Incidence of compartment syndrome of the arm in a large series of transradial approach for coronary procedures.

BACKGROUND: Despite the fact that transradial approach is widely used, literature on this devastating complication after transradial approach is scarce. Pubmed review from 1992 to 2007 includes only 5 isolated reports. In one small series with 250 patients, an incidence of 0.4% is suggested. METHODS: We conducted a retrospective review of the transradial cases in Laval Hospital from 1994 to September 2007 (51,296 procedures) to know the incidence of compartment syndrome of the arm (CSA) and compare it with the literature. RESULTS: In our institution CSA occurred in 2 of the 51,296 transradial procedures (0.004%). Both of them were in female patients with low BSA (1.7 and 1.5 m(2)) who received either an excess of unfractioned heparin during the procedure or uncorrected low-molecular-weight heparin after the procedure. Both of them underwent fasciotomy of the forearm. Recovery was complete in one patient. The other patient required skin graft and developed a partial Volkmann contracture at follow-up. This low incidence is due to a high index of suspicion when swelling or pain in the arm used for the procedure is noted and to the immediate application of a specific protocol. This protocol initiated by the nursing personnel consists of inflation of a tensiometer cuff at the point of pain or swelling. Cuff is inflated during at least 15 minutes up to 10-15 mmHg below the systolic pressure to allow distal pulsatile flow to the hand or forearm (monitored with oxymetry/plethismography) so the bleeding stops and diffuses to decrease the pressure within the forearm. Usually, two periods of 15 min of inflation are required to control bleeding. CONCLUSION: Incidence of CSA is very low at our institution. A high suspicion with any complaint of pain and swelling in the arm and a proper management of anticoagulation especially in the postprocedure period with great emphasis in patients with low BSA or low creatinine clearance are the key points. Implantation of an immediate specific nursing protocol is required.

Evaluation of the ulnopalmar arterial arches with pulse oximetry and plethysmography: comparison with the Allen's test in 1010 patients.

BACKGROUND: To avoid ischemic hand complications, the percutaneous transradial approach is only performed in patients with patent hand collateral arteries, which is usually evaluated with the modified Allen's test (MAT). This qualitative test measures the time needed for maximal palmar blush after release of the ulnar artery compression with occlusive pressure of the radial artery. The objectives were to evaluate the patency of the hand collateral arteries and to compare MAT with combined plethysmography (PL) and pulse oximetry (OX) tests before the percutaneous transradial approach. METHODS: Patients referred to the catheterization laboratory were prospectively examined with MAT, PL, and OX tests. PL readings during radial artery compression were divided into 4 types: A, no damping; B, slight damping of pulse tracing; C, loss followed by recovery; or D, no recovery of pulse tracing within 2 minutes. OX results were either positive or negative. Results of both tests were compared in 1010 consecutive patients. RESULTS: MAT results < or =9 seconds on either hand were seen in 93.7% of patients. PL and OX types A, B, or C on either hand were seen in 98.5% of patients. On the basis of the MAT < or =9 seconds criteria, 6.3% of patients were excluded from the transradial approach, whereas with PL and OX types A, B, and C, only 1.5% of patients were excluded. There was more exclusion in men and with increasing age by using both methods. CONCLUSIONS: In the evaluation of hand collaterals, PL and OX were found to be more sensitive than MAT. When applied to transradial approach screening, only 1.5% of patients were not suitable candidates for the transradial approach.

Delayed abrupt tamponade by isolated left atrial compression following coronary artery perforation during coronary angioplasty.

Cardiac tamponade following coronary artery perforation during percutaneous coronary intervention is a rare but potentially life-threatening complication. When associated with Ellis type III coronary perforations, tamponade develops rapidly during the intervention. In contrast, Ellis type I and II coronary perforations, because of their contained nature, are usually managed conservatively and rarely result in tamponade. We report two unusual cases of delayed but abrupt tamponade caused by localized left atrial compression after contained coronary artery perforation following angioplasty. This complication is an extremely rare event. Etiology, diagnostic modalities, and management are discussed.

Radial loop and extreme vessel tortuosity in the transradial approach: advantage of hydrophilic-coated guidewires and catheters.

Between October 2000 and October 2001, all transradial cases performed by the author necessitating radial and upper arm angiography because of difficult advancement of standard guidewires or catheters were analyzed retrospectively. Fourteen of 594 (2.4%) transradial cases met the study criteria. Radial loops or stenosis and tortuosity in the subclavian or innominate artery were responsible for the difficult access. Several examples of patients with access problems are presented. A technique using a hydrophilic-coated guidewire and a new hydrophilic-coated guiding catheter is described.

Transbrachial insertion of an intra-aortic balloon pump for complex coronary angioplasty.

Transfemoral insertion of intra-aortic balloon pump (IABP) for hemodynamic support is a useful adjunct in patients undergoing complex percutaneous revascularization procedures. However, this approach is not always possible, particularly in patients with severe occlusive peripheral vascular disease. We describe the first reported case of insertion of IABP through the brachial artery.