May 25, 2016

PARIS, FRANCE — Three-fourths of patients underoing PCI via the transradial route experienced upper-extremity dysfunction within 2 weeks of the procedure, new research suggests[1].

The three most common abnormalities were decreased sensibility of the fingertips, decreased wrist strength, and increased volumetry of the hand.

Dr Eva Zwaan

Principal investigator Dr Eva Zwaan (Albert Schweitzer Hospital, Dordrecht, the Netherlands) told EuroPCR 2016 attendees that physicians should ask their patients undergoing PCI what they do for a living because those dependent on their hands, such as professional artists and musicians, may have concerns about the transradial approach.

"Fortunately, the patients who are musicians didn't develop upper-extremity dysfunction, but I want to be a surgeon myself, and if I should have an elective PCI, I would not want it through the radial artery; I would want the femoral artery," she told heartwire from Medscape.

Zwaan noted that transradial PCI is already widely used in Europe and is gaining in popularity in the US. It is associated with lower major bleeding and mortality in STEMI patients, fewer access-site complications, shorter hospital stays, and lower costs, but the exact effects of transradial PCI on upper-extremity dysfunction are unknown.

"It feels to me like you've dropped a small hand grenade into the radial community," panelist Dr David Kettles (St Dominic's Hospital, East London, South Africa) said during a discussion of the study.

Session cochair and EuroPCR course director Dr William Wijns (Cardiovascular Center Aaslt, Belgium) told heartwire it may not have been a hand grenade but said, "We were all very impressed by the sophistication and the detailed analysis of the functional impact of the radial access on the upper arm. I think she probably did set the standard approach on how you should evaluate this."

Detailed Assessment

In the prospective multicenter study, 191 patients underwent the following tests and measurements in both the arm used for radial access (intervention) and the other arm at baseline, 24 hours, 2 weeks, 1 month, and 6 months:

  • Echo Doppler to assess vessel anomalies and radial artery occlusion.

  • Volumetry of the hand and forearm to assess swelling.

  • The Weinstien and Heart Sensory Test to determine sensibility of the fingertips.

  • Dynamometer testing for key and Palmar grip.

  • Isometric strength measurements at the wrist and elbow.

They also filled out several questionnaires to evaluate pain, disability of the arm, shoulder, and hands, and carpal-tunnel syndrome. A binary score was then compiled for upper-extremity dysfunction at 2 weeks vs baseline and the score validated by hand surgeons.

Upper-extremity dysfunction was identified in the intervention arm in 74.9% of patients, a statistically significant difference compared with the nonintervention arm (P<0.001).

Patients with upper-extremity dysfunction were significantly more likely to have radial artery occlusion than those without (9.8% vs 0%; P<0.001) and were younger (63.4 years vs 67.5 years; P=0.01).

"Future studies should focus on prevention using slender [PCI] techniques and treatment with early referral to a hand-rehabilitation specialist," she said.

The panel questioned whether the abnormalities detected were clinical relevant and what was driving the dysfunction if <10% of patients had radial artery occlusion.

Zwaan said it could be a hematoma that has not resolved at 2 weeks and is very invasive in the muscles and tendons. "This is very agitating and very painful, and there is strength loss."

To heartwire , Zwaan said the exact figures aren't available on patients at 1 and 6 months but that about 20 patients have been referred to hand-rehabilitation specialists for clinically relevant complaints. "Mainly they are men with symptoms that mimic carpal-tunnel syndrome, so really tingling and numbness of the hand."

Zwaan told the panel, "These are very interesting findings, but we still have a lot to do." The group plans to complete enrollment in the 500-patient trial, report follow-up data sometime next spring, and is also planning a femoral control group.

Zwaan reports no relevant financial relationships.

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