Of Hands and Hearts: Upper-Extremity Dysfunction Common Early After Transradial PCI

PARIS, France—Nearly three-quarters of patients undergoing PCI via the radial artery have some form of upper-extremity dysfunction 2 weeks after the procedure, according to interim results of a new study presented today at EuroPCR 2016. 

The most common forms of dysfunction include reduced wrist strength, increased volumetry of the hand, which measures swelling and edema, and decreased sensibility of the fingertips, a measure of motor and sensory nerve function. Overall, the rate of radial artery occlusion at 2 weeks was slightly less than 10%, researchers reported.

Lead investigator Eva Zwaan, MD (Albert Schweitzer Hospital, Dordrecht, the Netherlands), told TCTMD the study emerged after a rupture of the radial artery led to compartment syndrome in a patient. Following the adverse event, cardiologists and surgeons initiated the trial to assess the effects of radial artery access on hand and arm function.

“In terms of clinical relevance, we see a lot of patients complain 2 weeks after PCI,” said Zwaan. “A lot of patients still have problems with the hematoma—it has not resolved yet. It tends to really infiltrate the muscles and tendons, which irritates a lot. They can’t use their intervention hand properly.”

Some of these patients, she added, are in a lot of pain.

Working with two hand surgeons, the researchers devised a binary score to measure upper-extremity function. In addition to incorporating Doppler ultrasound to assess radial artery occlusion, the score quantifies patient symptoms using multiple questionnaires and measures volumetry in the hand and forearm, sensibility of the fingertips, grip strength, and flexion and extension of the wrist and elbow.

In total, the researchers documented upper-extremity dysfunction in the intervention arm of 74.9% of patients, a difference that was statistically significant when compared with the nonintervention hand. Overall, patients with upper-extremity dysfunction were younger than those without dysfunction (63.4 vs 67.5 years; P = 0.01) and were significantly more likely to have developed radial artery occlusion following the procedure. There were no differences in access-site complications, access-site hematoma, swelling, or dissection between those with and without upper-extremity dysfunction.

“It feels to me like you’ve dropped a small hand grenade into the radial community,” said David Kettles, MD (St. Dominic’s Hospital, East London, South Africa), one of the panel members discussing the study results.

As Zwaan pointed out during her presentation, radial-first PCI is the norm in Europe, Canada, and Asia, among other regions, and is growing in the United States. The procedure is associated with a significantly lower risk of major bleeding, as well as lower mortality rates in STEMI patients, fewer access-site complications, shorter hospital stays, and lower costs. While the identification of upper-extremity dysfunction, particularly the high incidence of patients who develop it following transradial procedures, is concerning, panel members said the 6-month results will be important to determine the severity and scope of the problem.

The researchers are planning on enrolling 500 patients in the study and will be reporting longer-term follow-up data when they are available. Right now, the group has just limited data on patients at 1 and 6 months, but Zwaan said they have seen patients retain numbness and tingling even after half a year.

Practically speaking, she told TCTMD that physicians should ask patients prior to PCI what they do for a living, noting that professional musicians and artists, for example, might be particularly concerned about the potential risks of the transradial approach. In time, they would like to develop a risk score to identify patients at higher risk of developing upper-extremity dysfunction, but right now the early data suggest younger patients, in contrast with conventional thinking, are at a higher risk than older patients. Zwaan speculated that older patients tend to rest after a procedure, whereas younger patients might jump straight back into regular activities, which would put them at risk of developing dysfunction after transradial PCI.

Most importantly, Zwaan emphasized the study doesn’t undermine radial access, but rather highlights a very real phenomenon after the procedure. For cardiologists, follow-up should entail not only checking out the heart, but the hand and arm as well. “Don’t be shy to refer to a rehabilitation specialist,” she said.

Related Stories:

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• Warfarin Offers Poor Protection Against Radial Occlusion After Transradial Angiography
• Sheath Size Associated with Radial Occlusion After Transradial PCI