Left Radial Artery Research Articles

Recanalization of a Chronic Radial Artery Occlusion Allowing Subsequent Complex Coronary Intervention

A 65-year-old man with previous coronary artery bypass grafting and recent recurrence of angina was referred for coronary angiography. His medical history included myelodysplasia with significant anemia (hemoglobin, 7.7 g/dL) and thrombocytopenia (platelets, 77×10 9 /L). A percutaneous coronary intervention was performed 4 years previous to an occluded native right coronary artery via the left radial artery. Given the increased risk of bleeding complications and a patent left internal mammary artery graft, coronary angiography was planned again via the left radial artery. The result of a modified Allen test was positive, demonstrating satisfactory ulnar arterial supply to the hand. Arterial puncture using a SURFLO micropuncture needle (Terumo Medical Corporation; Somerset, NJ) resulted in pulsatile blood flow back, but it proved impossible to advance the 0.021-inch introducer wire more than a few centimeters into the vessel. Therefore, the cannula on the introducer needle was advanced over the wire to secure arterial access and radial angiography was performed, which demonstrated radial artery occlusion (RAO; Figure 1; online-only Data Supplement Movie I). The occlusion was not believed to …

Case Scenario

Case Scenario

Comparison of the Feasibility and Effectiveness of Transradial Coronary Angiography Via Right Versus Left Radial Artery Approaches (from the PREVAIL Study)

It remains undefined if transradial coronary angiography from a right or left radial arterial approach differs in real-world practice. To address this issue, we performed a subanalysis of the PREVAIL study. The PREVAIL study was a prospective, multicenter, observational survey of unselected consecutive patients undergoing invasive cardiovascular procedures over a 1-month observation period, specifically aimed at assessing the outcomes of radial approach in the contemporary real world. The choice of arterial approach was left to the discretion of the operator. Prespecified end points of this subanalysis were procedural characteristics. Of 1,052 patients consecutively enrolled, 509 patients underwent transradial catheterization, 304 with a right radial and 205 with a left radial approach. Procedural success rates were similar between the 2 groups. Compared to the left radial group, the right radial group had longer procedure duration (46 ± 29 vs 33 ± 24 minutes, p <0.0001) and fluoroscopy time (765 ± 787 vs 533 ± 502, p <0.0001). At multivariate analysis, including a parsimonious propensity score for the choice of left radial approach, duration of procedure (beta coefficient 11.38, p <0.001) and total dose-area product (beta coefficient 11.38, p <0.001) were independently associated with the choice of the left radial artery approach. The operator's proficiency in right/left radial approach did not influence study results. In conclusion, right and left radial approaches are feasible and effective to perform percutaneous procedures. In the contemporary real world, however, the left radial route is associated with shorter procedures and lower radiologic exposure than the right radial approach, independently of an operator's proficiency.

Effect of the adjuvant dexmedetomidine on the hemodynamic at combined spinal-epidural anesthesia induction of elderly patients with lower limb surgery

Objective To investigate the influence of continuous infusion of low-dose dexmedetomidine (DEX) on the hemodynamic in elderly surgical patients during induction of combined spinal-epidural anesthesia (CSEA).Methods Fifty elderly lower limb surgical patients were randomly divded into DEX group and control group(25 cases each).After the cannulation of left radial artery,the non-invasive hemodynamic monitor was connected,and the hemodynamic index was continuously monitored,including systolic blood pressure (SBP),diastolic blood pressure(DBP),heart rate(HR);and respiratory index was monitored,including respiration rate(RR),pulse oxygen saturation( SpO2 ).Before CSEA,the patients in DEX group were administered DEX of loading dose(0.5 μg · kg-1),then continuously infused with DEX at 0.2 ～ 0.4μg · kg-1 · h-1 to keep Ramsay sedation score from 4point to 5point,and SpO2 ≥95％.Normal saline was administered with an equal volume in control group.The SBP,DBP,HR,RR,SpO2 were recorded immediately at the T0,T1,T2,T3,T4 and T5.Results All hemodyanmic and respiratory parameters in both groups were normal during induction.Compared with T2 in DEX group,differences of SBP and DBP between two groups were statistically significant,and the value significantly lower at T3 (P ＜ 0.05 ) ;compared T2 with T1 in control group,differences of SBP,DBP and HR among three groups were statistically significant,and the value was significantly higher at T2 ( P ＜ 0.05 ).Compared with T2,SBP,DBP,HR were significantly lower than T3,( P ＜0.05).And RR of T1,T2,T3,T4,T5 in DEX group was significanfly lower than T0,with statistical significance( P ＜0.05) ;the difference of RR among different time was not statistically significant in control group(P ＞ 0.05 ).Conclusion The continuous infusion of small-dosage DEX during CSEA in elderly lower limb surgical patients may have little impact on cardiac function index when achieved effective sedation and analgesia. Key words: Aged ; Anesthesia; Hemodynamic

