Conference Coverage

Upper extremity dysfunction from transradial PCI underappreciated




PARIS – Fully 75% of patients experience clinically significant upper extremity dysfunction in one or more key domains upon formal testing 2 weeks after transradial artery access percutaneous coronary intervention, according to an interim analysis of what’s believed to be the first-ever prospective multicenter observational study to examine this procedural complication.

Moreover, 7.3% of all patients who underwent transradial PCI and 1 in 10 of those who developed upper extremity dysfunction were found to have radial artery occlusion upon echo Doppler examination, performed routinely as part of the extensive testing in this study, Dr. Eva M. Zwaan said in presenting the preliminary findings at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

Dr. Eva M. Zwaan Frontline Medical News

Dr. Eva M. Zwaan

“Based upon what we’ve found, I think that for people who use their hands for their profession, like musicians, I would advise that they avoid transradial PCI in favor of femoral access,” added Dr. Zwaan of Albert Schweitzer Hospital in Dordrecht, The Netherlands.

Jaws were seen to drop among stunned audience members upon seeing Dr. Zwaan’s data. Transradial PCI is far more popular among European and Asian cardiologists than in the United States, and the possibility that the procedure might cause lingering upper extremity dysfunction or disability seems not to have occurred to most practitioners.

“This is a very important study because I think we’ve all taken it for granted that upper extremity function is good after transradial PCI,” said session chair Dr. Ibrahim Al Rashdan of Kuwait Heart Center. He added that in his view this new information is sufficiently compelling that it must be shared with patients in the preprocedural conversation about risks and benefits.

“It feels to me as if you’ve dropped a small hand grenade into the radial access community,” observed discussant Dr. David Kettles of St. Dominic’s Private Hospital in East London, South Africa. “I think your 6-month follow-up data will be absolutely key.”

Dr. Zwaan concurred. Even though the 2-week follow-up is the primary study endpoint, the same rigorous multidimensional testing of hand, wrist, arm, and shoulder function will take place at 1 and 6 months. By 6 months, she noted, the acute phase of injury is over, all hematomas should have been resorbed, and investigators will have a much clearer picture of the true long-term consequences.

“These are very interesting findings, but we still have a lot to do,” she said.

She reported on the first 191 patients to complete the upper extremity assessment 2 weeks after transradial PCI. Enrollment continues in the ongoing multicenter prospective study, planned for 500 patients. Investigators will look at whether the new slender PCI systems result in less upper extremity dysfunction. They also plan to conduct a substudy of the impact of early referral of affected patients to a hand rehabilitation specialist for treatment.

With input provided by distinguished Dutch hand surgeons, the investigators are assessing multiple domains of hand function pre- and post treatment. These include range of motion, coordination, sensation, absence of pain, anatomic integrity, and strength.

In addition to echo Doppler, the assessment includes volumetric measurements of hand and forearm swelling, fingertip sensation as measured by the Weinstein Enhanced Sensory Test, palmar grip and key strength tested by dynamometer, isometric strength at the wrist and elbow, the Disabilities of the Arm, Shoulder, and Hand Questionnaire, the Boston Carpal Tunnel Questionnaire, and a visual analog pain assessment. The tests are repeated on the uninvolved upper extremity as a control arm. Patients were classified as having clinically meaningful upper extremity dysfunction if they scored positive on any 2 or more of 14 test variables.

There were three main drivers of upper extremity dysfunction: diminished wrist strength, increased hand swelling, and decreased sensation, Dr. Zwaan continued.

Interestingly, a popular entertainment at EuroPCR 2016 was a self-congratulatory sort of mocking of what is widely viewed by European and Asian cardiologists as the laggardly low transradial PCR rates in the United States. At one session, a speaker asked for an audience show of hands as to what percentage of their PCIs are performed transradially. At 70% or more, virtually every arm in the room shot up. At 90%, plenty of hands remained in the air. “Well, I guess there are no American cardiologists in the audience,” the speaker quipped.

Dr. Zwaan had no financial conflicts of interest regarding this study, conducted free of commercial support.

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