Radial catheterization allen's test: Difference between revisions
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{{SI}} | {{SI}} | ||
{{CMG}} | {{CMG}}; {{AE}} {{AO}} | ||
==Overview== | ==Overview== | ||
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==Pre-procedure Assessment== | ==Pre-procedure Assessment== | ||
====Patient Evaluation==== | ====Patient Evaluation==== | ||
This is the first towards a successful transradial PCI. Effort should be made to assess the following: | This is the first step towards a successful transradial PCI. Effort should be made to assess the following: | ||
* Age - Patients with ages <70 years are better suitable for r-PCI | * Age - Patients with ages <70 years are better suitable for r-PCI | ||
* Patients' hemodynamic status | * Patients' hemodynamic status | ||
* History of previous ipsilateral brachial or transradial procedure | * History of previous ipsilateral brachial or transradial procedure | ||
* Strong radial arterial pulse and presence of a normal Allen’s test | * Strong radial arterial pulse and presence of a normal Allen’s test | ||
====Radial vs. Ulnar Approach==== | ====Radial vs. Ulnar Approach==== | ||
Although the ulnar artery is rarely used nowadays, it has been successfully attempted in the past with a high success rate comparable to the transradial approach.<ref name="Aptecar-2006">{{Cite journal | last1 = Aptecar | first1 = E. | last2 = Pernes | first2 = JM. | last3 = Chabane-Chaouch | first3 = M. | last4 = Bussy | first4 = N. | last5 = Catarino | first5 = G. | last6 = Shahmir | first6 = A. | last7 = Bougrini | first7 = K. | last8 = Dupouy | first8 = P. | title = Transulnar versus transradial artery approach for coronary angioplasty: the PCVI-CUBA study. | journal = Catheter Cardiovasc Interv | volume = 67 | issue = 5 | pages = 711-20 | month = May | year = 2006 | doi = 10.1002/ccd.20679 | PMID = 16557601 }}</ref> Compared with the radial artery, the ulnar artery have been shown to be larger<ref name="Ashraf-2010">{{Cite journal | last1 = Ashraf | first1 = T. | last2 = Panhwar | first2 = Z. | last3 = Habib | first3 = S. | last4 = Memon | first4 = MA. | last5 = Shamsi | first5 = F. | last6 = Arif | first6 = J. | title = Size of radial and ulnar artery in local population. | journal = J Pak Med Assoc | volume = 60 | issue = 10 | pages = 817-9 | month = Oct | year = 2010 | doi = | PMID = 21381609 }}</ref> and more prone to access site failures due to its higher rate of spasms and anatomical | Although the ulnar artery is rarely used nowadays, it has been successfully attempted in the past with a high success rate comparable to the transradial approach.<ref name="Aptecar-2006">{{Cite journal | last1 = Aptecar | first1 = E. | last2 = Pernes | first2 = JM. | last3 = Chabane-Chaouch | first3 = M. | last4 = Bussy | first4 = N. | last5 = Catarino | first5 = G. | last6 = Shahmir | first6 = A. | last7 = Bougrini | first7 = K. | last8 = Dupouy | first8 = P. | title = Transulnar versus transradial artery approach for coronary angioplasty: the PCVI-CUBA study. | journal = Catheter Cardiovasc Interv | volume = 67 | issue = 5 | pages = 711-20 | month = May | year = 2006 | doi = 10.1002/ccd.20679 | PMID = 16557601 }}</ref> Compared with the radial artery, the ulnar artery have been shown to be larger<ref name="Ashraf-2010">{{Cite journal | last1 = Ashraf | first1 = T. | last2 = Panhwar | first2 = Z. | last3 = Habib | first3 = S. | last4 = Memon | first4 = MA. | last5 = Shamsi | first5 = F. | last6 = Arif | first6 = J. | title = Size of radial and ulnar artery in local population. | journal = J Pak Med Assoc | volume = 60 | issue = 10 | pages = 817-9 | month = Oct | year = 2010 | doi = | PMID = 21381609 }}</ref> and more prone to access site failures due to its higher rate of spasms and anatomical variations.<ref name="Vassilev-2008">{{Cite journal | last1 = Vassilev | first1 = D. | last2 = Smilkova | first2 = D. | last3 = Gil | first3 = R. | title = Ulnar artery as access site for cardiac catheterization: anatomical considerations. | journal = J Interv Cardiol | volume = 21 | issue = 1 | pages = 56-60 | month = Feb | year = 2008 | doi = 10.1111/j.1540-8183.2007.00314.x | PMID = 18086137 }}</ref> Therefore, the transulnar approach is generally reserved as an alternative option in selected cases, and especially when the radial artery is being preserved in anticipation of its usage as a coronary bypass conduit.<ref name="Aptecar-2006">{{Cite journal | last1 = Aptecar | first1 = E. | last2 = Pernes | first2 = JM. | last3 = Chabane-Chaouch | first3 = M. | last4 = Bussy | first4 = N. | last5 = Catarino | first5 = G. | last6 = Shahmir | first6 = A. | last7 = Bougrini| first7 = K. | last8 = Dupouy | first8 = P. | title = Transulnar versus transradial artery approach for coronary angioplasty: the PCVI-CUBA study. | journal = Catheter Cardiovasc Interv | volume = 67 | issue = 5 | pages = 711-20 | month = May | year = 2006 | doi = 10.1002/ccd.20679| PMID = 16557601 }}</ref> | ||