Letter by Edelman et al Regarding Article, “Second Internal Thoracic Artery Versus Radial Artery in Coronary Artery Bypass Grafting: A Long-Term, Propensity Score-Matched Follow-Up Study”

To the Editor: We congratulate Ruttmann and colleagues on their propensity score analysis comparing the right internal thoracic artery and radial artery (RA) as the second-best conduit in coronary artery bypass grafting.1 The study raises several interesting points. The neurological event rate was significantly lower in patients receiving bilateral internal thoracic artery (BITA)±saphenous vein graft (SVG) in comparison with those receiving left internal thoracic and RA±SVG (unmatched, BITA 0.4% versus left internal thoracic artery/RA …

Effective Cerebral Protection Using Near-Infrared Spectroscopy Monitoring with Antegrade Cerebral Perfusion During Aortic Surgery

Antegrade cerebral perfusion (ACP) under moderate hypothermia may improve cerebral protection. Intraoperative measurement of cerebral regional oxygen saturations (rSO2) using near-infrared spectroscopy (NIRS) can provide accurate monitoring of cerebral perfusion during ACP. We evaluated the role, outcomes, and advantages of using NIRS in providing effective cerebral protection with ACP. Between May 2006 and March 2009, 27 patients (mean age 60%, 93% elective) underwent ascending aorta replacement with ACP monitored by NIRS. ACP was established through the right axillary artery (n = 26). All patients had continuous intraoperative measurement of both anterior cerebral rSO2 using NIRS (INVOS; Somanetics Corporation, Troy, MI, USA). Posterior cerebral perfusion was measured using left radial artery pressures. Quality of life (QoL) was assessed using a Short Form 36 questionnaire. Mean cardiopulmonary bypass and aortic cross clamp time were 169 ± 27 and 95 ± 22 minutes, respectively. Mean ACP rate of 1.27 ± 0.35 L/min provided a mean left radial artery pressure of at least 60 mmHg. All patients' cerebral rSO2 were maintained above their baseline using NIRS. Mean ACP time was 14.3 ± 2.6 minutes at a mean core temperature of 23.4 °C ± 2.0 °C. Temporary neurological deficit was observed in two patients (7.4%). No permanent neurological dysfunction was observed. Thirty-day mortality was 3.7%. At median follow-up of 18.3 (interquartile range 10.8 to 23.3) months survival was 92% and mean norm-based QoL score was above average at 52.5 ± 6.5. Cerebral rSO2 and left radial artery pressure monitoring with ACP during aortic surgery provides accurate measurement of cerebral perfusion resulting in minimal neurological and perioperative complications and good midterm QoL outcomes.

Left Radial versus Right Radial Approach for Coronary Artery Catheterization: A Prospective Comparison

Despite several advantages of the transradial over the transfemoral approach, the use of transradial access for coronary interventions in daily practice is still low. Major limitations are the technical and anatomical issues related with right radial artery access. The left radial approach may have an advantage from the point of view of the vascular anatomy. The aim of this study was to evaluate the safety and feasibility of routinely using the left radial compared to the right radial approach. This is a prospective single center study comparing left radial to right radial access for coronary artery catheterization. The overall in-hospital major adverse cardiac and cerebral events (MACCE), procedural success rate, bleeding, vascular and procedural complications, fluoroscopy time, number of catheters, and amount of contrast agent used were assessed. A total of 1,032 coronary angiograms were performed: 420 were performed using the right radial artery and 612 the left radial artery. No differences were observed in MACCE and success rate between the two groups. No cases of major or minor bleeding and vascular complications requiring surgical intervention were reported. Fluoroscopy time and the number of catheters used were significantly less in the left radial group (P = 0.001 and P = 0.007, respectively), while the volume of contrast was similar (P = 0.264). The left radial approach in our series was demonstrated to be safe and feasible in daily practice, and in this study was associated with a reduction in fluoroscopy time and number of catheters used.

