Taboo No More Allens Test Breast Cancer Ulnar

Taboo No More Allen's Test, Breast Cancer Ulnar Access Ian C Gilchrist, MD, FACC, FSCAI Professor of Medicine Penn State’s Hershey Medical Center Heart & Vascular Institute Hershey, PA Monday March 5, 2018

Disclosures Ian C Gilchrist, MD Consultant: Cardinal. Health/Cordis Terumo Interventional Systems Research Funding: Svelte Medical Systems Biosensors Research USA Medtronic Vascular Volcano Corporation Terumo Medical Corporation ICG 2018

Rituals & Myths Tour de France 1920’s: Bicycle Performance was rumored to be enhanced by tobacco & wine…today we know better. Many myths in Medicine, too ICG 2018

ICG 2018 Ritual of the Allen’s Test ritual rit·u·al (rĭch'ōō-əl) 
n. 
A detailed act or series of acts carried out by an individual (doctor) to relieve anxiety or to forestall the development of anxiety. Mayan Mural image of a Mayan Warrior and a captive. Licensed: Vital Imagery Ltd The American Heritage® Stedman's Medical Dictionary Copyright © 2002, 2001, 1995 by Houghton Mifflin Company. Published by Houghton Mifflin Company. icg 2016

RADAR Study ICG 2018 In addition, both tests (Allen & Barbeau) are unstable Handgrip Discomfort Lactate J Am Coll Cardiol 2014; 63: 1833– 41

Role for Collateral Testing? icg 2014 Image from: http: //www. pcronline. com/eurointervention/tools-and-techniques/radial-approach-for-percutaneous-coronary-intervention/ ICG 2018

Heart Disease & Breast Cancer Population needing cardiac catheterization (all femoral? ) 1: 8 Women with Breast Cancer 1: 4 Women will Die of Heart Disease Numbers based on USA population data American Heart Association/American Cancer Association ICG 2018

Classic Teachings of Arm Care After Breast Cancer Avoid IV’s/venipuncture Wear Gloves Maintain fingernails Avoid BP’s Avoid tight clothing No purse Avoid leg crossing Compression when flying Avoid vigorous exercise Avoid Heavy Lifting Mc. Laughlin SA. Lymphedema: Separating Facts from Fiction. Oncology, 2012; 26: 242 -9 To prevent lymphedema Image (July 2006): http: //assets. families. com/Encyclopedias/gea 2_02_img 0132. jpg Should we then avoid Radial Access? icg 2016 ICG 2018

Lack of Evidence ICG 2018 …there is little evidence-based literature regarding many of these practices, …the majority of the recommendations must at this time be based on the knowledge of pathophysiology & decades of clinical experience by experts in the field. National Lymphoma Network: NLN Position Papers 2011. Available at www. lymphnet. org. We do not avoid the femoral artery when leg lymphodema is present icg 2016

Demographics/Procedures 129 patients 134 procedures Transradial access same side as breast cancer Ipsilateral Alternate n= 42 n= 92 Lumpectomy 31% Lumpectomy 23% Partial Mastectomy 30% Partial Mastectomy 19% Radiation 50% Mastectomy 48% Axillary Dissection 53% Radiation 41% Equipment Size 4 F: 9% Equipment Size 4 F: 40% 5 F: 29% 5 F: 19% 6 F: 62% 6 F: 41% Mastectomy 50% Axillary Dissection 57% 6 included right hearts ≈ 20% had PCI Yadav PK, Gilchrist IC. J Am Coll Cardiol Intv 2015; 8(4): 638 -42. Access contralateral to breast cancer site or femoral No signs of lymphodemia or any cath related complication in either group 2 included right hearts ICG 2018

ICG 2018 Ulnar Access: Why Not S. Kedev, Duke Advanced Vascular Access Symposium 2015 Enter with a bias away from nerve Lack of radial artery, but no ischemia Permission: Gunther von Hagens' BODY WORLDS, Institute for Plastination, Heidelberg, Germany, www. bodyworlds. com Source: Mauricio Cohen, MD

Leverage Ulnar Access Artery access for STEMI PCI 2007 -2014 University of Skopje, Macedonia 100% 90% Percentage 80% Transfemoral 75% 70% 65% 60% Transulnar Bailout 60% 50% 40% 30% 20% 10% 0% 99. 9% 99. 7% 98. 5% 95% 35% 26% Transradial 4. 7% Crossover 6% 6% 2007 2008 4. 4% 2009 1. 6% 2010 1. 5% 0. 1% 2011 0. 3% 0. 1% 2012 Year Sasko Kedev, Duke Advanced Vascular Access Symposium 2015 0. 0% 0. 1% 2013 0. 0% 0. 04% 2014 ICG 2018

Todays Taboo is Tomorrows Adventure Radial, Ulnar, Pedal Search for Truth Always Question ICG 2018

Thank you icg 1@psu. edu @Radial_icg #Radial. First