of the ulnopalmar arterial arches with pulse oximetry and plethysmography: comparison with the Allen’s test in 1010 patients. Am Heart J. 2004; 147: 489-493.