====Left vs. Right Radial Artery==== | |||
[[Radial artery]] in right upper extremity is usually used in 90% of cases for catheterization due to both operator and patient convenience with typical catheterization.<ref name="Bertrand-2010">{{Cite journal | last1 = Bertrand | first1 = OF. | last2 = Rao | first2 = SV. | last3 = Pancholy | first3 = S. | last4 = Jolly | first4 = SS. | last5 = Rodés-Cabau | first5 = J. | last6 = Larose | first6 = E. | last7 = Costerousse | first7 = O. | last8 = Hamon | first8 = M. | last9 = Mann | first9 = T. | title = Transradial approach for coronary angiography and interventions: results of the first international transradial practice survey. | journal = JACC Cardiovasc Interv | volume = 3 | issue = 10 | pages = 1022-31 | month = Oct | year = 2010 | doi = 10.1016/j.jcin.2010.07.013 | PMID = 20965460 }}</ref> Other factors to consider in making a choice between left and right radial artery include the presence of a left internal mammary artery (IMA) graft and the possible future need for a bypass graft conduit from the non-dominant hand. | |||
The following factors favor the use of left radial artery for PCI:<ref name="Caputo-2011">{{Cite journal | last1 = Caputo | first1 = RP. | last2 = Tremmel | first2 = JA. | last3 = Rao | first3 = S. | last4 = Gilchrist | first4 = IC. | last5 = Pyne | first5 = C. | last6 = Pancholy | first6 = S. | last7 = Frasier | first7 = D. | last8 = Gulati | first8 = R. | last9 = Skelding | first9 = K. | title = Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI. | journal = Catheter Cardiovasc Interv | volume = 78 | issue = 6 | pages = 823-39 | month = Nov | year = 2011 | doi = 10.1002/ccd.23052 | PMID = 21544927 }}</ref> | |||
* Short statured patients | |||
* Patients with abdominal obesity who tend to have compressed abdominal aortas | |||
* Evaluation and treatment of infradiaphragmatic pathology | |||
* Left subclavian and left vertebral interventions | |||
* Reduced fluoroscopy time and radiation dose<ref name="Sciahbasi-2011">{{Cite journal | last1 = Sciahbasi | first1 = A. | last2 = Romagnoli | first2 = E. | last3 = Burzotta | first3 = F. | last4 = Trani | first4 = C. | last5 = Sarandrea | first5 = A. | last6 = Summaria | first6 = F. | last7 = Pendenza | first7 = G. | last8 = Tommasino | first8 = A. | last9 = Patrizi | first9 = R. | title = Transradial approach (left vs right) and procedural times during percutaneous coronary procedures: TALENT study. | journal = Am Heart J | volume = 161 | issue = 1 | pages = 172-9 | month = Jan | year = 2011 | doi = 10.1016/j.ahj.2010.10.003 | PMID = 21167351 }}</ref> | |||
== | ==The Clinical Implication of Allen's Test== | ||
This test is named after [[Edgar Van Nuys Allen]].<ref>{{WhoNamedIt|synd|189}}</ref>. The utility of the Allen's test has been questioned,<ref name="pmid11081899">{{cite journal |author=Jarvis MA, Jarvis CL, Jones PR, Spyt TJ |title=Reliability of Allen's test in selection of patients for radial artery harvest |journal=Ann. Thorac. Surg. |volume=70 |issue=4 |pages=1362–5 |year=2000 |month=October |pmid=11081899 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(00)01551-4}}</ref> and no direct association with ischemic complications of radial artery cannulation has ever been demonstrated. In 1983, Slogoff and colleagues reviewed 1,782 radial artery cannulations and found that 25% of them resulted in complete radial artery occlusion, without apparent adverse effects.<ref>Slogoff s, Keats AS, Arlund C. On the safety of radial artery cannulation. Anesthesiology 1983; 59:42-7</ref> A number of reports have been published in which permanent ischemic sequelae occurred even in the presence of a normal Allen's test.<ref>Thompson SR, Hirschberg A: Allen's test re-examined. Crit Care Med 16:915, 1988</ref><ref>Wilkins RG: Radial artery cannulation and ischaemic damage: A review. Anaesthesia 40:896-899, 1985</ref> In addition, the results of Allen's tests do not appear to correlate with distal blood flow as demonstrated by fluorescein dye injections<ref>McGregor AD: The Allen test-an investigation of its accuracy by fluorescein angiography. J Hand Surg [Br] 12:82-85, 1987</ref> or photo [[plethysmography]].<ref>Stead SW, Stirt JA: Assessment of digital blood flow and palmar collateral circulation. Int J Clin Monit Comput 2:29, 1985</ref> | |||
