Response by Costa et al to Letter Regarding Article, “The Rotterdam Radial Access Research: Ultrasound-Based Radial Artery Evaluation for Diagnostic and Therapeutic Coronary Procedures”

Abstract

In Response:In response to the comments of Chugh et al on our study, 1 we would like to point out that the rate of radial artery occlusion (RAO) ranged from <1% to 30% in recent studies (mean 7.89%), whereas in the Rotterdam Radial Access Research study, this was <4% at all time points. 1 The incidence of RAO varies and seems multifactorial, including anatomic substrate (ie, vessel size), access technique, and access management before, during, and after the procedure. Our study underscores the clinical importance of number of radial punctures to obtain arterial access and its association with RAO, radial pulse loss, and pain and discomfort. In contrast, radial artery size at baseline, which was handled as a continuous variable in our model, had no impact on RAO. We agree with Chugh et al that smaller radial artery size may result in serial puncture attempts. In fact, the median radial inner lumen at baseline in our study was 2.25 mm in patients receiving 1 puncture and 2.01 mm in those receiving >1 puncture. However, a lumen of <2.00 mm did not predict RAO at any time point in our study, confirming our hypothesis that the number of punctures could independently predict RAO.The use of low-dose heparin for short-lasting transradial diagnostic studies resembles standard practice in many institutions throughout the world. Systematic use of a higher heparin dose in a diagnostic setting may result in less RAO, especially when patent hemostasis could not be achieved.2 Still, full anticoagulation is associated with a significant increase in access site bleeding with no further benefit on RAO in a recent, large, double-blind randomized trial.3 Similarly, Pancholy et al 4 demonstrated that shorter compression times (2 versus 6 hours) also reduced RAO. Shorter compression time (15 minutes) with newer compression devices was associated with a higher bleeding rate. Noteworthy, kaolin-filled pads allow for short compression, but evidence on their efficacy is still limited, and these pads were not available in our institution at the time of the trial. 5The Rotterdam Radial Access Research (R-RADAR) study introduced novel noninvasive ultrasound imaging technology in the space of transradial access. Its relatively small sample size precludes any firm conclusions, yet we believe the findings in terms of arterial injury and healing after transradial access are original, refine current understanding and should spur further research to optimize planning, execution, and postprocedural management of transradial procedures. DisclosuresNone. Francesco

Radial Artery and Ulnar Artery Occlusions Following Coronary Procedures and the Impact of Anticoagulation: ARTEMIS (Radial and Ulnar ARTE ry Occlusion M eta‐Analys IS ) Systematic Review and Meta‐Analysis

“…Clinical methods (ie, arterial palpation) have been associated with both false‐negative and false‐positive findings attributed to low blood pressure, local edema and hematoma, subocclusive wall thrombus and trauma, remaining postprocedural tissue compression, as well as retrograde perfusion from the contralateral forearm artery. For example, although palpation appears to overestimate RAOs, one fifth to one third of patients with ultrasonographically documented RAOs may demonstrate palpable radial artery . Notably, the ulnar artery poses additional difficulties in determining patency status with palpation as a result of its deeper course compared with the radial artery .…”

Letter by Chugh et al Regarding Article, “The Rotterdam Radial Access Research: Ultrasound-Based Radial Artery Evaluation for Diagnostic and Therapeutic Coronary Procedures”

“…In this article, RAO was associated with the presence of multiple punctures, but they had no relationship with smaller arterial size, 1 a term for which authors do not offer a clear definition. Furthermore, there was a lack of data in the article on the distribution of various radial artery diameters in patients requiring >1 puncture attempts (16.1%) or in patients developing RAO on follow-up.…”

“…This information is relevant because radial arteries with smaller diameters often require multiple puncture attempts, facing greater intimal insult, and have hence been found to have higher postprocedure occlusions. 2,3 A lack of correlation between small radial arteries and RAO in this study 1 may also have been on account of a limited number of patients with smaller radial arteries, although these data are unavailable.…”

“…2 The study's conclusion about correlation of multiple punctures with RAO may have been more relevant if the 2 confounding variables of heparinization and compression time had also been used optimally, in keeping with current practice, and based on recent data. 2 Although this is a insightful study, 1 further exploration into various anatomic and procedural correlates of RAO, including the reported benefits of accessing the largest and straightest forearm artery based on ultrasound, 4 needs to be further validated in large randomized settings.…”

US-guided peripheral vascular interventions, comments on the EFSUMB guidelines

“…The rate of these complications is related to the lumen diameter of the artery, the age of the patient, the presence of peripheral vascular disease, peri-interventional use of heparin, the number of puncture attempts and the size of the indwelling catheter or sheath [30,31].…”