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Original research
Reaccessing an occluded radial artery for neuroendovascular procedures: techniques and complication avoidance
  1. Neil Majmundar,
  2. D Andrew Wilkinson,
  3. Joshua S Catapano,
  4. Tyler S Cole,
  5. Jacob F Baranoski,
  6. Andrew F Ducruet,
  7. Felipe C Albuquerque
  1. Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
  1. Correspondence to Dr Felipe C Albuquerque, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ 85013, USA; Felipe.Albuquerque{at}barrowbrainandspine.com

Abstract

Background Radial artery occlusion (RAO) occurs in 1% to 10% of cases following transradial arterial access (TRA) for neuroendovascular procedures. When repeat access is required in patients discovered to have RAO, a transfemoral approach is often used. This study reports experience with repeat TRA procedures at a single center and techniques for reaccessing an occluded radial artery in select patients.

Methods The electronic records of all patients who underwent multiple neuroendovascular procedures with an attempted TRA as the index procedure at a single center from July 2019 through February 2020 were reviewed.

Results There were 656 TRA attempts for diagnostic angiography or intervention from July 2019 through February 2020. A total of 106 patients underwent a repeated attempt at TRA. Techniques for reaccessing an occluded radial artery were implemented halfway through the study period. One hundred patients (94.3%) had a successful second radial catheterization. Six patients required conversion to a transfemoral approach: five for RAO and one for radial branch perforation during the index procedure. After we implemented our techniques for reaccess, four additional patients with RAO successfully underwent TRA. There were no short-term complications, including pain, vessel perforation, forearm hematoma, or hand ischemia, following successful repeat catheterization of a previously occluded radial artery.

Conclusion RAO is not an absolute limitation for attempting TRA in patients undergoing repeat catheterization. Reaccessing the radial artery after occlusion is feasible for repeat neuroendovascular procedures.

  • angiography
  • artery
  • complication
  • intervention
  • technique

Data availability statement

No data are available. There are no additional data to share.

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Introduction

Transradial arterial access (TRA) is a feasible and safe alternative to transfemoral access (TFA) for neuroendovascular procedures.1–5 TRA is increasingly being adopted by neurointerventionalists because of its improved safety profile, decreased costs and procedural times, increased patient comfort, and lower complication rates when compared with TFA.1 6–8

Despite its many advantages, TRA is often converted to TFA in cases of radial artery occlusion (RAO) or severe vasospasm.9 10 RAO most often occurs when catheterization is attempted after previous arterial line placement or previous radial access. RAO has been reported to occur following 1% to 10% of TRA procedures in the interventional cardiology literature.9 11 In many publications, the reported rate of RAO may be lower than the actual rate, as most institutions do not routinely monitor for RAO during long-term follow-up, and RAO is generally asymptomatic because the ulnar artery provides sufficient collaterals to avoid hand ischemia.12 13 Several methods to avoid RAO have been reported in the cardiology literature, including administration of intra-arterial (IA) or intravenous heparin after catheterization, using smaller sheaths when possible, and patent hemostasis with concurrent ulnar artery compression.14–16

RAO may be problematic in cases where repeat radial catheterization is required, as is common with staged embolization, administration of IA verapamil for symptomatic vasospasm, and follow-up diagnostic angiography. In cases in which radial artery access is not possible because of RAO, TFA is generally used. Here, we present techniques for reaccessing an occluded radial artery in selected patients and our experience with repeat TRA procedures.

Methods

The electronic medical records of all patients who underwent multiple endovascular procedures (diagnostic and interventional) with an attempted TRA at St Joseph’s Hospital and Medical Center from July 2019 through February 2020 were retrospectively reviewed. Institutional review board approval was obtained for this study. The need for patient consent was waived due to the retrospective nature of the research. Patients who required a second radial artery catheterization were included. We excluded patients who underwent an initial TRA followed by a planned TFA because these patients were not deemed crossover patients.

Results

There were 656 TRA attempts for diagnostic angiography or intervention from July 2019 through February 2020. During this 9-month study period, 106 patients underwent an attempted repeat TRA for diagnostic angiography or intervention. All patients who underwent attempted repeat TRA had a 5 Fr or 6 Fr sheath placed during the initial and any subsequent procedures. One hundred (94.3%) of 106 patients had a successful second radial catheterization, 22 of 22 patients had a third successful catheterization, six of six patients had a fourth successful catheterization, no patients had a successful fifth catheterization, and two of two patients had a successful sixth catheterization. A total of nine patients had an RAO (five before and four after implementing reaccess techniques). Of the six patients who could not undergo repeat TRA during the study period, five had RAO, and one had a radial artery branch perforation during the index case.

Halfway through the study period, we implemented techniques for reaccessing an occluded radial artery. Before implementing these techniques, the five patients with RAO had to undergo TFA for their repeat procedure. TRA was attempted in these patients, but the wire was not advanced because there was no bleedback after the initial puncture. Repeat TRA was not attempted in the patient who had a radial artery branch perforation during the index procedure. Once we implemented the technique, we discovered four additional patients with RAO. They all underwent repeat TRA without requiring conversion to TFA. All four of these patients underwent repeat access within 3 weeks of the index procedure. None of the patients required reaccess of an occluded artery more than once. There were no short-term complications of forearm pain, vessel perforation, forearm hematoma, or hand ischemia following the implementation of the technique.

