Radial Artery Cannulation: A Comprehensive Review of Recent Anatomic and Physiologic Investigations : Anesthesia & Analgesia

Secondary Logo

Journal Logo

Cardiovascular Anesthesiology: Review Article

Radial Artery Cannulation: A Comprehensive Review of Recent Anatomic and Physiologic Investigations

Brzezinski, Marek MD, PhD*†; Luisetti, Thomas MD; London, Martin J. MD*†

Author Information
Anesthesia & Analgesia 109(6):p 1763-1781, December 2009. | DOI: 10.1213/ANE.0b013e3181bbd416


Continuous arterial blood pressure monitoring via direct radial artery cannulation along with easy access for blood sampling can provide the clinician with vital information in the perioperative period.1 Historically, this technique can be traced to 1733 when Stephen Hales inserted a narrow brass pipe into an artery of a horse and fitted a 9-foot-long vertical glass tube to the pipe. He witnessed how the systemic pressure pushed the blood to a height of 8 feet 3 inches. Catheterization of arteries by surgical exposure was described by Farinas and Radner in the first half of the 20th century.2 In humans, continuous recording of pulse waves and arterial blood pressure with small plastic catheters was first described in 1949 by Peterson et al.3 The catheters were inserted percutaneously into the brachial artery through a metal needle and used during the perioperative period for as long as 10 h. Percutaneous catheterization with a polyethylene catheter through a large-bore needle in the femoral artery was first described by Peirce4,5 in 1951. Soon thereafter, Seldinger6 introduced the percutaneous catheterization method over a guidewire. Percutaneous cannulation of the radial artery with a teflon catheter was described by Barr7 in 1961. However, most radial artery catheters between 1955 and 1970 were inserted by surgical cutdown.

The consistent anatomic accessibility, ease of cannulation, and a low rate of complications make the radial artery the preferred site for arterial cannulation.8 Although some consider the ulnar artery the larger of the 2 arteries supplying the hand,9–11 its cannulation can be technically challenging because of its more tortuous and deeper course.12 In 1990, the number of arterial catheters placed perioperatively was estimated to be 8 million in the United States and 2.5 million in Europe.13 An increasingly older and medically complex patient population, together with an increase in the complexity of surgical procedures, have likely led to an increase in the perioperative use of this procedure. Invasive arterial monitoring, nonetheless, is associated with risk including bleeding, hematoma, pseudoaneurysm, infection, nerve damage, and distal limb ischemia.14–18 The use of the radial artery as an alternative arterial conduit for coronary artery bypass grafting,19,20 its use for newer reconstructive hand surgeries,21,22 and as an alternative route for diagnostic and therapeutic cardiac catheterization23–26 has provided new knowledge about the anatomy and physiology of this artery and perfusion of the hand.

We present a detailed review of issues important for radial artery cannulation including the anatomy of the blood supply to the hand, complications and methods for predicting and treating such complications, and a discussion of the efficacy of heparinized versus nonheparinized solutions to maintain arterial catheter patency.


The radial and ulnar arteries form the arterial blood supply to the forearm and the hand. The radial artery originates from the brachial artery in the cubital fossa, medial to the biceps tendon, and continues its course toward the styloid process of the radius.27 Variants in the origin or in the course of the radial artery28–39 have been found in up to 30% of individuals28 (Table 1). Less anatomic variation is found in the distal forearm, where arterial cannulation is usually performed.28 The ulnar artery originates medial to the biceps tendon in the cubital fossa and gives rise to the common interosseous artery, continuing its course toward the lateral side of the pisiform bone.27 Anatomic variation in the origin and course of the ulnar artery is relatively infrequent (3%–5%).28

Table 1:
Variants in the Origin or in the Course of the Radial Artery

The “classic” anatomic literature views the radial artery as the smaller of the 2 major hand arteries,11,27,43 implying that radial artery removal is safe and better tolerated than removal of the ulnar artery. There is strong evidence that the ulnar artery diameter is larger in the cubital fossa where both arteries arise.44,45 However, this relationship is less clear at the wrist44,46—49 because the ulnar artery gives off multiple branches in the forearm, whereas the radial artery serves mainly as an arterial conduit to the hand (Table 2).44,45,49–51 This view is further supported by a recent postmortem study measuring the internal diameters of the radial and ulnar arteries at the wrist.50 The radial artery was larger or equal to the ulnar artery in 87% of arms, and the mean radial artery diameter was reported to be 26%–28% larger than that of the ulnar artery. The radial artery diameter was also found to be significantly larger than the ulnar artery diameter (2.45 vs 2.3 mm, P = 0.0001) in a retrospective review of duplex ultrasound findings from 327 patients.54

