Search Results (24)

Background: Arterial variations in the upper limb, although infrequent, carry critical clinical implications. The presence of superficial ulnar and radial arteries, especially when originating from high levels, increases the risk of iatrogenic injury, misdiagnosis, and surgical complications. To confirm and describe, through ultrasound and anatomical dissection, the presence of a high-origin superficial ulnar artery and a superficial radial artery in a cadaver, highlighting their anatomical trajectory and clinical relevance. Methods: A cross-sectional ultrasound and anatomical study was conducted on 150 upper limbs from fresh-frozen cadavers. High-frequency ultrasound was used to scan the vasculature from the axilla to the wrist. Subsequently, dissection was performed to confirm sonographic findings. Results: One case (0.66%) of concurrent superficial ulnar artery and superficial radial artery was identified in the left arm of a 79-year-old male cadaver. The superficial ulnar artery originated from the axillary artery and coursed superficially along the forearm, anterior to the flexor muscles. The superficial radial artery emerged from the brachial artery and ran subcutaneously in the distal forearm. These arteries remained in close relation to key neural and venous structures, increasing their vulnerability to clinical error. Conclusions: The identification of high-origin superficial arteries is essential for clinical practice. Ultrasound serves as a reliable, non-invasive method for detecting such variations preoperatively. Awareness of these anomalies can prevent inadvertent vascular injuries, improve diagnostic accuracy, and inform safer surgical and anesthetic approaches in upper limb interventions. Full article

Background: This study aims to evaluate the feasibility, efficacy, and safety of distal transradial access (dRA) for the endovascular management of malfunctioning dialysis fistulas. This study also compares dRA with conventional access techniques, such as proximal radial and transvenous access, focusing on technical success, clinical outcomes, and vascular access site complications (VASCs). Methods: A retrospective multicenter study was conducted across four hospitals, including 292 patients treated between January 2019 and June 2024. Of these, 57 patients underwent dRA, and 235 received proximal radial or transvenous access. Key outcomes included technical success (successful completion of the procedure), clinical success (restoration of functional dialysis access), and complication rates. Data were collected on procedure times and complication profiles. Results: Technical success was achieved in 96.5% of patients undergoing dRA, compared to 98.3% in those receiving conventional access (p = 0.388). Clinical success was similar between groups (96.5% vs. 97%, p = 0.835). The overall complication rate was 10.5% for dRA and 8.5% for conventional access (p = 0.632). Cannulation time was longer for dRA (109.1 vs. 91.9 s, p < 0.001), but total procedure duration was comparable between the groups. No major complications were observed in either cohort, and improved post-procedure access flow rates were recorded in all patients. Conclusions: Distal transradial access is a feasible and effective approach for the endovascular management of malfunctioning dialysis fistulas, with outcomes comparable to conventional access techniques. It provides a safe alternative, particularly for patients with complex fistulas, while maintaining a low complication profile. Full article

Minimally invasive, sternum-sparing total coronary revascularization in multivessel disease via left anterior mini-thoracotomy (TCRAT) was introduced recently. Intra-aortic balloon occlusion is a conceivable option to avoid manipulation of the ascending aorta, to reduce the risk of stroke and to be able to treat patients with severe calcifications and unfavorable aortic anatomies. Background/Objectives: The aim of our study was to show that the use of the IntraClude^® device, as part of minimally invasive coronary artery bypass grafting (CABG) via left anterior mini-thoracotomy, is feasible. Methods: From May to December 2023, CABG via left anterior mini-thoracotomy on cardiopulmonary bypass and cardioplegic arrest was successfully performed in 20 patients (17 male, 67.6 ± 8.2 (51–82) years). All patients had significant coronary artery disease (three-vessel: n = 6; two-vessel: n = 11; one-vessel: n = 3) with indication for surgical revascularization. The mean EuroScore2 was 2.6. Results: All patients successfully underwent minimally invasive CABG using endo-aortic balloon occlusion. A total of 43 distal anastomoses (2.2 ± 0.6 (1–3) per patient) were performed by using left internal artery mammary (n = 20) and radial artery (n = 14) for grafting the left anterior descending (n = 19), circumflex (n = 15) and right (n = 6) coronary artery. There was no hospital mortality, no stroke, no myocardial infarction or repeat revascularization. A total of 15 out of 20 patients left hospital within 8 days after surgery. Conclusions: TCRAT by using the IntraClude^® device is feasible without compromising surgical principles while avoiding the external manipulation of the ascending aorta. The use of intra-aortic balloon occlusion instead of transthoracic clamps further reduces the invasiveness of the procedure. Full article