Reply to Kestelli et al.

I appreciate the interest of Kestelli et al. [1] in our article published in the June 2010 issue of the Journal [2], and would like to draw their attention to two aspects. First, the title of their letter implies that it concerns the techniques of antegrade cerebral perfusion for brain protection during circulatory arrest, but it actually addresses the aspects of arterial return during cardiopulmonary bypass. Yet, the aim of our study was exclusively the comparison of rightand left-sided unilateral cerebral perfusion (UCP) for efficiency of cerebral protection rather than the suitability of a particular carotid artery for arterial return. The assessment of pressure in the left radial artery is of utmost importance in UCP, regardless if rightor left-sided perfusion is performed, because it reveals the efficiency of collateral pathways. As explained elaborately in the paper, our monitoring tools include therefore, amongst others, pressure measurement in both radial arteries. Nevertheless, the monitoring of the arterial return should not rely on the measurement of the pressure in the right radial artery alone, even if the right carotid or right axillary artery is cannulated with a side-graft, because the pressure is always higher on the directly perfused side. Cannulating the innominate artery that is very close to the aortic arch is surely the best haemodynamic, but for anatomo-pathological reasons, a rare option. Secondly, Kestelli et al. suggest, even without the support of any haemodynamic data, that the right carotid artery is a better approach for arterial return than the left carotid artery. This is in accordance with our study in which specific flow and pressure characteristics were examined during cardiopulmonary bypass [3]. This study was published elsewhere in 2010 and mentioned in our paper as reference number 23, leading to the conclusion that ‘we consider the right-sided cerebral perfusion as the standard, especially because the right carotid artery and the innominate artery are more suitable for cannulation than the left carotid artery’. We hope that this statement as well as the referenced study will be clear to attentive readers.

Vascular complications and access crossover in 10,676 transradial percutaneous coronary procedures

Randomized trials have shown that transradial approach, compared with transfemoral, reduces vascular complications (VCs) of coronary procedures in selected patients. Yet, radial approach is associated to a variety of access-site VC as well as to a higher failure rate compared with femoral access. At our institution, from May 2005 to May 2010, we prospectively assessed the occurrence and outcome of VC in consecutive patients undergoing transradial percutaneous coronary procedures performed by trained radial operators. The need of access crossover to complete the procedure was also prospectively investigated. Vascular complications were classified as "radial related" or "nonradial related" (in the case of access crossover). Vascular complications were also classified "major" if requiring surgery and/or blood transfusions or causing hemoglobin drop >3 g/dL. Ten thousand six hundred seventy-six procedures were performed using a right radial (87.5%), left radial (12.4%), or ulnar (0.1%) artery as primary access. A total of 53 VCs (0.5%) were observed: 44 (83%) radial related and 9 (17%) nonradial related. Major VCs occurred in 16 patients only (0.2%) and were radial related in 10 (62.5%) and nonradial related in 6 (37.5%) patients. Vascular complications rate was stable during the study and independent of operator's experience. Access crossover rate was 4.9%, differed according to the operator radial experience and significantly decreased over time. The present study, conducted in a center with high volume of radial procedures, shows that transradial approach is associated with a very low rate of VC, which is stable over time. On the contrary, access crossover rate decreased over time and differed according to operator (radial) experience.

