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Training Collections
Library Memberships
On-demand course library with video lectures, expert case reviews, and more
Fellowship Certificate™ Programs
Practice-focused training programs designed to help you gain experience in a specific subspecialty area.
Ultimate Learning Pass
Unlock access to our full Course Library and all self-paced Fellowships.
Continuing Medical Education (State CME)
Complete all of your state CME requirements in one convenient place.
Noon Conference (Free)
Get access to free live lectures, every week, from top radiologists.
Case of the Week (Free)
Get a free weekly case delivered right to your inbox.
Case Crunch: Rapid Case Review (Free)
Register for free live board reviews.
Dr. Resnick's MSK Conference
Learn directly from the MSK Master himself.
Lower Extremities MRI Conference
Musculoskeletal Imaging
Emergency Imaging
PET Imaging
Pediatric Imaging
For Training Programs
Supplement your training program with case-based learning for residents, registrars, fellows, and more.
For Private Practices
Upskill in high growth, advanced imaging areas.
Compliance
NewTrack, fulfill, and report on all your radiologists' credentialing and licensing requirements.
Emergency Call Prep
Prepare trainees to be on call for the emergency department with this specialized training series.
1 topic, 1 min.
3 topics, 21 min.
3 topics, 13 min.
2 topics, 9 min.
5 topics, 18 min.
2 topics, 15 min.
2 topics, 6 min.
3 topics, 8 min.
2 topics, 5 min.
2 topics, 5 min.
4 topics, 13 min.
2 topics, 6 min.
2 topics, 5 min.
1 topic, 6 min.
0:01
So let's progress with this limb
0:02
ischemia complication discussion.
0:04
It's a 59-year-old male presenting 24 hours
0:06
after coronary catheterization via right
0:09
radial artery access, and we have an
0:11
18-gauge needle that was used to achieve this.
0:13
The patient now has pain, numbness, and
0:15
coolness of the right hand and forearm.
0:17
So what are you suspicious of?
0:19
Common things being common, hand ischemia.
0:23
So we perform this sonographic evaluation of the
0:26
right forearm, and we are looking at sort of the
0:28
access here, and what do we see on the imaging?
0:34
Well, we have a color Doppler sort of box that
0:38
shows there's no flow in the radial artery, in
0:40
keeping with the thrombotic occlusion from the
0:43
level of the wrist to the antecubital fossa.
0:45
No bueno.
0:46
So diagnostic arteriography of the right forearm
0:48
is performed. What do you see on imaging?
0:50
Well, I think you see this.
0:53
Which is, there's brisk flow through
0:55
a widely patent ulnar artery.
0:57
There's no anterograde flow
0:58
through the radial artery.
0:59
And there's no retrograde flow noted
1:01
secondary to the dominance of the palmar arch.
1:05
So, let's conduct a little bit of
1:07
root cause analysis of this case.
1:09
So what was likely not performed?
1:12
You guessed it.
1:13
A pre-procedure Barbeau or modified Allen's
1:15
test was actually not performed in this setting.
1:19
So unfortunately, knowing is half of the battle.
1:24
Applying is the full story.
1:26
To know that a Barbeau test has to assess the
1:28
patency of the ulnar artery in the setting of
1:32
simulating radial artery thrombosis but
1:35
not doing it is missing the boat, unfortunately.
1:38
And that's what occurred in this setting.
1:41
So let's summarize.
1:42
Any condition that compromises collaterals to
1:45
the palmar arches can actually predispose a
1:47
patient to hand ischemia after radial artery
1:50
access, and it is important to identify before,
1:54
not after or during the procedure.
1:57
The Barbeau test should always be used
2:00
routinely as a point of standardized
2:02
practice to check the patency of the
2:04
ulnar artery to prevent limb ischemia as
2:06
a potential complication post-procedure.
Interactive Transcript
0:01
So let's progress with this limb
0:02
ischemia complication discussion.
0:04
It's a 59-year-old male presenting 24 hours
0:06
after coronary catheterization via right
0:09
radial artery access, and we have an
0:11
18-gauge needle that was used to achieve this.
0:13
The patient now has pain, numbness, and
0:15
coolness of the right hand and forearm.
0:17
So what are you suspicious of?
0:19
Common things being common, hand ischemia.
0:23
So we perform this sonographic evaluation of the
0:26
right forearm, and we are looking at sort of the
0:28
access here, and what do we see on the imaging?
0:34
Well, we have a color Doppler sort of box that
0:38
shows there's no flow in the radial artery, in
0:40
keeping with the thrombotic occlusion from the
0:43
level of the wrist to the antecubital fossa.
0:45
No bueno.
0:46
So diagnostic arteriography of the right forearm
0:48
is performed. What do you see on imaging?
0:50
Well, I think you see this.
0:53
Which is, there's brisk flow through
0:55
a widely patent ulnar artery.
0:57
There's no anterograde flow
0:58
through the radial artery.
0:59
And there's no retrograde flow noted
1:01
secondary to the dominance of the palmar arch.
1:05
So, let's conduct a little bit of
1:07
root cause analysis of this case.
1:09
So what was likely not performed?
1:12
You guessed it.
1:13
A pre-procedure Barbeau or modified Allen's
1:15
test was actually not performed in this setting.
1:19
So unfortunately, knowing is half of the battle.
1:24
Applying is the full story.
1:26
To know that a Barbeau test has to assess the
1:28
patency of the ulnar artery in the setting of
1:32
simulating radial artery thrombosis but
1:35
not doing it is missing the boat, unfortunately.
1:38
And that's what occurred in this setting.
1:41
So let's summarize.
1:42
Any condition that compromises collaterals to
1:45
the palmar arches can actually predispose a
1:47
patient to hand ischemia after radial artery
1:50
access, and it is important to identify before,
1:54
not after or during the procedure.
1:57
The Barbeau test should always be used
2:00
routinely as a point of standardized
2:02
practice to check the patency of the
2:04
ulnar artery to prevent limb ischemia as
2:06
a potential complication post-procedure.
Report
Faculty
Mikhail CSS Higgins, MD, MPH
Director, Radiology Medical Student Clerkships; Director, ESIR
Boston University Medical Center
Tags
Vascular Imaging
Vascular
Ultrasound
Interventional
Iatrogenic
Fluoroscopy
Angiography
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