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Patients Report No Damage to Upper Extremity Function After Radial Procedures

March 27, 2015

While coronary catheterization via radial access potentially can induce anatomic and physiological changes, patients who undergo these procedures are no more likely to report having upper-limb disability afterward than those receiving femoral procedures, according to results of a small study published online March 25, 2015, ahead of print in JACC: Cardiovascular Interventions.

For the ACRA (Assessment of disability after Coronary procedures using Radial Access) study, researchers led by Niels van Royen, MD, PhD, of VU University Medical Center (Amsterdam, the Netherlands), assessed upper-limb changes in 338 patients (mean age 64 years; 72% male) who had coronary cath via femoral (n = 52) or radial (n = 286) access at 2 centers in the Netherlands between January 2013 to February 2014.

To test upper-limb function, patients took a shortened version of the Disabilities of Arm, Shoulder, and Hand questionnaire (QuickDash). The 11-item, self-reported survey measures physical function, symptoms, and effect on daily life. Additionally, cold intolerance was assessed with the self-reported Cold Intolerance Symptom Severity (CISS) questionnaire, consisting of 6 questions. Both tests were taken immediately before the procedure and at 30-day follow-up.

No Uptick in Limb Problems vs Femoral Access

Patients undergoing femoral procedures had higher rates of prior CABG and longer procedures than those treated radially (P < .01 for both). Worse upper-extremity function at baseline on QuickDash was seen in women and patients aged 75 and older, but there were no differences in the overall scores between the radial and femoral groups (P = .28).

When baseline and 30-day scores were compared, there were no differences between the radial and femoral groups on either the QuickDash (P = .06 and P = .19, respectively) or the CISS (P = .91 and P = .96, respectively) assessments. Cold intolerance was noted in 6.3% of patients in the radial group and 7.7% in the femoral group but was not associated with access route (P = .71).

Although 8.0% of radial patients had a lack of patent dual palmar arch circulation on the Allen test (6.2% on Barbeau) and 6.4% had inadequate postprocedural patency on reverse Barbeau, there was no association between abnormal vascular communication or patency and loss of upper-extremity function on either the Allen (P = .99) or Barbeau tests (P = .88). The same findings were true of CISS.

At 30 days, similar percentages of patients in the radial and femoral groups reported having some level of either procedure-related or persistent upper extremity problems (table 1).

Upper-Extremity Problems Reported at 30 Days by Access Route

Types of persistent complaints after radial procedures were:

Pain (43%)

Tingling (10%)

Stiffness (7%)

Less Power (7%)

Numbness (7%)

Other (26%)

Builds on Previous Observations

Ian C. Gilchrist, MD, of Penn State Hershey Medical Center (Hershey, PA), who has performed radial procedures for 20 years, told TCTMD in a telephone interview that, given how often patients ask about injury or permanent disability to their arm or hand, the data are “very reassuring.”

“It puts on paper, in a more scientific manner, what a lot of us have observed for years: that this is a relatively safe procedure to do in the arm and there really isn’t a hazard of hand or arm function problems afterward,” he said. “While I can never guarantee anything 100 percent to a patient, I can tell them that I believe [radial] is the safer way to go, and this study builds on observations from other trials over the years including the RADAR trial.”

Dr. Gilchrist cautioned however, that while the literature contains only “a handful” of reported hand or arm issues related to radial procedures, “the event rate may be so low that a population of 300-some patients, as we see in this trial, may not be enough to pick up minor differences between the 2 approaches.”

‘Complex and Elegant’ Anatomy

“This study is the latest in a series of studies that have challenged our preconceived notions about the structure and function of the hand vasculature, the role of testing for dual circulation, and alternative arm access for cardiac catheterization,” write Sunil V. Rao, MD, of the Duke Clinical Research Institute (Durham, NC), and Sasko Kedev, MD, PhD, of University of St. Cyril & Methodius (Skopje, Macedonia), in an accompanying editorial.

“These findings are not surprising when considering the arterial anatomy of the human arm and hand, which provides extensive superficial and deep collaterals,” they add. “This complex and elegant arterial circulation also suggests another route for angiography—the ulnar artery.”

But the issue of whether the ulnar artery is suitable for primary access is controversial. A direct comparison of radial vs ulnar in the AURA of ARTEMIS trial showed inferiority of the ulnar approach, and the trial was stopped as a result, Drs. Rao and Kedev note. They suggest that ulnar access is appropriate in cases of radial failure, although risk of injury to the ulnar nerve and forearm hematoma are important considerations.

Dr. Gilchrist agreed. “If for some reason I don’t like the radial artery, I do feel comfortable using the ulnar as an alternative—but I don’t use it as first-line mainly because of the nerve being right next to it and it doesn’t have the same safety features, so to speak,” he said. “Still, I would rather go to the ulnar if I have to rather than go down to the femoral artery because the lower risk of complications with the radial or ulnar beat out the femoral by an arm and a leg.”

Sources:

1. van Leeuwen MAH, van Mieghem NM, Lenzen MJ, et al. The effect of transradial coronary catheterization on upper limb function. J Am Coll Cardiol Intv. 2015;Epub ahead of print.

2. Rao SV, Kedev S. Approaching the post-femoral era for coronary angiography and intervention [editorial]. J Am Coll Cardiol Intv. 2015;Epub ahead of print.

Disclosures: