Factibilidade e segurança do acesso ulnar homolateral em casos de impossibilidade ou falha do acesso radial para cineangiocoronariografia ouintervenção coronariana percutânea em um hospital quaternário
Factibilidade e segurança do acesso ulnar homolateral em casos de impossibilidade ou falha do acesso radial para cineangiocoronariografia ouintervenção coronariana percutânea em um hospital quaternário
Data
2021-05
Autores
Duarte, Paulo Vinicios Falcão
Journal Title
Journal ISSN
Volume Title
Publisher
Instituto Nacional de Cardiologia
Resumo
Introdução: Os exames e procedimentos na cardiologia intervencionista são
muito frequentes em todo mundo. A principal via de acesso na última década foi
a transradial,a qual se mostrou superior à via transfemoral na redução das taxas
de sangramento, complicações vasculares, mortalidade, além de proporcionar
maior conforto para o paciente. Na falha na obtenção do acesso, a via
transfemoral ainda permanece como segunda via de escolha na maioria dos
laboratórios de hemodinâmica. A via transulnar homolateral tem sido proposta
como segunda via de acesso para procedimentos coronarianos, porém a sua
escolha ainda é pouco frequente, possivelmente pela falta deexperiência dos
operadores e a escassez de estudos, principalmente nacionais, em demonstrar a
segurança e eficácia do seu uso quando a radial é falha.
Objetivo: Avaliar a factibilidade e a segurança do uso do acesso ulnar na
cineangiocoronariografia e na intervenção coronariana percutânea, na falha do
acesso radial homolateral.
Métodos: Foram avaliados prospectivamente, em um hospital quaternário,
pacientes submetidos a cineangiocoronariografia ou intervenção coronariana
percutânea por via transulnar, em caso de falha ou contraindicação na obtenção
do acesso radial homolateral. Foram registradas a frequência de complicações
locais, como hematoma, trombose arterial, pseudoaneurisma, fístula
arteriovenosa, oclusão arterial, lesão do nervo ulnar e isquemia da mão em até
30 dias após o procedimento.
Resultados: Entre agosto de 2018 e março de 2020 foram realizados 5.916
procedimentos coronarianos invasivos, dos quais 89,6% pela via transradial,
8,2% pela via transfemoral, 2,2% pela via transulnar e nenhum procedimento pela
via braquial. Nos130 pacientes avaliados, a idade média foi de 63 ± 9,6 anos, com
predomínio do sexo masculino (57,7%). A indicação para utilização da via
transulnar foi predominantemente o pulso radial de baixa amplitude e de difícil
palpação quando comparado à artéria ulnar(39,2%), seguido de oclusão da artéria radial homolateral pelo exame físico (33,1%) e espasmo após tentativa de
punção da artéria radial (23,8%). A eficácia da técnica transulnar foi de 96,2%.
As complicações da utilização da via transulnar foram o hematoma superficial
ou de baixa infiltração muscular com extensão ≤ 10 cm, em 6 pacientes
(4,5%), e em 5 casos (3,8%) se observou hematoma > 10 cm. Houve um casode
isquemia transitória da mão após hematoma do antebraço, tratado de forma
conservadora. Não foram observados casos de trombose arterial,
pseudoaneurisma, fistula arteriovenosa, oclusão sintomática da artéria ulnar ou
lesão de nervo ulnar no seguimento de até 30 dias.
Conclusão: A via de acesso transradial permanece como primeira via de escolha
na maioria dos procedimentos na cardiologia intervencionista, porém quando este
acesso não for viável, a via transulnar homolateral apresentou-se como uma
alternativa segura e factível.
