Radial Artery and Ulnar Artery Occlusions Following Coronary Procedures and the Impact of Anticoagulation: ARTEMIS (Radial and Ulnar ARTE ry Occlusion M eta-Analys IS) Systematic Review and Meta-Analysis

George Hahalis, Konstantinos Aznaouridis, Gregory Tsigkas, Periklis Davlouros, Ioanna Xanthopoulou, Nikolaos Koutsogiannis, Ioanna Koniari, Marianna Leopoulou, Olivier Costerousse, Dimitris Tousoulis, Olivier F Bertrand, George Hahalis, Konstantinos Aznaouridis, Gregory Tsigkas, Periklis Davlouros, Ioanna Xanthopoulou, Nikolaos Koutsogiannis, Ioanna Koniari, Marianna Leopoulou, Olivier Costerousse, Dimitris Tousoulis, Olivier F Bertrand

Abstract

Background: Incidence of radial artery occclusions (RAO) and ulnar artery occclusions (UAO) in coronary procedures, factors predisposing to forearm arteries occlusion, and the benefit of anticoaggulation vary significantly in existing literature. We sought to determine the incidence of RAO/UAO and the impact of anticoagulation intensity.

Methods and results: Meta-analysis of 112 studies assessing RAO and/or UAO (N=46 631) were included. Overall, there was no difference between crude RAO and UAO rates (5.2%; 95% confidence interval [CI], 4.4-6.0 versus 4.0%; 95% CI, 2.8-5.8; P=0.171). The early occlusion rate (in-hospital or within 7 days after procedure) was higher than the late occlusion rate. The detection rate of occlusion was higher with vascular ultrasonography compared with clinical evaluation only. Low-dose heparin was associated with a significantly higher RAO rate compared with high-dose heparin (7.2%; 95% CI, 5.5-9.4 versus 4.3%; 95% CI, 3.5-5.3; Q=8.81; P=0.003). Early occlusions in low-dose heparin cohorts mounted at 8.0% (95% CI, 6.1-10.6). The RAO rate was higher after diagnostic angiographies compared with coronary interventions, presumably attributed to the higher intensity of anticoagulation in the latter group. Hemostatic techniques (patent versus nonpatent hemostasis), geography (US versus non-US cohorts) and sheath size did not impact on vessel patency.

Conclusions: RAO and UAO occur with similar frequency and in the order of 7% to 8% when evaluated early by vascular ultrasonography following coronary procedures. More-intensive anticoagulation is protective. Late recanalization occurs in a substantial minority of patients.

Keywords: coronary angiography; radial occlusion; transradial; transulnar; ulnar occlusion.

© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Figures

Figure 1
Figure 1
Electronic literature search. Summary of the literature search results.
Figure 2
Figure 2
Overall rates of radial and ulnar occlusions. The diamonds and their width represent the pooled rates and the 95% CI (confidence interval), respectively.
Figure 3
Figure 3
Rates of early vs late arterial occlusions (combined radial and ulnar occlusions) in studies reporting both early and late occlusions. Diamonds and their width as in Figure 1. CI indicates confidence interval.
Figure 4
Figure 4
Effect of intensity of anticoaggulation on radial occlusion rate in unselected (randomized and observational) studies. Diamonds and their width as in Figure 1. CI indicates confidence interval.
Figure 5
Figure 5
Effect of intensity of anticoaggulation on radial occlusion rate in randomized studies. Squares indicate the occlusion rate and lines indicate the respective 95% confidence interval (CI). The size of the squares corresponds to the number of subjects in each study. Diamonds and their width as in Figure 1.
Figure 6
Figure 6
Effect of procedural characteristics on radial occlusion rates. Diamonds and their width as in Figure 1. CAG indicates coronary angiography; CI, confidence interval; PCI, percutaneous coronary intervention.
Figure 7
Figure 7
Effect of study design characteristics on radial occlusion rates. Diamonds and their width as in Figure 1. CI indicates confidence interval.
Figure 8
Figure 8
Publication bias and its potential impact. The funnel plots of precision plot a study's effect size against its precision, which is the inverse of standard error. The white circles represent individual original studies and the white diamond is the pooled mean difference and 95% CI for the meta‐analysis. Large studies tend to appear toward the top and cluster near the mean effect. Small studies tend to appear toward the bottom and are dispersed across a range of values. A symmetric funnel plot (white circles symmetrically around the mean effect) indicates absence of publication bias. To check for publication bias, the trim‐and‐fill method imputes the—theoretically—missing studies (shown in black circles) and then recomputes the pooled effect (black diamond). Although the plots were slightly asymmetric, there was no significant difference between the recomputed effect and the respective effects derived from the original studies, suggesting absence of significant publication bias. CI indicates confidence interval; RAO, radial artery occlusion.

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