Endovascular Stent Grafting via the Left Radial Artery for a Spontaneous Isolated Dissecting Rupture of the Superior Mesenteric Artery

A 56-year-old man presented with abrupt onset epigastric and back pain for 4 hours. Computed tomography angiography (CTA) revealed a dissection at the proximal part of the superior mesenteric artery (SMA) without a limitation in distal flow or bowel ischemia (Fig. 1A). However, an 1-week follow-up CTA showed progression of the SMA dissection down to the distal jejunal branch (Fig. 1B). Thus, we decided to perform endovascular interventional treatment. Fig. 1 A 6-Fr introducer sheath was inserted into the left radial artery. A 6-Fr multi-purpose angiographic 1 guiding catheter (Cordis, Miami, FL, USA) was then used to pass a 0.014-inch floppy guidewire into the true lumen of the SMA. A subsequent angiography (Fig. 1C, arrow indicates dissecting inlet) and intravascular ultrasound (IVUS) examination (Fig. 1D, arrow indicates dissecting inlet) showed a huge communicating dissecting rupture at the proximal portion of the SMA. We confirmed blood flow to the false lumen through the dissecting inlet by IVUS Chroma-flow imaging (Fig. 1E, arrow indicates dissecting inlet). Two stent-grafts (Jostent®, Abbott Laboratories, Inc., Abbott Park, IL, USA) (3.5×19 mm followed by 3.5×16 mm) with overlap were deployed consecutively in the proximal SMA to cover the dissection. The follow-up CTA at 9 months (Fig. 1F) showed good patency of the stent-grafts and restoration of the SMA true lumen. The patient remained asymptomatic for 12 months on 100 mg of aspirin daily. There are some reports of isolated SMA dissection, particularly in the Asian population. The causes of an isolated SMA dissection are unknown, and treatment options vary and include surgery, endovascular treatment, or conservative management depending on the extent of dissection and associated complications.1),2) Chromaflow imaging and IVUS were valuable to detect the SMA dissection inlet. The left radial artery is alternative vascular access for treating an SMA lesion, because it offers good alignment and proper backup support by a guiding catheter.

Trudności w obrazowaniu choroby Takayasu – opis przypadku i przegląd literatury

Takayasu arteritis is an inflammatory disease of large-diameter arteries. Aorta and its branches are most frequently affected. Takayasu arteritis occurs mainly in young women and, if left untreated, leads to fatal complications. Digital subtraction angiography (DSA) is considered the gold standard in imaging of Takayasu arteritis. A thirty-five-year-old woman was admitted to the hospital with transient loss of consciousness, effort-associated vertigo, upper limb weakness and temporary vision problems. On admission, there was no pulse on the left radial artery while there were bruits over subclavian arteries. Imaging of the aortic arch (computed tomography angiography, DSA) revealed stenoses of its main branches, indicating Takayasu arteritis. Computed tomography angiography (CTA) performed with a 64-slice unit revealed high effectiveness in localization of vascular wall and lumen pathologies resulting from Takayasu arteritis. Thanks to this fast diagnostic method, it is now possible to perform successful monitoring of patients with Takayasu arteritis and to plan possible interventional treatment.

Paradoxical air embolism due to electrosurgical vaporization during hysteroscopic myomectomy

Paradoxical air embolism due to electrosurgical vaporization during hysteroscopic myomectomy

Extensive skin color change caused by extravasation of indigo carmine

Extensive skin color change caused by extravasation of indigo carmine

Anesthetic management of a 6 month-old infant for near total pancreatectomy with persistent hyperinsulinemic hypoglycemia

Anesthetic management of a 6 month-old infant for near total pancreatectomy with persistent hyperinsulinemic hypoglycemia

左前側方開胸アプローチ，左内胸動脈－橈骨動脈 I-composite graftを用いたredo CABGの1例

症例は72歳の男性．56歳時，経皮的冠動脈形成術を施行された際，左前下行枝が解離により閉塞したため緊急冠動脈バイパス術(Ao-SVG-#7，Ao-SVG-#9-#14，Ao-SVG-#4PD)を施行された．定期評価でAo-SVG-#7，Ao-SVG-#4PDのグラフト閉塞とAo-SVG-#9-#14グラフトの中枢側に狭窄を認め，再冠動脈バイパス術を施行した．手術は左第5肋間前側方開胸アプローチ，PCPS補助下でLITA-RA I-composite graftを#14に側々吻合し，引き続き#4PDに端側吻合した．Redo CABGにおいては，適切な到達経路，使用グラフトの選択，バイパスグラフトデザインを選択することが重要であり，左開胸アプローチ，composite graftを用いたグラフトデザインは有効な術式の一つと考えられた．