Background/Objectives: The distal transradial approach (dTRA) is increasingly used in interventional cardiology. Doppler Ultrasound (DUS) effectively assesses radial artery (RA) characteristics. This study aims to identify specific RA DUS characteristics in patients undergoing coronary procedures via dTRA. Methods: Participants from the ANTARES trial who completed the intervention per-protocol and retained RA patency were included. DUS was performed at baseline, 1 day, and 60 days post-procedure. Results: Among 400 participants, 348 had either dTRA (n = 169) or conventional transradial access (cTRA) (n = 179). Distal RA lumen diameter was 12% smaller than that of the proximal RA (p < 0.001). Men had a 14% larger distal RA diameter than women (2.33 ± 0.31 mm vs. 2.04 ± 0.27 mm, p < 0.0001), similar to the proximal RA relationship. Peak flow velocities were similar between the sexes. Univariate linear regression showed that height, weight, body mass index, and body surface area (BSA) predicted arterial size, with BSA remaining significant in multivariate analysis (beta coefficient 0.62; confidence interval 0.49–0.75; p < 0.0001). Distal RA diameter correlated positively with palpable pulse at the snuffbox and wrist. The dTRA resulted in an immediate 14% and 11% increase in distal and proximal RA diameter, respectively (both p < 0.05). Sixty days after dTRA, the distal RA remained slightly dilated (p < 0.05), while the proximal RA returned to baseline. Conclusions: Distal RA diameter is significantly associated with sex, measuring smaller than the forearm segment. A strong palpable pulse correlates with larger distal RA size. The dTRA induces RA lumen expansion. A thorough understanding of distal RA anatomy is essential for optimizing patient selection and refining techniques for transradial procedures. Full article

Radial artery spasm (RAS) is a common complication associated with transradial access (TRA) for coronary interventions, particularly affecting elderly patients in whom radial access is preferred due to its benefits in reducing bleeding complications, improving clinical outcomes, and lowering long-term costs. This review examines the incidence, prevention, and treatment of RAS. Methods included an online search of PubMed and other databases in early 2024, analyzing meta-analyses, reviews, studies, and case reports. RAS is characterized by a sudden narrowing of the radial artery due to psychological and mechanical factors with incidence reports varying up to 51.3%. Key risk factors include patient characteristics like female sex, age, and small body size as well as procedural factors such as emergency procedures and the use of multiple catheters. Preventive measures include using distal radial access, hydrophilic sheaths, and appropriate catheter sizes. Treatments involve the intraarterial administration of nitroglycerine and verapamil as well as mechanical methods like balloon-assisted tracking. This review underscores the need for standardizing RAS definitions and emphasizes the importance of operator experience and patient management in reducing RAS incidence and improving procedural success. Full article

Vascularized bone grafts of the wrist and hand help to achieve bone union in various clinical settings such as bone fusion or nonunion treatment. Among the multiple possible donor sites, the base of the second metacarpal is convenient because of its relatively straightforward harvesting, lack of impairment of the hand vascularization, sufficient bone supply for small joint fusion and phalanx or metacarpal nonunion management. The flap is versatile as it can reach any carpal and metacarpal bone as well as the proximal phalanx of all fingers. The arc of rotation of the flap depends on which side of the dorsal intercarpal arch it is based, either radially or ulnarly. It can also be pedicled distally by a retrograde flow through the second dorsal metacarpal artery. The robust vascularization of the flap allows for reliable healing. We present five new indications in various clinical settings that illustrate the versatility of the arc of rotation of the flap. Full article