This test is named after [[Edgar Van Nuys Allen]].<ref>{{WhoNamedIt|synd|189}}</ref>.The utility of the Allen's test has been questioned,<ref name="pmid11081899">{{cite journal |author=Jarvis MA, Jarvis CL, Jones PR, Spyt TJ |title=Reliability of Allen's test in selection of patients for radial artery harvest |journal=Ann. Thorac. Surg. |volume=70 |issue=4 |pages=1362–5 |year=2000 |month=October |pmid=11081899 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(00)01551-4}}</ref> and no direct association with ischemic complications of radial artery cannulation | |||
Modifications to the test have been proposed to improve reliability.<ref name="pmid17643672">{{cite journal |author=Asif M, Sarkar PK |title=Three-digit Allen's test |journal=Ann. Thorac. Surg. |volume=84 |issue=2 |pages=686–7 |year=2007 |month=August |pmid=17643672 |doi=10.1016/j.athoracsur.2006.11.038 |url=http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(06)02283-1}}</ref> | Modifications to the test have been proposed to improve reliability.<ref name="pmid17643672">{{cite journal |author=Asif M, Sarkar PK |title=Three-digit Allen's test |journal=Ann. Thorac. Surg. |volume=84 |issue=2 |pages=686–7 |year=2007 |month=August |pmid=17643672 |doi=10.1016/j.athoracsur.2006.11.038 |url=http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(06)02283-1}}</ref> | ||
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Despite this lack of association with outcomes, the Allen's Test is often performed in clinical practice. | Despite this lack of association with outcomes, the Allen's Test is often performed in clinical practice. | ||
=== | ===Performing the Allen's Test=== | ||
This is used to test the patency of the palmer arch. | |||
* The hand is elevated and the patient/person is asked to make a fist for about 30 secs. | |||
* Pressure is applied over the ulnar and the radial arteries so as to occlude both of them. | |||
* Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails). | |||
* Ulnar pressure is released and the color should return in 7 secs. | |||
'''Inference:''' Ulnar artery supply to the hand is sufficient and it is safe to cannulate the radial artery | '''Inference:''' Ulnar artery supply to the hand is sufficient and it is safe to cannulate the radial artery | ||
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'''Reverse Allen's test''' may be performed in patients who require a second procedure through the same radial site. In reverse Allen's test, the physician releases pressure over the radial artery rather than the ulnar. This may detect proximal radial artery disease/occlusion that may be asymptomatic. Patients with an abnormal Reverse Allen's Test should not undergo a repeat transradial procedure from same radial site. | '''Reverse Allen's test''' may be performed in patients who require a second procedure through the same radial site. In reverse Allen's test, the physician releases pressure over the radial artery rather than the ulnar. This may detect proximal radial artery disease/occlusion that may be asymptomatic. Patients with an abnormal Reverse Allen's Test should not undergo a repeat transradial procedure from same radial site. | ||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
Latest revision as of 18:10, 29 November 2013
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]
Overview
The hand is normally supplied by blood from the ulnar and radial arteries. The arteries undergo anastomosis in the hand. Thus, if the blood supply from one of the arteries is cut off, the other artery can supply adequate blood to the hand. A minority of people lack this dual blood supply. Allen's test or oximetry/plethysmography should be performed before the procedure to confirm that there is sufficient blood flow in the ulnar artery should there be loss of patency in the radial artery due to either thrombosis or spasm which can result in gangrenous finger or had loss.