Right versus left radial artery access for coronary procedures: An international collaborative systematic review and meta-analysis including 5 randomized trials and 3210 patients

BackgroundRadial artery access is a mainstay in the diagnosis and treatment of coronary artery disease. However, there is uncertainty on the comparison of right versus left radial access for coronary procedures. We thus undertook a systematic review and meta-analysis comparing right versus left radial access for coronary diagnostic and interventional procedures. MethodsPertinent studies were searched in CENTRAL, Google Scholar, MEDLINE/PubMed, and Scopus, together with international conference proceedings. Randomized trials comparing right versus left radial (or ulnar) access for coronary diagnostic or interventional procedures were included. Risk ratios (RR) and weighted mean differences (WMD) were computed to generate point estimates (95% confidence intervals). ResultsA total of 5 trials (3210 patients) were included. No overall significant differences were found comparing right versus left radial access in terms of procedural time (WMD=0.99 [−0.53; 2.51]min, p=0.20), contrast use (WMD=1.71 [−1.32; 4.74]mL, p=0.27), fluoroscopy time (WMD=−35.79 [−3.54; 75.12]s, p=0.07) or any major complication (RR=2.00 [0.75; 5.31], p=0.49). However, right radial access was fraught with a significantly higher risk of failure leading to cross-over to femoral access (RR=1.65 [1.18; 2.30], p=0.003) in comparison to left radial access. ConclusionsRight and left radial accesses appear largely similar in their overall procedural and clinical performance during transradial diagnostic or interventional procedures. Nonetheless, left radial access can be recommended especially during the learning curve phase to reduce femoral cross-overs.

Usefulness of Catheter Guide Wires for Identifying Sites of Vascular Injuries

We report 2 cases in which catheter guide wires were useful for detection of vascular injury site. Case 1: A woman was died of hemorrhagic shock after being slashed at the extremities, but the vessels were so collapsed that it was not easy to find the injured site. After a wound track on the left forearm was cut open and a guide wire was inserted, the injury site was detected expeditiously at the left radial artery. Case 2: A woman was stabbed and died of hemorrhagic shock. An autopsy revealed 2 stab wounds in the back, one of which made a cut in the left lung. The wound track was cut open, and the injured vessel was revealed. It was too small in diameter to macroscopically determine whether the injured branch arose from, and so a guide wire was introduced from the injured site, and the injured vessel was easily determined to be a branch of the left pulmonary artery. Guide wires have many features, such as elasticity, flexibility, and hydrophilicity, which are considered to be applicable to forensic uses. The guide wire technique is easy, less invasive, highly vasoselective, and reproducible in identifying vascular injury sites.

Abstract 8526: Comparison of Transradial Coronary Angiography via Right or Left Radial Artery Approaches in Contemporary Real World Cardiology Practice. A PREVAIL Study data subanalysis