Table 2:
Inner Diameter of the Radial and Ulnar Arteries Measured at the Level of the Wrist

At the level of the wrist and hand, the radial and ulnar arteries create a dense anastomotic network of 4 arches, which provide the arterial blood flow to the hand (Fig. 1). Three of these arches occur on the palmar side of the hand and include the palmar carpal arch, the deep palmar arch, and the superficial palmar arch. The arterial network on the dorsal side consists of the dorsal palmar rete. The superficial palmar arch is formed by the terminal part of the ulnar artery.27,43 The deep palmar arch is formed by the terminal part of the radial artery.27,43 The deep palmar arch gives rise to 3 or 4 palmar metacarpal arteries,22,43 and the superficial palmar arch to 3 or 4 common palmar digital arteries.56 The superficial palmar arch and deep palmar arch are the most clinically significant arches because they provide blood flow to all the digits of the hand.

Figure 1.:
Variations in the anatomy of the superficial palmar arch (SPA) and the deep palmar arch (DPA). A, Classic (and complete) SPA: the SPA from the ulnar artery (UA) supplies the index finger and thumb and anastomoses with the superficial palmar branch of the radial artery (RA). B, Complete SPA: the SPA from the UA supplies the thumb. Complete DPA: the distal end of the DPA anastomoses with the deep palmar branch of the UA. C, Incomplete SPA: the SPA does not provide a metacarpal branch to supply the thumb. D, Incomplete DPA: no continuity is found between the DPA of the UA and the RA. The dotted line represents the dorsal artery. (Reproduced from Ruengsakulrach et al.55 with permission.)

Although the blood supply of the hand has been studied by numerous investigators,22,28,46,47,52,55,57–65 substantial variability in the anatomy of the superficial and deep palmar arches seems to be the only consistent finding (Fig. 1, Table 3).60 Jaschtschinski59 in 1897 originally subdivided the superficial palmar arch into 2 types: complete and incomplete. This classification is still useful today to identify patients with an anastomotic network potentially inadequate to tolerate radial artery ligation, particularly the thumb (Fig. 1, Table 3).60,68 Theoretically, a patient with a complete superficial palmar arch and deep palmar arch should be able to tolerate ligation of the radial or ulnar artery because collateral flow will preserve perfusion to the digits. Conversely, radial artery occlusion in a patient with 2 incomplete arches might substantially increase the risk for digital ischemia.60

Table 3:
Anatomical Variations in the Arterial Patterns of the Deep and Superficial Palmar Arches

Even though the described anatomic variations of the superficial palmar arch and deep palmar arch are numerous,22,28,46,47,52,55,57–65 few general statements can be made. First, a complete superficial palmar arch is present in between 43% and 97% of hands,11,48,49,52,55,58,60,62 with the majority of the studies showing its presence in ≥80% of patients. Second, the incidence of a complete deep palmar arch varies between 67% and 100%, with most studies reporting a complete deep palmar arch in at least 90%–95% of hands. It is important to note that multiple techniques have been used in these anatomic studies (e.g., gross dissection,11 latex injection,52 or stereoscopic arteriographs62) each of which may result in different measurements. Finally, physiologic studies using noninvasive methods reported a complete superficial palmar arch in between 84% and 95% of hands. Although physiologic studies cannot necessarily identify anatomic structures, these results suggest a high physiologic adaptability of the hand’s dense arterial network47,56,63–65,69 (Web Supplement Table 1, see Supplemental Digital Content 1, https://links.lww.com/AA/A30).


The popularity of the radial artery as a conduit for coronary revascularization has led to an increased interest in assessment of the prevalence of atherosclerotic disease of this artery. Advancing age is associated with adaptive thickening of the intima.70,71 This process differentially affects various arterial beds and can vary between relatively harmless adaptive intimal thickening70 to advanced atherosclerotic lesions.71 Regardless of intimal involvement, the media can develop calcifications (Mönckeberg’s calcifications).72 The incidence of atherosclerosis demonstrated by ultrasound imaging has been reported to be far less common in the radial artery than in the common carotid artery.73 Preoperative Doppler ultrasound examination in patients with cardiac disease demonstrates atherosclerosis and calcification of the radial artery in 7%–9% and 8%–25% of patients, respectively74–77 (Table 4). The incidence of calcifications in diabetic patients (Fig. 2) has been reported to be as high as 82%, with dense calcifications in 34%.78

Table 4:
Prevalence of Preexisting Disease in the Radial Artery Using Doppler Ultrasound Technique
Figure 2.:
Ultrasound images showing longitudinal views of normal (A) and calcific (B) radial arteries. The normal vessel has a thin, homogeneous wall and smooth luminal surface (A). The calcified artery (B) is characterized by multiple echogenic areas in the vessel wall (vertical arrows) and by an irregular luminal surface. The horizontal arrow indicates a calcific plaque extending into the vessel lumen. (Reproduced from Nicolosi et al.78 with permission.)