Technique

Technique in cases of RAO

The well-known steps for patient positioning and radial access were performed. During both the index and repeated-access procedures, all patients received 5000 units of heparin along with the vasodilatory cocktail administered after sheath placement. Following the completion of the case, patent hemostasis was achieved using a radial band for compression.

We encountered three different scenarios when attempting TRA in repeat cases of RAO: the artery was occluded at the site of the puncture but patent distally, the artery was occluded from the puncture site extending distally and patent only proximally, or the artery was completely occluded (figure 1).

Figure 1

We encountered three scenarios when attempting TRA in repeat cases of RAO. (A) The artery was occluded at the puncture site but was patent more proximally and distally. (B) The artery was occluded from the puncture site extending distally and patent only proximally. (C) The artery was completely occluded proximally and distally to the previous puncture site. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

In all repeated punctures, we used the earlier puncture site as a guide. When the artery was found to be occluded on the basis of visualization of thrombus within the artery on ultrasound, lack of pulsatility, or lack of bleedback from the artery after the puncture, the ultrasound probe was guided more proximal to (first choice) or more distal from (second choice) the prior puncture site. Our limit for proximal puncture was one-third of the distance up the forearm, where the radial artery is surrounded within the forearm musculature. A puncture should not be performed proximal to where the artery enters the underside of the brachioradialis muscle because reliable compressive patent hemostasis is lost, and the risk of a forearm hematoma is increased.

In cases where a more proximal site was chosen, the artery was punctured using the abovementioned technique. Once blood was noted within the needle hub and the needle tip was visualized within the artery’s lumen, the wire was advanced. Using tactile feedback and ultrasound to visualize the wire within the lumen of the artery, we slowly advanced the wire. We obtained an anterior-posterior (AP) image to confirm the wire’s position in the upper forearm.

In cases where a distal site was chosen (either antebrachial or anatomical snuffbox), we used ultrasound guidance to puncture the artery (figure 2). During the performance of the distal puncture technique, there was no brisk pulsatile flow from the needle after the puncture. Ultrasound was used to confirm that the echogenic tip of the needle was within the lumen of the artery. The wire was then advanced under both ultrasound and tactile feedback guidance to ensure that the wire remained within the true lumen of the artery and traveled past the site of occlusion. Once the wire was advanced to the upper forearm, the needle was removed, and the sheath and introducer were advanced over the wire. We ensured no resistance during this maneuver to avoid passing the sheath into a false lumen or to avoid arterial perforation. If resistance had been encountered, we would have aborted the procedure. We checked for blood return through the sheath before the administration of the vasodilatory cocktail. A radial artery angiogram was performed to assess its patency (figure 3).

Figure 2

Ultrasound images showing (A) the radial artery, (B) color Doppler, (C) the radial artery with the echogenic needle tip within the lumen, (D) color Doppler, (E) the radial artery with wire within the lumen, and (F) longitudinal view of the wire within the radial artery. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Figure 3

Radial artery angiogram after reaccessing the right radial artery of a patient with RAO. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

In selected patients, the radial artery can be occluded over a longer segment (figure 1C), limiting a more proximal and distal puncture technique. In these patients, we used ultrasound to visualize the length of the artery to ensure that it was occluded and not in spasm or injured due to a prior puncture. If the caliber of the artery was at least 2 mm, we proceeded. Once the artery was identified on ultrasound, we used a 21 G needle to puncture the artery, ensuring that the tip could be seen within the lumen of the artery. In some patients, bleedback was evident, and in others, there was just a small amount of blood at the hub of the needle. Next, the 0.021-inch wire was slowly advanced under direct ultrasound visualization. If any resistance was encountered, the wire was withdrawn, and ultrasound was used to ensure that the needle was truly within the artery. Once the wire was advanced to the forearm, an AP fluoroscopic image was taken, and the needle was removed. The introducer and sheath were advanced over the wire, and blood return was ensured.

Discussion

As TRA gains popularity among neurointerventionalists, RAO will undoubtedly be a more frequently encountered entity, particularly among patients undergoing repeated radial punctures. Although some interventional cardiology studies have reported RAO rates following TRA as high as 30%, most recent studies have indicated the rate to be anywhere from 1% to 10%.9 11 16–18 A recent systematic review of the transradial approach in neurointerventions showed an asymptomatic RAO rate of 2%.3 RAO rates have been shown to depend on sheath size, administration of heparin during the procedure, and a postoperative hemostasis technique that relies on the concept of “patent hemostasis”.16

Damage to the arterial wall during initial puncture and sheath insertion is thought to initiate the prothrombotic cascade. The intima and media layers sustain damage during TRA, impairing the antithrombotic and anti-inflammatory function of the endothelial cells.19–21 Chronic intimal thickening has also been shown to follow TRA, resulting in a narrower caliber of the artery seen on follow-up imaging.20 The smaller caliber of the radial artery, compared with that of the femoral artery, increases the likelihood of the thrombus becoming occlusive.