A novel combination of variations involving the extensor carpi radialis (ECR) muscle group was observed bilaterally in a 75-year-old female cadaver during routine dissection. An accessory tendon was observed arising from the extensor carpi radialis longus (ECRL) and traveling with the primary tendon through the second compartment of the extensor retinaculum. While the primary tendon inserted on the base of the second metacarpal, as is typical of ECRL, the accessory tendon inserted on the base of the third metacarpal. This insertion is typical of the extensor carpi radialis brevis (ECRB) muscle. Additionally, bilateral agenesis of the ECRB was reported. Thirty-two additional forearms were assessed for similar variations, with none being observed. This combination of variations adds to the literature regarding the ECR muscle group, while also being of interest to clinicians, specifically regarding tendon reconstructive procedures as well as accessing the distal radial artery via the anatomical snuffbox. Full article

Aims: To describe through emblematic images rare but clinically relevant carotid artery stenting complications that occurred at two high-volume centres for carotid artery stenting (CAS). Background: CAS is an alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis in patients judged to be at high risk for CEA. CAS complications range between 1 and 9% and are higher in older patients complaining of neurological symptoms at the time of presentation. Besides periprocedural or early-after-procedure stroke, which remains the true Achilles’ heel of CAS, other dramatic complications might compromise the clinical outcomes of this procedure. Methods: Five infrequent complications, out of more than 1000 CAS performed in the years 2016–2021, have been described. Results: Among CAS complications, acute carotid stent thrombosis, rescue retrieval of a disconnected distal cerebral embolic protection device, plaque prolapse after carotid stenting, cerebral hyperperfusion syndrome (CHS), and radial artery long sheath entrapment requiring surgical intervention were found to account for 0.3% of the total number of procedures performed by operators with high CAS volume. Conclusions: Unusual CAS complications may infrequently occur, even in hands of expert operators. To know how to deal with such complications might help interventionalists to improve CAS performance. Full article

The distal transradial approach (dTRA) through the anatomical snuffbox is hypothesized to offer greater benefits than the conventional transradial access (cTRA) for patients undergoing coronary procedures. Our goal was to assess the safety and efficacy of dTRA. Out of 465 consecutive Caucasian patients, 400 were randomized (1:1) to dTRA or cTRA in a prospective single-center trial. Clinical and ultrasound follow-ups were obtained at 24 h and 60 days post-procedure. The primary combined endpoint consisted of access crossover, access-related complications, and major adverse cardiovascular events (MACE). Secondary endpoints included clinical success endpoints (puncture success, crossover, and access time), access-site complications endpoints, and MACE at 60 days. The primary endpoint was significantly higher in the dTRA [odds ratio (OR): 2.31, 95% confidence interval (CI): 1.38–3.86, p = 0.001]. Clinical success endpoints, namely crossover (10% vs. 3.5%, p < 0.05) and access-time [median: 140s (85–322) vs. 80s (58–127), p < 0.001], did not favor the dTRA, despite a similar success rate in radial artery puncture between the dTRA and cTRA (99.5% vs. 99%). Radial artery spasm (19% vs. 4.5%, p < 0.0001), physical discomfort during access, and transient thumb numbness after the procedure occurred more frequently with the dTRA. However, early (2.5% vs. 4.5%, p = 0.41) and mid-term (2.5% vs. 3%, p = 0.98) forearm radial artery occlusion rates were comparable between the dTRA and cTRA. Randomization to the dTRA, lower forearm radial pulse volume, higher body mass index, and lower body surface area independently predicted the primary endpoint in multivariate analysis. In the interaction effect analysis, only diabetes increased the incidence of the primary endpoint with the dTRA (OR: 18.67, 95% CI: 3.96–88.07). The dTRA was a less favorable strategy than cTRA during routine coronary procedures due to a higher incidence of arterial spasm and the necessity for access crossover. The majority of local complications following the dTRA were clinically minor complications. Individuals with diabetes were particularly susceptible to complications associated with the dTRA. Full article

