Pediatric Cardiology

, 30:1089 | Cite as

Transradial Coronary Angiography in Children and Adolescents

Original Article

Abstract

Radial arterial access for coronary angiography is widely used in adults. We aimed to determine its safety and feasibility in pediatric practice. Twelve children and adolescents post cardiac transplantation (13 procedures) were studied. The radial artery was cannulated with a 5-Fr sheath after subcutaneous injection of 2% lidocaine. A mixture of verapamil, heparin, and isosorbide dinitrate was administered to reduce spasm. Selective coronary angiograms were obtained using Judkin or Amplatz coronary catheters. Following the procedure, hemostasis was achieved with a TR Band. Median age was 16.7 years (range, 12.1–18.8 years), and median weight 55.2 kg (range, 39–81 kg). Seventy percent of cases were under local anesthetic. Radial access was successful in 85%. Severe arterial spasm led to abandonment in one and failure to complete the study adequately in two patients. No vascular complications occurred. On direct questioning all but one patient preferred the radial approach. We conclude that the radial approach to coronary angiography is safe and feasible in children and adolescents. Radial artery spasm can be a problem and difficult to reverse once it occurs, leading to procedure abandonment. However, the technique is successful in the majority of cases and provides an alternative approach to arterial access in this age group.

Keywords

Coronary angiography Cardiac transplantation Radial artery Pediatrics 

The radial artery approach to coronary angiography has gained favor in the adult population, with many centers utilizing this method for coronary interventions [1, 2]. Radial arterial access has the advantage of reduced vascular complications, immediate ambulation, and earlier discharge for patients, thereby reducing hospitalization costs associated with coronary angiography [1]. There are no previous reports in the literature of the use of this technique in children and adolescents.

Annual coronary angiography and cardiac biopsy is routinely performed in children following cardiac transplantation in our institution. Following the successful use of radial access for coronary angiography in a child in whom femoral access was not possible, subsequent children with a weight >35 kg and listed for coronary angiography were given the option of having the procedure performed from the radial instead of the femoral approach.

Methods

Thirteen radial arterial procedures were performed in 12 children and adolescents over a 16-month period. One patient had two procedures, 13 months apart.

Procedure

Informed consent was obtained from all patients and their guardians. Procedures were performed using either local or general anesthesia, according to patient preference. All patients had previous experience of coronary angiography via the femoral route.

An Allen’s test was performed prior to the procedure using pulse oximetry. Digital compression was applied simultaneously to the radial and ulnar arteries, causing a flattened wave form on the oximeter trace. If releasing pressure on the ulnar artery while maintaining digital compression of the radial artery led to reappearance of the normal wave trace, this provided proof that, should the radial supply to the hand be compromised, flow through the ulnar artery would likely be sufficient. All patients in our series had evidence of a functioning palmar arch using this test.

Right radial arterial cannulation was attempted in all patients. The patient’s arm was extended at 90 deg and rested on a pillow placed on a radial arm board. The wrist area was cleansed using a povidone-iodine preparation (Betadine). Two to three milliliters of 2% lidocaine was injected subcutaneously above the radial artery, one finger’s breadth above the proximal wrist crease, taking care not to enter the artery. The radial artery was then punctured using a 21-gauge needle through which a 0.18-in. guidewire was inserted. The needle was removed, and over the wire a 5-Fr Cook or Arrow pediatric sheath (Fig. 1) was inserted into the artery using the Seldinger technique. Following sheath insertion a mixture of 2.5 mg of verapamil, 3,000 IU of heparin, and 200 μg of isosorbide dinitrite (ISDN) made up to 10 ml with 0.9% sodium chloride was administered through the side arm of the sheath to try and prevent arterial spasm. The right arm was then brought to lie in a trough arm board at the patient’s side and the radial arm board removed. Selective coronary angiography was performed using standard 5.2-Fr left and right Judkins or Amplatz diagnostic catheters. Following the procedure, the sheath was removed and hemostasis secured with the TR Band radial compression device (Terumo) (Fig. 2) inflated with 15 ml of air. The band was left in place for 2 h, checked every 10–15 min, and then deflated by 3 ml every 15 min until empty. The TR Band was then left in place for a further 5 min before removal.
Fig. 1

Radial sheaths with 5-Fr, 7-cm Cook sheath (top), 5-Fr, 11-cm Arrow sheath (middle), and 5-Fr, 23-cm hydrophilic Cook sheath (bottom)

Fig. 2

TR band in place

In this series, 70% (9/13) of procedures were performed using local anesthetic and in seven it was the patient’s first procedure under local. Three patients were premedicated with 5 mg of intravenous midazolam immediately prior to arterial puncture. Topical local anesthetic in the form of EMLA was used in one patient. A 7-cm, 5-Fr Pediatric Cook sheath was used in 8 of 11 (73%) patients. In three of these eight patients we changed to a longer hydrophilic-coated (23-cm) sheath because of severe spasm in the radial artery.