Pre-procedure Assessment
Patient Evaluation
This is the first step towards a successful transradial PCI. Effort should be made to assess the following:
- Age - Patients with ages <70 years are better suitable for r-PCI
- Patients' hemodynamic status
- History of previous ipsilateral brachial or transradial procedure
- Strong radial arterial pulse and presence of a normal Allen’s test
Radial vs. Ulnar Approach
Although the ulnar artery is rarely used nowadays, it has been successfully attempted in the past with a high success rate comparable to the transradial approach.[1] Compared with the radial artery, the ulnar artery have been shown to be larger[2] and more prone to access site failures due to its higher rate of spasms and anatomical variations.[3] Therefore, the transulnar approach is generally reserved as an alternative option in selected cases, and especially when the radial artery is being preserved in anticipation of its usage as a coronary bypass conduit.[1]
Left vs. Right Radial Artery
Radial artery in right upper extremity is usually used in 90% of cases for catheterization due to both operator and patient convenience with typical catheterization.[4] Other factors to consider in making a choice between left and right radial artery include the presence of a left internal mammary artery (IMA) graft and the possible future need for a bypass graft conduit from the non-dominant hand.
The following factors favor the use of left radial artery for PCI:[5]
- Short statured patients
- Patients with abdominal obesity who tend to have compressed abdominal aortas
- Evaluation and treatment of infradiaphragmatic pathology
- Left subclavian and left vertebral interventions
- Reduced fluoroscopy time and radiation dose[6]
The Clinical Implication of Allen's Test
This test is named after Edgar Van Nuys Allen.[7]. The utility of the Allen's test has been questioned,[8] and no direct association with ischemic complications of radial artery cannulation has ever been demonstrated. In 1983, Slogoff and colleagues reviewed 1,782 radial artery cannulations and found that 25% of them resulted in complete radial artery occlusion, without apparent adverse effects.[9] A number of reports have been published in which permanent ischemic sequelae occurred even in the presence of a normal Allen's test.[10][11] In addition, the results of Allen's tests do not appear to correlate with distal blood flow as demonstrated by fluorescein dye injections[12] or photo plethysmography.[13]
Modifications to the test have been proposed to improve reliability.[14]
Despite this lack of association with outcomes, the Allen's Test is often performed in clinical practice.
Performing the Allen's Test
This is used to test the patency of the palmer arch.
- The hand is elevated and the patient/person is asked to make a fist for about 30 secs.
- Pressure is applied over the ulnar and the radial arteries so as to occlude both of them.
- Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails).
- Ulnar pressure is released and the color should return in 7 secs.
Inference: Ulnar artery supply to the hand is sufficient and it is safe to cannulate the radial artery
If color does not return or returns after 7 seconds, then the ulnar artery supply to the hand is not sufficient and the radial artery therefore cannot be safely cannulated.