Introduction. Previous studies in small subgroups of patients undergoing transradial catheterization have suggested that the right radial artery approach may encounter more technical difficulties than the left radial approach. Hypothesis. We performed a subanalysis of the PREVAIL study in order to test the hypothesis that the two approaches are actually different in the contemporary real world practice. Methods. PREVAIL study was a prospective, observational survey of unselected consecutive patients undergoing invasive cardiovascular procedures at 9 Italian hospitals over a one month observation period specifically aimed at assessing the outcomes of radial approach in contemporary real world. The choice of arterial approach (radial vs femoral, right radial vs left radial) were left to the discretion of the operator. Pre-specified end-points of this subanalysis were the procedural characteristics, expressly defined in the case report form to control for confounders Results. Of 1,052 patients consecutively enrolled, 509 patients underwent transradial catheterization (304 right radial and 205 left radial approach). The clinical characteristics were similar between the 2 groups. A similar proportion of patients in the 2 groups had coronary angiography only (59% vs 61%) or percutaneous coronary intervention (41% vs 39%), with no difference in urgent cases (37% vs 34%). Also, procedural success rates were similar in the 2 groups (97% vs 96%, respectively). As compared with left radial, the right radial group had longer total duration of the procedure (46+29 vs 33+24 min, P&lt;0.0001) and fluoroscopy time (765+787 vs 533+502 s, P&lt;0.0001). No differences were found in quantity of contrast injected (182+115 vs 176+112 ml) and numbers of catheters used per procedure (2.8+1.1 vs 2.8+1.1). Similar results were obtained when only operators with high (&gt;65%) right radial vs left radial volume were compared. Conclusions. The right and left radial artery approaches are feasible and effective to perform coronary angiography and intervention. In contemporary real world, however, patients undergoing the left radial route had shorter procedures and lower radiological exposure as compared to those undergoing a right radial approach.

Successful management of contrast medium extravasation injury through stellate ganglion block and intra-arterial nitroglycerin

We describe the successful management of extravasation injury to the left hand by contrast medium with stellate ganglion block and intra-arterial nitroglycerin in a patient which befell during contrast-enhanced imaging. The incidence of contrast-medium extravasation injury is increasing because of the convenience and availability of contrast-enhanced imaging and ease of injection access. Extravasation of contrast medium may results in severe pain, erythema, cyanosis, and edema or even skin necrosis, which is largely related to the ionization, osmolarity, and volume of the contrast medium. The conservative treatment is often adequate in small amount extravasation, but if the extravasation is overwhelming further energetic management is mandatory. A 29-year-old man was brought to our emergency because of diffuse abdominal pain and he was arranged to receive intravenous contrast media enhanced abdominal computed tomography for diagnosis. Ruptured appendicitis with abscess formation was suspected; then the patient underwent emergent appendectomy and drainage of the abscess. However, severe swelling and cyanotic change that radiated from the intravenous catheter insertion site in every direction over the entire dorsum of the left hand were noted after the surgery. Contrast-medium extravasation injury was highly contemplated and a left stellate ganglion block was performed immediately for relief of symptoms. The consulting surgeon ruled out compartment syndrome, but advised emergent left upper limb arteriography, which revealed signs of vasospasm with high intravascular pressure of the left distal ulnar and radial arteries; thus nitroglycerin was injected into left distal ulnar and radial arteries for relief of vasospasm. The clinical symptoms were improved after the above managements and the patient was discharged 7 days later without any sequela.

39 A randomised controlled trial comparing conventional coronary artery bypass graft surgery with a composite arterial graft technique

Background Composite (Y/T) coronary artery bypass graft surgery (CABG) confers full arterial revascularisation, and “hands off” aorta compared to conventional bypass graft surgery. However, the composite surgical configuration could lead to preferential blood flow down one arm than the other (left internal mammary artery LIMA or radial artery RA) with its potential impact on graft patency. Aim To investigate the impact of bypass graft configuration on short-term grafts patency and cardiac related quality of life. Methods and Results This is a single centre randomised, controlled trial Between March 2006 and July 2007, 322 patients undergoing isolated bypass graft surgery at our institution were screened and 89 (27%) met the inclusion criteria and were randomised. Patients were allocated to conventional (conv n=46) or composite (comp n=43). The two primary end points were graft patency defined as (Thrombolysis In Myocardial Infarction) TIMI III flow in distal anastomosis at angiography 12–24 months after surgery, and cardiac-related health status assesses by Seattle angina questionnaire (SAQ). Baseline characteristics were similar between the two groups apart from diabetes where there were more diabetic patients in the composite arm than the conventional one (15(35%) vs 5(11%) p Conclusions In our randomised trial, composite bypass graft surgery was associated with higher graft failure rate at 12–24 months after surgery compared to conventional type. This difference may be due to the composite conduit configuration. Further blood flow characteristics study in this configuration can help understand such an important finding and its implication on our clinical practice. Despite the difference in graft patency there were no differences in physical limitation, angina stability, angina frequency, or quality of life between the two groups.