Samir B Pancholy (The Wright Center for Graduate Medical Education, The Commonwealth Medical College, Scranton, USA) and others report in JACC: Cardiovascular Interventions that prophylactic ipsilateral ulnar compression, during radial artery haemostasis, significantly reduces the risk of radial artery occlusion after transradial access. According to the authors, the “simplicity and the safety” of the manoeuver should encourage most radial operators and staff to “embrace the technique as default protocol”.
Pancholy et al report that the contemporary “real-world” incidence of acute radial artery occlusion “is approaching 10%” in institutions with expertise in performing transradial artery access. They add: “With rapidly growing adoption of transradial access worldwide with a large mix of operators at several stages of the learning curve and increasing patient as well as procedural complexities, this incidence may increase and hence radial artery occlusion prevention should take centre stage to preserve the safest access site in patient with a chronic recurrent illness such as atherosclerotic vascular disease”.
The authors report that ipsilateral ulnar compression has been shown to be “an effective, safe, and inexpensive” technique to facilitate radial artery recanalisation in patients who have already developed acute radial artery occlusion. Therefore, they evaluated whether prophylactic ipsilateral ulnar compression would reduce the risk of radial artery occlusion.
In PROPHET-II (Prophylactic hyperperfusion evaluation trial), 3,000 patients scheduled to undergo cardiac catheterisation with transradial access were randomised to receive standard patent haemostasis after the procedure (1,497; group 1) or patent haemostasis with prophylactic ipsilateral ulnar compression (1,503; group 2). “The ipsilateral ulnar artery was compressed at the Guyon’s canal by placing a cylindrical composite made by wrapping 4inch X 4inch gauze around a 1inch plastic needle cap, or the barrel of a 3ml plastic syringe, and compressing it using a circumferentially applied Hemoband (Hemoband Corporation),” Pancholy et al explain.
The incidence of radial artery occlusion was significantly reduced in group 2 immediately after haemostasis (1.5% vs. 13.9% for group 1; p<0.0001) and 24 hours afterwards (1.5% vs. 4.3%, respectively; p<0.0001). The authors note: “The primary endpoint, 30-day rate of radial artery occlusion, was significantly lower in group 2 compared with group 1 (0.9% vs. 3%; p=0.0001).” Furthermore, patent haemostasis was achieved in significantly more patients in group 2 than in group 1: 96% vs. 74%; p=0.001. In a multivariate analysis, age, female gender, history of diabetes, pain during compression, and prophylactic ipsilateral ulnar compression or randomisation to group 2 were all independent predictors of 30-day radial artery occlusion.
According to Pancholy et al, the “two primary concerns” with ipsilateral ulnar compression—hand ischaemia and ulnar artery trauma—were “alleviated to a large extent by our findings” because none of the patients in the study developed symptoms or clinical signs of digital ischaemia, and an ultrasound subgroup in the study showed no ulnar artery thickening or oclusion. “The simplicity and safety of the manoeuver of ipsilateral ulnar compression, with lack of need for complex equipment, combined with its highly significant efficacy and safety in lowering the incidence of radial artery occlusion should encourage most radial operators and staff to embrace the technique as a default protocol,” they conclude.