0:01

Let's transition to limb ischemia complications.

0:03

What we have here is a finding.

0:06

So, in this patient, who is 68 years of age,

0:10

had a STEMI, treated with percutaneous coronary

0:13

intervention via the radial arterial axis.

0:15

Now, your team calls you and says, you know, the patient

0:18

has hand pain, weakness, and tingling at rest.

0:21

So what are you suspicious of?

0:24

I would say, maybe, I would be suspicious of hand

0:26

ischemia secondary to radial artery thrombosis.

0:30

So the patient is sent to the OR

0:31

for the acute surgical emergency.

0:34

So fluoroscopy reveals the following imaging.

0:37

What do you see?

0:39

What is the significant finding on this imaging?

0:43

Well, I would say this vessel's intact,

0:46

but this vessel's kind of petering out.

0:49

So what we see is the absence of the radial

0:51

artery, which was the vessel that we accessed.

0:54

So not a good look.

0:56

So what might be a significant

0:57

history for this patient?

0:59

Well, previous access of the ulnar artery,

1:02

previously diagnosed ulnar artery stenosis,

1:05

or an anatomic variation where the ulnar

1:07

artery does not connect to the palmar arches.

1:10

I would say all of the above.

1:12

Okay?

1:13

So previous access to the ulnar artery would

1:15

obviously, you know, if, if, if the thrombosis

1:17

occurs in the radial artery and there's no ulnar

1:20

artery to feed it retrograde, that can cause issues.

1:24

If the ulnar artery had stenosis,

1:26

critically and now under stress because

1:28

the radial artery is not sort of patent,

1:32

it's hemodynamically significantly stenosed.

1:35

That's a problem.

1:37

If we have an anatomic variation where there

1:39

is no connection between the two, like in that

1:41

sort of type D formation in the waveform for the

1:44

Barbeau test, where there's no connection between

1:47

the two systems, the ulnar or the radial artery

1:49

system, the palmar arches are not intact, then

1:52

that could also, sort of, increase this patient's

1:54

predisposition to this sort of ischemia.

1:57

So you want to, sort of, really understand

1:58

anything that compromises the collaterals to

2:00

the palmar arteries can predispose a patient to

2:02

hand ischemia after radial artery access and

2:05

is important to identify before the procedure.

2:08

So which examination should have been

2:10

completed to have prevented this complication?

2:13

Should you have checked

2:15

the patency of the radial artery with ultrasound?

2:17

Should you have used ultrasound to

2:18

measure the diameter of the ulnar artery?

2:20

What about a Barbeau test to check

2:22

the patency of the ulnar artery?

2:24

What about double-checking the radial

2:25

artery pulse before and after the procedure?

2:28

Well, I would say a Barbeau test to check the patency

2:30

of the ulnar artery, which is what you're doing.

2:32

You're trying to determine that there is collateral

2:33

flow from the ulnar artery in the setting of

2:38

thrombosis or, sort of, manual compression of

2:41

the radial artery, where you're simulating,

2:43

sort of, a worst-case scenario situation.

2:45

So here we have duplex ultrasonography.

2:48

And it's important to know that it can be

2:50

used to assess for collateral circulation

2:52

prior to radial artery access, but this is

2:54

actually not routinely used in practice.