We had two operators in our series, a high-volume adult interventional cardiologist (Operator 1) experienced in radial procedures and a pediatric cardiologist (Operator 2) experienced in femoral coronary angiography. The pediatric cardiology operator had undergone a period of training on adult patients beforehand and the first three procedures were performed jointly.

Results

Patients

Median age was 16.7 years (range, 12.1–18.8 years), and median weight 55.2 kg (range, 39–81 kg). All 12 patients (8 females) underwent planned annual coronary angiography following cardiac transplantation (Table 1). Mean time posttransplant was 7.9 years (range, 2.1–16.3 years). One procedure was for percutaneous coronary stenting of the left anterior descending coronary artery in a 17-year-old, 39-kg girl with coronary artery vasculopathy.
Table 1

Procedure by age, weight, and outcome

Patient No.

Age (yr)

Weight (kg)

Premed

Anesthetic

Outcome

Sheath

Spasm

Operatora

Other problems/comments

1

12.1

80

None

General

Successful

5-Fr Cook

No

1

 

2

16.7

39

None

General

Successful

5-Fr Cook

No

1

Inadvertent insertion of sheath into right radial vein

3

16.9

48

None

Local

Failure

5-Fr Cook

Yes

2

 

4 (a)

17.3

45

Midazolam

Local

Successful

5-Fr Arrow

No

2

 

4 (b)

17.7

39

None

General

Successful

5-Fr Cook

No

1

Intervention: stenting of left coronary artery

5

17.1

59

None

Local

Failure

Nil

No

2

Unable to palpate radial pulse

6

15.9

75

None

Local

Successful

5-Fr Cook

No

2

 

7

14.9

72

None

Local

Successful

5-Fr Arrow

No

2

 

8

18.7

81

None

General

Successful

5-Fr Arrow

No

2

 

9

16.4

52

Midazolam

Local

Failure

Nil

No

2

Failure to access right radial Artery

10

15.1

47

None

Local

Successful

5-Fr Cook

No

2

Right aortic arch

11

16.9

55

None

Local

Partial success

5-Fr Cook

Yes

2

Unable to image right coronary artery due to spasm

12

12.8

55

Midazolam

Local

Successful

5-Fr Cook

Yes

2

 

a(1) Adult interventionist; (2) pediatric cardiologist

Outcomes

Radial access was successfully achieved in 11 of 13 patients (85%). In one patient the radial artery, although palpable, could not be successfully cannulated. The second failure was due to an absent radial pulse after application of EMLA cream, and no attempt to puncture the artery was made.

Radial spasm was the main complication, occurring in three cases. In one patient the spasm was not relieved with medication and the procedure was abandoned. In a second patient spasm resolved with buccal glyceryltrinitrite (3 mg Suscard) and intravenous diamorphine, and the study was completed successfully. In a third patient severe spasm occurred upon exchanging catheters after successful left coronary engagement, and this precluded advancement of the right Judkins catheter to the ascending aorta.

One of the 13 procedures (patient 4, Table 1) was for coronary revascularization. A diagnostic procedure had been performed in this patient via the radial route 13 months previously. A bare metal stent was deployed to the left coronary artery following balloon dilation of the marginal branch of the right coronary artery. The procedure was uneventful, with a good result. One patient had selective renal angiography performed after completion of coronary angiography, with no complications.

Screening time ranged from 4.5 to 21.9 min (median, 17.46 min), with a median radiation exposure of 722 cGy/cm2 (range, 311–1,578 cGy/cm2). There was no significant difference in screening time (P = 0.62) or radiation exposure (P = 0.31) between the patients’ radial procedure and their preceding femoral procedure.

After the procedure patients were asked their preferred vascular access site. Eleven patients (92%) expressed a preference for the radial over the femoral approach. At outpatient follow-up at 1 year, all had easily palpable radial pulses. No patient had granuloma or abscess formation.

Discussion

Our study in a small series of patients confirms the safety and feasibility of using the radial artery as an alternative access site for coronary angiography in pediatric practice. All patients in the study were post cardiac transplant and routinely undergo coronary angiography on an annual basis in our institution. The majority of the patients studied preferred the radial route to their previous femoral procedure.

