However, new data makes us reconsider the use of this practice. These patients were traditionally considered as good candidates for TRA. Positive modified Allen’s test is recorded when the color of the hand is regained within 5–10 seconds, indicating adequate collateral circulation. Traditionally, assessment of dual hand circulation to assess eligibility for transradial access is performed by the modified Allen’s test: while occlusive pressure to both the ulnar and the radial arteries is applied by the examiner’s fingers, the patient clenches their first for about one minute the hand is then relaxed and pressure on the ulnar artery is released. Some patients may experience pain at the site of the occlusion, paresthesias or reduced limb function ( 23). However, cases of hand ischemia after RAO have been described in the setting of inadequate collateral circulation ( 31- 33). Thus, if the radial artery is occluded, blood supply of the hand can be maintained by the ulnar collateral circulation and RAO is a quiescent event. This is due to dual blood supply of the hand and the usually rich network of collateral circulation: the radial and ulnar arteries undergo multiple anastomoses before they are connected in the hand by the superficial and deep palmar arches. RAO is, in the majority of patients, asymptomatic. found a 5.3% rate of RAO at the time of hospital discharge in a study of 563 patients who underwent transradial artery coronary angioplasty ( 20). In most cases RAO occurs promptly after the procedure and up to 50% of patients have spontaneous recanalization of the artery within 1–3 months ( 22, 30). Imaging studies, such as vascular ultrasound ( 27), angiography ( 28), optical coherence tomography ( 24) and histopathological examination of materials aspirated after mechanical recanalization of occluded radial arteries ( 29) support this thrombus formation theory.
Radial artery stenosis has been shown to occur in 31% of patients within 2 days after TRA and in 28% late after the procedure ( 23). In addition, repeated radial artery cannulation can promote intimal hyperplasia and increased intima-media thickness ( 22, 24, 25), resulting in negative remodeling of the arterial wall and further predisposition to RAO ( 26). Endothelial injury of the radial artery and decrease in blood flow after sheath and catheter insertion appear to contribute to thrombus formation and are predisposing factors for RAO ( 18, 19, 23). The most common complication of TRA is RAO, which occurs in about 1–10% of cases ( 19- 22). Table 1 Potential access site complications during percutaneous procedures performed via a transradial approach Potential access site complications during percutaneous procedures performed with a TRA are summarized in Table 1. However, treatment of complications after TRA depends on the experience of the interventional cardiologist performing the procedure. New complications associated with TRA, like forearm pain or upper extremity loss of strength are under further evaluation in order to evaluate their impact on patients function and quality of life ( 18). In the majority of cases performed through TRA, access site complications are predictable and easy to treat ( 17). However, the increasing operators experience on TRA is followed by decreased experience in TFA, leading to more access site complications when this access site is chosen, the so called “Campeau Radial Paradox” ( 16). Furthermore, multiple studies have demonstrated significant benefit with TRA, due to its relatively lower potential for access site bleeding and high patient comfort/satisfaction, while maintaining an overall high procedural success rate ( 7- 15). While the transfemoral approach (TFA) remains the most common method for coronary angiography and interventions, an increasing number of interventional cardiologists are performing percutaneous interventions through the radial artery ( 3- 6). were the first to document coronary angioplasty and stenting via the transradial approach (TRA) in 1993 ( 2). Accepted for publication Jan 20, 2017.įollowing the introduction of transradial coronary angiography by Campeau et al. Keywords: Radial approach radial artery occlusion (RAO) hemostasis
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