Distal transradial artery access for coronary angiography in a patient having rheumatoid arthritis-related severe arthropathies

Abstract

Conventional radial access has become the default access for coronary angiography. Sometime, it is difficult to take a conventional radial access, especially in patients having severe arthropathies leading to limited wrist joint mobility. In such scenarios, distal transradial access (dTRA) can be adopted. We describe a case of an elderly male patient having rheumatoid arthritis with arthropathies. He presented to us with unstable angina; coronary angiogram was advised for ischaemia assessment. Right dTRA was adopted due to severe joint deformity at wrist joint, limiting joint extension. A successful coronary angiogram was performed via the right dTRA without major discomfort and complications. Haemostasis was secured with TR band radial artery compression device. In this case report, we have evaluated the importance of practising dTRA in a patient with severe arthropathies.

Background

Coronary angiography and angioplasty are the most common invasive procedures done in cardiac catheterisation laboratories. The primary route of access for these procedures was the femoral artery initially. Now better patient comfort and lesser complications have led to conventional radial approach being the default route of access.^{1 2} Recently, a further refinement of transradial access in the form of distal transradial access (dTRA) via the anatomical snuff box has gained traction.

dTRA is superior to conventional radial access in terms of faster haemostasis, decreased rate of radial artery occlusion and patient comfort.³ In patients having severe joint deformities such as rheumatoid arthritis, due to difficulty in hyperextension of the hand, a conventional transradial access is very difficult to gain. In this report, we describe the use of dTRA in a patient having severe rheumatoid arthritis with gross joint deformities and diminished joint mobility. Our case emphasises that dTRA approach can be a feasible option in patients with severe joint arthropathies.

Case presentation

A 64-year-old man, with a history of hypertension and rheumatoid arthritis (diagnosed 25 years back), presented to cardiology clinic with unstable angina. Patient was admitted and prepared for coronary angiography. Laboratory investigations are listed in table 1. Physical examination of hand showed severe joint deformities (figure 1) including ulnar deviation, Z deformity of thumb, Swan neck deformity and diminished joint moments (figure 2). Due to the above-mentioned deformities and inability of the patient to hyperextend the wrist joint, the decision was made to gain access through distal transradial artery via the anatomical snuff box. After sterilisation and proper draping in semiprone position, the periarterial and subcutaneous tissue surrounding the anatomic snuff box was infiltrated with 2 mL of lidocaine. A 6F (French) hydrophilic radial sheath was inserted using seldinger technique after puncturing with 16-gauge cannula without complications (figure 3). Intra-arterial cocktail of heparin and glyceryl trinitrate was administered via the side port of the sheath. Coronary angiography was performed successfully using 5F Tiger diagnostic catheter which showed two vessels coronary artery disease. Successful haemostasis was achieved with TR band for 2 hours (figure 4). We experienced slight difficulty in applying TR band at the access site due to non-availability of dedicated dTRA haemostasis device in our setup. The pulse oximeter showed a normal wave form and oxygen saturation after the application of TR band. No complications were noted during hospital stay (figure 5) and on 1-week outpatient follow-up. The patient did not report any significant discomfort at the access site during hospital stay or in the period of follow-up. Radial artery patency was noted by palpation and by using portable Doppler ultrasound predischarge and postdischarge on follow-up.

Table 1.

Labs investigations

Serial no	Investigations	Results	Normal range
1.	Haemoglobin	116 g/L	(110–145)
2.	Haematocrit	38.2%	(34.5–45.4)
3.	White cell count	4.8	(4.6–10.8)
4.	Platelets	220	(154–433)
5.	Prothrombin time	10.8 s	(13.7–16.3)
6.	Activated partial thromboplastin time	27.6 s	(25–36)
7.	Baseline creatinine	1.1 mg/dL	(0.6–1.2)
8.	Creatinine after 72 hours	1.2 mg/dL	(0.6–1.2)

Figure 1.

Preprocedure, showing severe joint deformity.

Figure 2.

We can also appreciate, Ulnar deviation, swan neck deformity and limited joint hyperextension.

Figure 3.

6-French sheath inserted in right distal transradial artery.

Figure 4.

Haemostasis secured with TR band.

Figure 5.

After TR band removal, no bleeding or haematoma seen.

Treatment

Patient was revascularised by percutaneous coronary intervention with drug eluting stent on follow-up.

Outcome and follow-up

No complications noted on follow-up. Radial artery patency was confirmed by palpation and portable Doppler ultrasound after 1 week on follow-up.

Discussion

This experience demonstrates the convenient access, patient comfort, satisfaction and safety of the dTRA approach in this patient with gross joint deformity. At our centre, we prefer the conventional radial approach to the femoral approach for coronary angiograms and interventions. The dTRA access has been used several times in our catheterisation laboratory; however, this case was challenging because of the gross joint deformities leading to diminished joint mobility.

In some scenarios, conventional radial approach is challenging, both in taking access and securing post procedure haemostasis, especially, if patient is unable to hyperextend his/her hand at wrist joint. In such cases, we can offer them dTRA for operator feasibility, lesser complications and better patient comfort.⁴ We believe that dTRA can be an option rather than switching directly to femoral approach in patients having joint deformity or mobility issues at wrist joint. dTRA has been adopted as default access site by some catheterisation labs with better outcomes.¹

The conventional radial approach has a class I recommendation over femoral access by European Society of Cardiology. dTRA is gaining traction over time due to decreased incidence of radial artery occlusion, faster haemostasis and lesser bleeding risks as compared with conventional radial access.^{5 6} Disadvantages of dTRA are prolonged cannulation time, increased rate of cannulation failure, and increased learning curve.⁶ The dTRA has also been used for non-cardiac interventions like diagnostic cerebral angiography,⁷ proximal radial artery occlusion intervention,⁸ and arteriovenous fistula fistula for haemodialysis.⁹

Increasing in person experiences and centred data gathering will further elaborate the pros and cons of this becoming default access for the interventionist in the future. Each procedure requires operator learning curve, as it is vital for interventional cardiologist to learn different routes of access because in some patients conventional approach is not applicable.

Conclusion

dTRA can be an alternative option in patients with difficult conventional radial access due to severe joint diseases and deformities.

Patient’s perspective.

I, patient myself, am extremely thankful to the whole team on providing me quality treatment with minimal discomfort despite having major joint deformities.

Learning points.

• Instead of switching to femoral access from conventional radial accesses, distal transradial access (dTRA) can be adopted in patients having severe joint deformities leading to limited wrist joint mobility.

• dTRA carries lesser complications as compared with conventional radial approach but needs further studies in this regard.

• With dTRA, faster haemostasis is achieved with lesser patient discomfort.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s)