A Novel Method for Achieving Patent Hemostasis in Patients Undergoing Percutaneous Coronary Intervention Through the Distal Radial Artery

The distal radial approach from the anatomical snuff box on the dorsal side of the hand was first described to open occluded ipsilateral radial arteries.¹ This new vascular access site has recently been introduced for percutaneous coronary intervention (PCI) and is expected to reduce bleeding complications and enhance patient comfort.² However, a hemostatic method for the distal radial approach has not yet been established. Furthermore, the occlusion rate at the access point is considered to be higher in the distal radial artery than in the forearm radial artery access, because of its relatively small caliber. To avoid radial artery occlusion, patent hemostasis is achieved using the Barbeau test, in which the ulnar artery is occluded during radial artery compression.³ For distal radial access, however, the Barbeau test is not feasible, because of the dual palmar arch arteries in the hand. To ensure complete patent hemostasis by the distal radial approach, we attempted hydraulic compression by modifying a conventional hemostatic device, which enables direct blood flow visualization at the compression site with sonography.

Representative Case

A 78-year-old man with effort angina underwent percutaneous coronary intervention (PCI) of the left anterior descending artery and the right distal radial artery using a 6 French (Fr) Glidesheath Slender introducer sheath (Terumo). After successful stent implantation in the lesion, we applied the hemostatic device, which was modified from the TR Band (Terumo). The modification involved removal of the plastic plate and inner layer of the band in the dual layer portion (Figure 1). After this device was applied to the access site before removal of the introducer, 10 mL of saline was injected into the balloon. During inflation, the sheath introducer was promptly removed. Then the sonography probe was applied at the balloon surface, and the radial artery was detected. Saline was then slowly removed until blood flow was detected by color Doppler imaging (Figure 2A-B). After completion of hemostasis, decompression was attempted every 30 minutes until complete removal of the saline. The initial size of the radial artery was 2.3 mm, and it was 2.5 mm 24 hours after PCI without radial occlusion. 

Discussion

To our knowledge, this is the first report describing a method for achieving patient hemostasis in patients who underwent PCI through distal radial access. For direct visualization of the blood flow with Doppler sonography, we filled the compression balloon of the radial hemostatic band with water, which was subjected to modification to facilitate penetration of ultrasound. 

Several methods for hemostasis have been proposed to date for the distal radial approach. All of these methods applied the hemostatic technique used in conventional radial access. For conventional radial access, patent hemostasis with the Barbeau test is recommended to prevent the radial artery occlusion.⁴ However, no method has been reported to achieve patent hemostasis in distal radial access. There are anatomical differences between the forearm radial artery and distal radial artery. In the case of the conventional radial approach, two major arteries, i.e., the radial and ulnar arteries, supply blood flow into the hand. Therefore, patency of the radial artery can be evaluated by occlusion of the ulnar artery. However, in the distal part of the wrist, there are two palmar arch arteries originating from the forearm radial artery, i.e., the superficial and deep palmar arch arteries. Therefore, during evaluation of patent hemostasis in the access site by occlusion of the ulnar artery, the superficial palmar arch artery can provide blood to the hand and may cause false positive results. The direct 

detection of the blood flow in the current study is considered a contributing factor for the prevention of radial artery occlusion.

There are several limitations to this technique. The modifications to the conventional hemostatic band may affect its strength. The balloon and the one-way valve connecting the balloon are not designed for water injection. The sonographic machine should be prepared in a catheter laboratory during angiography and PCI. Finally, the properties differ between air and water, which may affect arterial compression.

Conclusion

The hemostatic method described in the current study is feasible and may contribute to preventing radial artery occlusion by detecting blood flow during compression with sonography. 

References

1. Babunashvili A, Dundua D. Recanalization and reuse of early occluded radial artery within 6 days after previous transradial diagnostic procedure. Catheter Cardiovasc Interv. 2011 Mar 1; 77(4): 530-536. doi: 10.1002/ccd.22846.
2. Kiemeneij F. Left distal transradial access in the anatomical snuffbox for coronary angiography (ldTRA) and interventions (ldTRI). EuroIntervention. 2017 Sept; 13(7):  851-857.
3. Barbeau GR1, Arsenault F, Dugas L, et al. Evaluation of the ulnopalmar arterial arches with pulse oximetry and plethysmography: comparison with the Allen’s test in 1010 patients. Am Heart J. 2004 Mar; 147(3): 489-493.
4. Sanmartin M, Gomez M, Rumoroso JR, et al. Interruption of blood flow during compression and radial artery occlusion after transradial catheterization. Catheter Cardiovasc Interv. 2007 Aug 1; 70(2): 185-189.

Disclosures: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via Akihiko Takahashi MD, PhD, at a-takahashi@wine.ocn.ne.jp.