The initial injury to the arterial wall can be compounded by repeat puncture, leading to lower TRA success rates with each subsequent case.16 Alternating proximal radial with distal snuffbox puncture sites may decrease the risk of RAO in subsequent procedures.9

A recent publication by Chen et al9 discusses repeated radial puncture in neurointerventional cases. The authors report a high success rate of 94.7% with recatheterization in 133 cases involving repeat TRA cases over 4 years. Six of the 133 cases (4.5%) were converted to TFA because of the inability to access the radial artery due to RAO. Because the authors do not mention whether repeat puncture and cannulation were attempted for these RAO cases, it is unknown whether those patients could have undergone repeat TRA with the techniques we describe above.

Reaccessing an occluded radial artery has been previously described in the interventional cardiology literature.22–28 Avoiding TFA in patients with RAO through the techniques described above can minimize TFA-related complications and avoid the femoral-access challenges experienced in patients with severe aortoiliac occlusive disease, prior iliac stent placement, and severe obesity. Interventional cardiologists have described accessing the radial artery more proximal to the occlusion site, puncturing the radial artery more distal to the occlusion site, using a balloon to dilate the artery, and using a transulnar access site for the recanalization of the radial artery.22 24 28 We do not advocate puncturing the ulnar artery where there is RAO because it may become occluded, causing symptomatic hand ischemia.

In our series of 106 patients who underwent repeat radial puncture over 9 months, we used our reaccess techniques to avoid conversion to TFA in four patients, resulting in a 6% overall conversion rate to TFA. This rate could potentially have been lower if the reaccess techniques were implemented earlier.

Although they were successful in accessing the occluded radial arteries, our techniques are not without potential complications. A recent study by Balaban and Elevli demonstrated successful radial reaccess in 22 of 25 (88%) patients.23 The authors described puncturing the artery distal to the site of occlusion and using drug-coated balloons. Of note, forearm pain was seen in 12 patients who successfully underwent repeat TRA. The pain persisted in seven patients at 1 week after repeat TRA. Additionally, two patients developed antebrachial hematomas alongside the occluded sites of the radial arteries. The authors state that forearm pain and hematoma were most likely attributable to balloon dilation. We did not use similar techniques for reaccess and would likely convert to TFA if the techniques we described were unsuccessful.

Embolization of thrombus distal to the hand and fingertips is also a significant concern, especially in patients with risk factors for vasculopathy, resulting in poor collateral blood supply. In our technique, we place the pulse oximeter on the first or second digit and ensure adequate readings before reaccessing the occluded artery. Furthermore, the use of ultrasound is important to avoid potential perforation or further dissection of the artery. Puncturing the artery under ultrasound guidance, ensuring that the tip of the needle is within the lumen of the artery, and passing the wire using tactile feedback and ultrasound visualization are necessary for achieving recatheterization. In some cases of RAO, there is no blood visible at the hub of the needle, but the tip of the needle can be visualized within the lumen of the artery. If there is resistance when advancing the wire, or if the wire is not seen within the lumen of the artery on ultrasound, further advancement of the wire may dissect or perforate the vessel. In addition, passing the sheath through the occluded portion of the artery should also be done under careful tactile feedback. If there is resistance, the sheath may not be within the true lumen of the artery. Before injecting through the sheath, it is important to withdraw blood first or open the stopcock to allow blood flow in case there is a thrombus at the tip of the sheath. We also recommend against using a longer radial sheath in these cases because the longer sheaths may potentially track the thrombus into the brachial artery and place the ulnar artery at risk of occlusion. It is important to ensure that the tip of the sheath remains within the radial artery so that any thrombus does not propagate more proximally into the brachial artery.

Our experience demonstrates that recanalization of an occluded radial artery is possible in select cases. None of the four patients for whom these techniques were used experienced any postprocedural, access-related complications. Further evaluation of this technique is needed on a larger scale to validate its advantages and safety.

Limitations

This 9-month retrospective study identified patients with RAO only among those undergoing repeat access. Thus, true RAO rates cannot be attained from this study. The techniques we describe for reaccessing the radial artery were implemented halfway through the study period.

Data availability statement

No data are available. There are no additional data to share.

Ethics statements

Ethics approval

This study was approved under IRB PHX-18-500-415-73-12.

Acknowledgments

The authors thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.

References

Footnotes

  • Contributors Primary writing of the text, manuscript preparation, data collection, and interpretation and approval of the text: NM, DAW, AFD, and FCA. Assistance with manuscript preparation and critical revision, data collection and interpretation, and approval of the text: JSC, TSC, and JFB. Project design: NM, AFD, and FCA. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: NM, DAW, JSC, TSC, JFB, AFD, and FCA.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests AFD is a consultant for Medtronic (Dublin, Ireland); Cerenovus (Johnson & Johnson, New Brunswick, NJ); Stryker (Kalamazoo, MI); Penumbra (Alameda, CA); and Koswire, Inc (Flowery Branch, GA).

  • Provenance and peer review Not commissioned; externally peer reviewed.