Τransradial artery access has recently gained widespread acceptance as the preferred approach for coronary angiography and interventions, due to its lower incidence of bleeding and vascular complications compared to transfemoral access. However, thrombotic occlusion of the radial artery has emerged as the most common complication of this method, impeding its use in future interventions, and in the creation of arteriovenous fistulae for hemodialysis patients, or as a graft for coronary artery bypasses grafting. In this comprehensive review, we delve into the anatomy of the radial artery, the pathophysiology and diagnosis of radial artery occlusion, the identification of potential risk factors and, finally, prevention and treatment strategies. We acknowledge that distal transradial access provides an effective alternative for coronary angiography and catheterizations, with a reduced incidence of radial artery occlusion. Full article

In patients undergoing percutaneous coronary intervention, the second-generation drug-eluting stents (DES) are considered the gold standard of care for revascularization. By reducing neointimal hyperplasia, drug-eluting coronary stents decrease the need for repeat revascularizations compared with conventional coronary stents without an antiproliferative drug coating. It is important to note that early-generation DESs were associated with an increased risk of very late stent thrombosis, most likely due to delayed endothelialization or a delayed hypersensitivity reaction to the polymer. Studies have shown a lower risk of very late stent thrombosis with developing second-generation DESs with biocompatible and biodegradable polymers or without polymers altogether. In addition, research has indicated that thinner struts are associated with a reduced risk of intrastent restenosis and angiographic and clinical results. A DES with ultrathin struts (strut thickness of 70 µm) is more flexible, facilitates better tracking, and is more crossable than a conventional second-generation DES. The question is whether ultrathin eluting drug stents suit all kinds of lesions. Several authors have reported that improved coverage with less thrombus protrusion reduced the risk of distal embolization in patients with ST-elevation myocardial infarction (STEMI). Others have described that an ultrathin stent might recoil due to low radial strength. This could lead to residual stenosis and repeated revascularization of the artery. In CTO patients, the ultrathin stent failed to prove non-inferiority regarding in-segment late lumen loss and showed statistically higher rates of restenosis. Ultrathin-strut DESs with biodegradable polymers have limitations when treating calcified (or ostial) lesions and CTOs. However, they also possess certain advantages regarding deliverability (tight stenosis, tortuous lesions, high angulation, etc.), ease of use in bifurcation lesions, better endothelialization and vascular healing, and reducing stent thrombosis risk. In light of this, ultrathin-strut stents present a promising alternative to existing DESs of the second and third generation. The aims of the study are to compare ultrathin eluting stents with second- and third-generation conventional stents regarding procedural performance and outcomes based on different lesion types and specific populations. Full article

Background: The distal radial artery has emerged as an alternative vascular-access site to conventional transfemoral and transradial approaches. The main advantage over the conventional transradial route is the reduced risk of radial artery occlusion, especially in those patients who, for various clinical reasons, have to undergo repeated endovascular procedures. This study aims to assess the efficacy and safety of distal radial access for transcatheter arterial chemoembolization of the liver. Methods: This investigation is a single-center retrospective analysis of 42 consecutive patients who had undergone, from January 2018 to December 2022, transcatheter arterial chemoembolization of the liver with distal radial access for intermediate-stage hepatocellular carcinoma. Outcome data were compared with a retrospectively constituted control group of 40 patients undergoing drug-eluting beads-transcatheter arterial chemoembolization with femoral access. Results: Technical success was achieved in all cases, with a 2.4% conversion rate for distal radial access. A superselective chemoembolization was performed in 35 (83.3%) cases of distal radial access. No episode of radial artery spasm or radial artery occlusion occurred. No significant differences in efficacy and safety were observed between the distal radial access group and the femoral access group. Conclusions: Distal radial access is effective, safe, and comparable to femoral access in patients undergoing transcatheter arterial chemoembolization of the liver. Full article

