Author + information
- Michael Greenwood, MBBS, FRACP⁎ ()
- ↵⁎Gold Coast Heart Centre, Spendelove Street, Southport, Queensland 4215, Australia
At the Royal Jubilee Hospital we are also strong proponents of transradial coronary angiography. We have used this technique since 1993 and now perform 80% of ∼3,000 procedures annually via the radial artery. Although many centers no longer perform an Allen’s test prior to transradial angiography, and it seems unlikely that ischemic complications will result, we have a responsibility to ensure that this is a safe practice. The lack of published cases of hand ischemia does not necessarily mean it has not occurred, as there is a potential reluctance to publish adverse outcomes. It is also possible that mild ischemia, presenting as late claudication or sensory changes, could go unnoticed.
Our study (1) found that patients with an abnormal Allen’s test had significantly reduced blood flow to the thumb associated with evidence of ischemia, based on capillary lactate levels, after 30 min of radial artery occlusion. Whether permanent radial artery occlusion would lead to ischemic complications in these patients is not known. Furthermore, 3 of 20 patients with an abnormal Allen’s test had no ulnar artery flow. These patients were excluded from the study and would almost certainly suffer ischemic complications if the radial artery was occluded.
Though it is well documented that the femoral artery approach is associated with a higher rate of access site complications, the majority of these are not limb-threatening ischemia. Complete occlusion of the radial artery occurs in 4.8% to 19% of radial procedures (although the risk is probably lower in patients with an abnormal Allen’s test owing to the trend toward a larger diameter radial artery in these patients). This would put many patients at risk of developing hand ischemia should we ignore the Allen’s test.
Based on these facts we must conclude that use of the radial artery for coronary angiography or intervention is not recommended in patients with an abnormal Allen’s test unless there is excessive risk in using the femoral approach. Until there is prospective data on the incidence and consequence of radial artery occlusion in these patients, they should be excluded from transradial angiography for both ethical and medicolegal reasons.
- American College of Cardiology Foundation