Below is a video demonstrating Allen's test
{{#ev:youtube|jq0ai5uXx68}}
Reverse Allen's test may be performed in patients who require a second procedure through the same radial site. In reverse Allen's test, the physician releases pressure over the radial artery rather than the ulnar. This may detect proximal radial artery disease/occlusion that may be asymptomatic. Patients with an abnormal Reverse Allen's Test should not undergo a repeat transradial procedure from same radial site.
References
- ↑ 1.0 1.1 Aptecar, E.; Pernes, JM.; Chabane-Chaouch, M.; Bussy, N.; Catarino, G.; Shahmir, A.; Bougrini, K.; Dupouy, P. (2006). "Transulnar versus transradial artery approach for coronary angioplasty: the PCVI-CUBA study". Catheter Cardiovasc Interv. 67 (5): 711–20. doi:10.1002/ccd.20679. PMID 16557601. Unknown parameter
|month=ignored (help) - ↑ Ashraf, T.; Panhwar, Z.; Habib, S.; Memon, MA.; Shamsi, F.; Arif, J. (2010). "Size of radial and ulnar artery in local population". J Pak Med Assoc. 60 (10): 817–9. PMID 21381609. Unknown parameter
|month=ignored (help) - ↑ Vassilev, D.; Smilkova, D.; Gil, R. (2008). "Ulnar artery as access site for cardiac catheterization: anatomical considerations". J Interv Cardiol. 21 (1): 56–60. doi:10.1111/j.1540-8183.2007.00314.x. PMID 18086137. Unknown parameter
|month=ignored (help) - ↑ Bertrand, OF.; Rao, SV.; Pancholy, S.; Jolly, SS.; Rodés-Cabau, J.; Larose, E.; Costerousse, O.; Hamon, M.; Mann, T. (2010). "Transradial approach for coronary angiography and interventions: results of the first international transradial practice survey". JACC Cardiovasc Interv. 3 (10): 1022–31. doi:10.1016/j.jcin.2010.07.013. PMID 20965460. Unknown parameter
|month=ignored (help) - ↑ Caputo, RP.; Tremmel, JA.; Rao, S.; Gilchrist, IC.; Pyne, C.; Pancholy, S.; Frasier, D.; Gulati, R.; Skelding, K. (2011). "Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI". Catheter Cardiovasc Interv. 78 (6): 823–39. doi:10.1002/ccd.23052. PMID 21544927. Unknown parameter
|month=ignored (help) - ↑ Sciahbasi, A.; Romagnoli, E.; Burzotta, F.; Trani, C.; Sarandrea, A.; Summaria, F.; Pendenza, G.; Tommasino, A.; Patrizi, R. (2011). "Transradial approach (left vs right) and procedural times during percutaneous coronary procedures: TALENT study". Am Heart J. 161 (1): 172–9. doi:10.1016/j.ahj.2010.10.003. PMID 21167351. Unknown parameter
|month=ignored (help) - ↑ Template:WhoNamedIt
- ↑ Jarvis MA, Jarvis CL, Jones PR, Spyt TJ (2000). "Reliability of Allen's test in selection of patients for radial artery harvest". Ann. Thorac. Surg. 70 (4): 1362–5. PMID 11081899. Unknown parameter
|month=ignored (help) - ↑ Slogoff s, Keats AS, Arlund C. On the safety of radial artery cannulation. Anesthesiology 1983; 59:42-7
- ↑ Thompson SR, Hirschberg A: Allen's test re-examined. Crit Care Med 16:915, 1988
- ↑ Wilkins RG: Radial artery cannulation and ischaemic damage: A review. Anaesthesia 40:896-899, 1985
- ↑ McGregor AD: The Allen test-an investigation of its accuracy by fluorescein angiography. J Hand Surg [Br] 12:82-85, 1987
- ↑ Stead SW, Stirt JA: Assessment of digital blood flow and palmar collateral circulation. Int J Clin Monit Comput 2:29, 1985
- ↑ Asif M, Sarkar PK (2007). "Three-digit Allen's test". Ann. Thorac. Surg. 84 (2): 686–7. doi:10.1016/j.athoracsur.2006.11.038. PMID 17643672. Unknown parameter
|month=ignored (help)