Carotid artery stenting (CAS) is usually performed through a femoral vascular access using 6–9 Fr guiding catheters. We investigated whether a systematic distal radial approach using 5 Fr guiding sheaths was a safe and effective alternative to transfemoral approach for CAS. From July 2020 to October 2022, two operators at our center systematically performed CAS using a 5 Fr distal radial approach in consecutive patients. The main endpoints of the study were procedural success via distal radial and via proximal or distal radial access. The learning curve was evaluated by comparing the first half of patients versus the second half of patients enrolled. Procedural data and 30-day clinical outcomes were collected. Fifty-one patients were prospectively enrolled. CAS was effectively performed via distal radial access in 45 patients (88%). Overall radial artery success was 92%. Distal radial CAS was successfully performed in 20 out of the first 25 patients enrolled (80%), and in 25 of the last 26 patients enrolled (96%; p = 0.07). Significantly less contrast was administered in the last 26 patients compared to the first 25 enrolled (110 (70, 140) mL vs. 120 (107, 150) mL; p = 0.045). Radial artery occlusion was reported in 1 patient (2%). Only 1 minor stroke (2%) was reported in-hospital and at 30-day follow-up. In conclusion, distal radial CAS using 5 Fr catheters was a safe procedure with a high success rate. The procedure had a relatively short learning curve in operators familiar with transfemoral CAS. Full article

Background: Radial artery (RA) catheterization for invasive blood pressure monitoring is often performed via palpation, and an ultrasound is used secondarily only in case of multiple unsuccessful attempts. Although more elaborate, it has been shown that primary ultrasound-guided catheterization may be advantageous compared with palpation. The aim of this study was to identify factors associated with difficult RA catheterization. Methods: Left RA ultrasound assessments were performed in patients with indicated invasive blood pressure monitoring the day before surgery. RA catheterization was performed by personnel blinded to the ultrasound results. Based on the number of attempts needed for successful catheter placement, the cohort was divided into uncomplicated (group 1) and difficult (more than one attempt, group 2) catheterization cases. Cases subjected to primary ultrasound were excluded from the analysis. Results: Body weight, height and surface area (BSA) of patients in group 2 (n = 16) were significantly lower than those of patients in group 1 (n = 25), and internal RA diameters were significantly smaller in group 2 patients. In the whole cohort, BSA was significantly associated with distal and proximal internal RA diameters. In contrast, no differences were observed in the skin-to-artery distance, the longitudinal axis deviation (kinking) or blood flow velocity. Median time to successful catheterization was 77 (47–179) s. Prolonged time needed for cannulation was significantly associated with lower body weight, BMI and BSA, and with reduced distal and proximal internal RA diameter. Conclusions: RA catheterization performed through pulse palpation may be difficult, especially in adult patients with lower body weight and height, due to reduced arterial diameters. Initial use of ultrasound in these patients may reduce first-attempt failure, preventing procedural delays and patient discomfort. Full article

In an effort to refine transcatheter vascular interventions, radial artery access has moved more distally at the anatomical snuffbox. Here, more challenges appear as the artery is smaller, more angulated, and more difficult to palpate. Including ultrasound guidance as a mandatory step during puncture may encourage more operators to switch to this approach. In the femoral approach, ultrasound guidance is strongly recommended because of bleeding complications, whereas in the proximal (conventional) radial approach, the role of ultrasound remains optional, and in current practice, almost all cases are performed by palpation of the pulse only. However, in distal radial access, the situation is different because the artery differs in caliber and position, and imaging can help the operator for a clean puncture, especially since repeated punctures are not only painful but also any hematoma formation leads to the complete compression of the artery and failure of access. The aim of this review is to investigate the rationale of vascular ultrasound during distal radial access and to establish some techniques and anatomical landmarks for the ultrasonographic exploration of the dorsal area of the hand. Full article