Preventing Radial Artery Occlusion in Cardiac Catheterization

The risk of radial artery occlusion after transradial access in cardiac catheterization can be minimized via prophylactic ipsilateral ulnar compression, according to research published in JACC: Cardiovascular Interventions.

PROPHET-II (PROPhylactic Hyperfusion Evaluation Trial) investigators sought to evaluate the rate of radial artery occlusion after administering prophylactic ipsilateral ulnar compression in patients undergoing cardiac catheterization.

A total of 3000 patients were randomly assigned to receive either standard patent hemostasis protocol (group 1) or prophylactic ipsilateral ulnar compression plus patent hemostasis (group 2). The researchers measured radial artery patency using plethysmography at the time of device removal, 24 hours after, and 30 days after the procedure.

For group 2 patients, the authors described applying an inflatable band (TR band, Terumo Interventional Systems) at the sheath entry site and then compressing the ipsilateral ulnar artery at the Guyon’s canal. The investigators compressed the nerve by applying a Hemoband (Hemoband Corporation; Portland, Oregon) around 4-inch by 4-inch gauze wrapped around a 1-inch plastic needle cap or the barrel of a 3-mL plastic syringe.

At 30 days, the rate of radial artery occlusion was significantly lower in group 2 compared with group 1 (0.9% vs 3%; P =.0001), as was the rate immediately post-hemostasis (1.5% vs 13.9%; P <.0001) and 24 hours after (4.3% vs 1%; P <.0001). Patent hemostasis was achieved in nearly all of the patients in group 2 (96%) compared with 74% of patients in group 1 (P =.0001).

Female patients, patients with diabetes, older patients, and patients with pain during compression were determined to be univariate predictors of 30-day radial artery occlusion (P <.0001, P <.0001, P <.0001, and P <.021, respectively). Meanwhile, multivariate analysis revealed the following significant predictors: age (odds ratio [OR]: 1.1; 95% confidence interval [CI], 1.03-1.09; P =.0001), female gender (OR: 4.0; 95% CI, 2.3-7.2; P =.0001), history of diabetes (OR: 4.1; 95% CI, 2.2-7.5; P =.0001), prophylactic ulnar compression or randomization to group 2 (OR: 0.3; 95% CI, 0.16-0.57; P =.0001), and pain during compression (OR: 3.9; 95% CI, 1.0-14.9; P =.049).

Of note is the lack of significant difference in ipsilateral ulnar artery wall thickness between group 1 and group 2 patients. However, radial artery wall thickness did increase significantly at 30-day follow-up compared with baseline.

“The physiologic relationship between ulnar compression and radial flow, hence patent hemostasis, and their temporal relationship as well as the previously observed findings of the multivariable analyses suggest that patent hemostasis may be the main mediator variable responsible for the significant preventive effect of prophylactic ulnar compression on 30-day RAO [radial artery occlusion],” the authors wrote.

Prophylactic ipsilateral ulnar artery compression is an effective, safe, and inexpensive method to lower the risk of radial artery occlusion in patients who undergo cardiac catheterization via transradial access, they concluded.

Study Limitations

Because the radial centers used in this study were “dedicated to meticulous radial artery patent hemostasis protocol,” the results will need to be confirmed in other centers with varied levels of expertise.

Findings cannot be applied to patients with Barbeau type D pattern or those without palpable ulnar pulse in the distal forearm because those patients were excluded from the study.

Disclosures: Dr Pancholy has served as a consultant for Terumo Medical Corporation and has reported equity interest in VasoInnovations, Inc.

Reference

Pancholy SB, Bernat I, Bertrand OF, Patel TM. Prevention of radial artery occlusion after transradial catheterization. The PROPHET-II randomized trial. JACC Cardiovasc Interv. 2016;9(19):1992-1999. doi:10.1016/j.jcin.2016.07.020.