Repeated transradial coronary procedures: ultrasound-validated incidence of symptomatic radial artery occlusion

Background

Current guidelines recommend the radial artery as the primary access site for coronary catheterization. Radial artery occlusion (RAO) is the most common complication of the transradial approach (TRA) and is thought to occur more frequently after repeated TRA procedures. Reported RAO incidences after multiple TRA procedures range up to >20% in studies lacking ultrasound confirmation. In such studies, a non- or weakly palpable radial pulse despite a patent artery may mimic RAO, potentially leading to overestimation of RAO rates.

Purpose

To address this limitation, we performed the first duplex-validated assessment in patients (Pts) who had undergone three TRA procedures, aiming for the true incidence of RAO and the reliable prevalence of RAO-associated symptoms in this population.

Methods

Using our institutional cardiac catheterization database, we identified all individuals who had undergone three TRA procedures between Sep 2016 and Dec 2021. After patient contact, all participants underwent structured history taking, physical examination, and duplex sonography (2D, color duplex, pulsed-wave Doppler) of the thrice-punctured proximal radial artery. Examinations were conducted by experienced sonographers; in cases suggestive of RAO, a confirmatory assessment by a board-certified vascular medicine specialist was added. The data collected included the presence and, if applicable, the characterization of persistent hand symptoms since the last TRA procedure.

Results

Within the 63-month study period n=153 Pts were identified who had n=3 TRA procedures (male: n=127 (83%)); median age 65 years [44–85]; median BMI 28.7 kg/m² [17.5–42]), corresponding to n=459 procedures performed by 29 operators. All TRA procedures used the right proximal radial artery, and all Pts received ≥5000 IU unfractionated heparin. Duplex sonography was performed 31 ± 6 months after the last TRA.

RAO was detected in n=10/153 (6.5% CI 0.026–0.105). After diagnostic TRA (n=76) RAO was observed in n=4/10 and after TRA-PCI (n=77) in n=6/10 Pts. The final, causative TRA procedure was performed with a 4F sheath (n=2) causing no RAO, with 5F (n=41) causing n=3/10 RAO, with hydrophilic 6F (n=107) causing n=6/10 RAO and hydrophilic 7F (n=3) causing n=1/10 RAO.

Persistent hand symptoms were reported by only n=2 Pts (1.3%): one with occasional right-hand paresthesia and one with intermittent muscle pain during gripping. Thus, 98.7% of Pts were asymptomatic prior to being informed of the RAO finding, and of those pts with diagnosed RAO only 20% had symptoms.

Conclusion

This first duplex ultrasound-controlled observational study in Pts following three TRA procedures demonstrates a 6.5% RAO incidence — low compared to non-ultrasound controlled studies and consistent with expected rates in studies on single TRA procedures.

The occurance of symptomatic RAO (1.3%) should explicitly mentioned during informed-consent discussions with patients in selected occupational groups.