Introduction: Tests and procedures in interventional cardiology are very common worldwide. In the last decade the transradial was the main access of choice, which provedto be superior to the transfemoral in reducing bleeding rates, vascular complications, andmortality, in addition to providing greater comfort for the patient. In the failure to obtain transradial access, the transfemoral still remains the second approach of choice in most hemodynamic laboratories. The ipsilateral transulnar approach has been proposed as the second access of choice for coronary procedures, however it is still infrequent, possibly due to the operators’ lack of expertise and the very few studies, mainly in demonstrating the safety and effectiveness of its use when the radial is not feasible. Objective: To evaluate the feasibility and safety of using ulnar access in coronary angiography and percutaneous coronary intervention, in the failure of ipsilateral radial access, by assessing the frequency of complications. Methods: We prospectively evaluated, in a quaternary hospital, patients undergoing coronary angiography or percutaneous coronary intervention by transulnar approach, in case of failure or contraindication in obtaining ipsilateral radial access. The frequency of local complications, such as hematoma, arterial thrombosis, pseudoaneurysm, arteriovenous fistula, arterial occlusion, ulnar nerve injury and hand ischemia wererecorded within 30 days after the procedure. Results: Between August 2018 and March 2020, 5,916 invasive coronary procedures were performed, of which 89.6% by transradial approach, 8.2% by transfemoral approach,2.2% by transulnar approach and no procedure by brachial approach. In the 130 patientsevaluated, the mean age was 63 ± 9.6 years, with a predominance of males (57.7%). Theindication for use of the transulnar approach was predominantly the low-amplitude radialpulse or difficult to palpate when compared to the ulnar artery (39.2%), followed by occlusion of the ipsilateral radial artery by physical examination (33.1%) and spasm afterattempted puncture of the radial artery (23.8%). The effectiveness of the transulnar technique was 96.2%. Complications of using the transulnar approach were superficial hematoma or low muscle infiltration with extension ≤ 10 cm in 6 patients (4.5%), and in 5 cases (3.8%) hematoma > 10 cm was observed. There was a case of transient ischemia of the hand after forearm hematoma, treated conservatively. No cases of arterial thrombosis, pseudoaneurysm, arteriovenous fistula, symptomatic ulnar artery occlusion or ulnar nerve injury were observed after 30 days follow up. Conclusion: The transradial approach remains the first access of choice in most procedures in interventional cardiology, however, when this access is not viable, the ipsilateral transulnar approach appears to be a safe and feasible alternative.
Introduction: Tests and procedures in interventional cardiology are very common worldwide. In the last decade the transradial was the main access of choice, which provedto be superior to the transfemoral in reducing bleeding rates, vascular complications, andmortality, in addition to providing greater comfort for the patient. In the failure to obtain transradial access, the transfemoral still remains the second approach of choice in most hemodynamic laboratories. The ipsilateral transulnar approach has been proposed as the second access of choice for coronary procedures, however it is still infrequent, possibly due to the operators’ lack of expertise and the very few studies, mainly in demonstrating the safety and effectiveness of its use when the radial is not feasible. Objective: To evaluate the feasibility and safety of using ulnar access in coronary angiography and percutaneous coronary intervention, in the failure of ipsilateral radial access, by assessing the frequency of complications. Methods: We prospectively evaluated, in a quaternary hospital, patients undergoing coronary angiography or percutaneous coronary intervention by transulnar approach, in case of failure or contraindication in obtaining ipsilateral radial access. The frequency of local complications, such as hematoma, arterial thrombosis, pseudoaneurysm, arteriovenous fistula, arterial occlusion, ulnar nerve injury and hand ischemia wererecorded within 30 days after the procedure. Results: Between August 2018 and March 2020, 5,916 invasive coronary procedures were performed, of which 89.6% by transradial approach, 8.2% by transfemoral approach,2.2% by transulnar approach and no procedure by brachial approach. In the 130 patientsevaluated, the mean age was 63 ± 9.6 years, with a predominance of males (57.7%). Theindication for use of the transulnar approach was predominantly the low-amplitude radialpulse or difficult to palpate when compared to the ulnar artery (39.2%), followed by occlusion of the ipsilateral radial artery by physical examination (33.1%) and spasm afterattempted puncture of the radial artery (23.8%). The effectiveness of the transulnar technique was 96.2%. Complications of using the transulnar approach were superficial hematoma or low muscle infiltration with extension ≤ 10 cm in 6 patients (4.5%), and in 5 cases (3.8%) hematoma > 10 cm was observed. There was a case of transient ischemia of the hand after forearm hematoma, treated conservatively. No cases of arterial thrombosis, pseudoaneurysm, arteriovenous fistula, symptomatic ulnar artery occlusion or ulnar nerve injury were observed after 30 days follow up. Conclusion: The transradial approach remains the first access of choice in most procedures in interventional cardiology, however, when this access is not viable, the ipsilateral transulnar approach appears to be a safe and feasible alternative.
Description
Palavras-chave
Artéria ulnar, Cateterismo cardíaco, Angioplastia transluminal percutânea, Ulnar artery, Cardiac catheterization, Percutaneous transluminal coronary angioplasty
Citação
Duarte PVF. Factibilidade e segurança do acesso ulnar homolateral em casos de impossibilidade ou falha do acesso radial para cineangiocoronariografia ouintervenção coronariana percutânea em um hospital quaternário. Dissertação [Mestrado Profissional em Ciências Cardiovasculares]. Instituto Nacional de Cardiologia; 2021.