The radial approach to arterial access was first introduced in 1989 by Campeau [3] for coronary angiography in adult patients and is now in widespread use for both diagnostic and interventional procedures in this population. To our knowledge, the use of this approach has not previously been described in children and adolescents. The radial artery has a number of advantages over femoral arterial access, especially for adolescents undergoing annual coronary angiography as part of post cardiac transplant monitoring. First, the radial artery is easily compressible, making for easier hemostasis and reduced vascular complications. There are no major nerves located near the artery and it is relatively distant from the vein, thereby minimizing the risk of neurovascular complications or venoarterial fistula formation. The radial approach also allows for immediate ambulation, especially when performed under local anesthetic, and all of our patients were admitted as day cases and discharged early. By using the TR Band we were able to easily observe the condition of the puncture site through its transparent plate. The majority of adolescents in this study preferred the radial approach, citing reasons such as less discomfort and embarrassment than with femoral access and the fact that they were able to be ambulatory immediately following the procedure.

The risk of radial arterial occlusion following cannulation in adults has been quoted as 4.8–19% [4]. This is usually of no clinical consequence due to the dual blood supply of the hand, via the radial and ulnar arteries. Some patients may have inadequate dual supply or poor communications between these vessels and therefore it is important to test for ulnar patency before radial puncture. Using the modified Allen’s test, the dual arterial supply of the palmar arch was adequate in all patients in our series. The right radial approach was used due to both the setup of the cardiac catheterization laboratory at our institution and its more comfortable proximity to the operators.

EMLA cream is a mixture of lidocaine and prilocaine that is effective at providing topical cutaneous anesthesia and is now in widespread use for routine venepuncture in the pediatric group. Jolly et al. published a randomized trial comparing the use of EMLA with 2% lidocaine in adults undergoing radial coronary angiography [5] which demonstrated easier cannulation and less severe pain in the EMLA group. We used EMLA as a local anesthetic in only one of our patients. Unfortunately following its application the radial artery was impalpable (a complication not described by Jolly et al.) and the femoral approach had to be used.

The major complication in our series was that of radial or brachial arterial spasm (Fig. 3) and this has been reported in the adult literature as occurring in up to 30% of cases [4]. Spasm has not been shown to be related to multiple puncture attempts and can occur with initial wire or later catheter manipulation. A cocktail of verapamil, ISDN, and heparin was given intra-arterially immediately after sheath insertion in an attempt to avoid spasm. If spasm occurred during the procedure glyceryltrinitrite spray, buccal suscard, and diamorphine were given. Despite this, once spasm occurred it was difficult to reverse and was the leading cause of failure of the procedure. The use of premedication in the form of anxiolytics, especially for first procedures under local anesthetic, may reduce the incidence in this population, as patient stress and anxiety have been reported to provoke spasm [1]. This may be particularly important in children and adolescents, and interestingly, in our series spasm did not occur in those having the procedure under a general anesthetic.
Fig. 3

Angiographic image showing spasm in the brachial artery

The use of longer sheaths may also reduce the development of radial artery spasm. Longer sheaths cover a greater length of the artery and offer more protection from the effect of catheter manipulation within the vessel. In our series there was no spasm when the longer, 11- or 23-cm sheaths were used.

Previous studies in adults have shown a 1.6% incidence of sterile inflammation and a 2.8% risk of abscess formation at the site of arterial access [6]. This has been linked to the hydrophilic coating of some sheaths and usually develops 2–3 weeks following the procedure. These complications were not seen in our small series.

The radial approach is more demanding for the operator, and as with any new technique, there is a learning curve [2]. Techniques for gaining access and catheter manipulation are different compared to those for the femoral approach. Although we used coronary catheters such as the Judkins or Amplatz catheters designed for use from the femoral approach, it is possible that the use of specially designed radial catheters may reduce the time taken to engage the coronary arteries.

Radial angiography has also been shown to be associated with a significant increase in fluoroscopy time and radiation exposure, both to the patient and to the operator [7]. In our experience, screening times and radiation exposure were not significantly different compared to those in the patient’s previous femoral procedure.

We have shown that the radial approach is possible in children as young as 12 years and in patients weighing only 39 kg. It is our view, providing that general anesthesia is used to reduce the risk of spasm, that the limiting factor is the size of the radial artery compared to the sheath size. In this series we used only 5-Fr sheaths and would not have been comfortable using this approach with patients weighing <35 kg. 4-Fr sheaths are commonly used in adult practice, and both 4- and 3-Fr sheaths are used for the femoral arterial approach in small infants. The use of these smaller sheaths may allow the lower limit of patient size to be reduced further.

In conclusion, our experience demonstrates that the radial approach is safe and technically possible in children and adolescents and is preferred by them. Spasm is an issue, but with increasing operator experience, as shown in adult cardiology practice, success rates are likely to be high, with a low incidence of complications in the teenage population. This technique can therefore provide an alternative approach to arterial access in this population group.

References

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Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  1. 1.Department of Paediatric Cardiology and Cardiothoracic TransplantationFreeman HospitalNewcastle upon TyneUK
  2. 2.Department of Adult CardiologyFreeman HospitalNewcastle upon TyneUK

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