Investigators using histopathologic and morphometric analyses reported that in patients with coronary artery disease, the radial artery is more likely to have intimal hyperplasia, atherosclerosis, and medial calcification than the internal mammary artery (Table 5).79–82 Intimal hyperplasia has been reported in 67%–94%,79–81,83 atherosclerosis in 5%–6%,80,83 and medial calcification in 6%–13% of radial artery samples.80,83 Atherosclerosis of the radial artery is a segmental disease with predilection to the distal part of the artery.83 The most consistently reported predictors of radial artery atherosclerosis and medial calcifications are peripheral vascular disease, smoking, age, and diabetes (Table 5).74,78,80,81,83 In contrast, radial artery specimens obtained in 59 hemodialysis patients at the time of fistula surgery showed no atherosclerotic changes and an incidence of intimal hyperplasia of 76%.84 Old age and diabetes were identified as risk factors for the latter. The incidence of ischemic heart disease was significantly greater in the group with intimal hyperplasia (48% vs 14%, P = 0.035).84

Table 5:
Prevalence of Preexisting Disease in the Radial Artery (RA) Using Histopathologic and Morphometric Analyses

Indwelling radial artery catheters have been found to induce local injury (e.g., intimal damage and proliferation).85 Even cannulation for only 6 h has been associated with arterial wall scarring. Significant long-term structural changes have been reported after transradial cardiac catheterization86–90 leading to a significant reduction in the radial artery diameter,86,89 stenosis (segmental or diffuse), or even radial artery occlusion.87,91 The incidence of radial artery occlusions 1 mo after transradial artery coronary angioplasty was reported to be 2.8%.92


Allen’s Test

Both the necessity and the optimal method to assess adequacy of collateral blood flow to the hand before radial artery cannulation are controversial.16 Clinically, the Allen’s Test is most often used to evaluate baseline hand circulation. It was first described in 1929 by Dr. Allen93,94 as a means to evaluate collateral circulation simultaneously in both hands of patients with thromboangiitis obliterans, and then modified by Wright95,96 in the 1950s as a means to evaluate flow in a single hand. The Modified Allen’s Test has been subsequently used to assess collateral blood flow to the hand. With firm occlusive pressure held on both the radial and ulnar arteries, the patient is asked to clench his or her fist several times until the palmar skin is blanched. The arteries should be compressed proximal to the expected tip of the arterial catheter because proximal branches of radial artery to the hand circulation could elicit falsely normal results.97,98 The patient is then instructed to unclench the fist, and then ulnar artery pressure is released while maintaining occlusion of the radial artery. Overextension of the hand and wide spreading of the fingers should be avoided because it can lead to falsely abnormal results.99,100 The time required for palmar capillary refill is noted. The test is then repeated with the radial artery pressure released while maintaining occlusion of the ulnar artery (inverse Modified Allen’s Test). Although it is simple to perform, there are several limitations including the primary end point (return to normal skin color), which is prone to observer variability.99 Not unexpectedly, a wide range of values for the time required for hand reperfusion has been reported (from 3 to 15 s).14,68,85,97,99–107 The frequency of an abnormal Modified Allen’s Test (variously defined) ranges from <1% to 27%.100,108 Its clinical reliability as a screening tool varies greatly as well. Ruengsakulrach et al.68 compared the Modified Allen’s Test (≤10 s) with Doppler ultrasonography of the thumb artery in 71 patients and found the Modified Allen’s Test to have a sensitivity of 100% and specificity of 97%. They further reported use of the Modified Allen’s Test as a screening tool in 1657 radial artery harvests from 1323 patients with no ischemic complications.68 Others reported a similar lack of ischemic complications when the Modified Allen’s Test was used to guide suitability of radial artery harvest.97,109–111 The major argument against the routine use of the Modified Allen’s Test is the lack of evidence that it can predict hand ischemia after radial artery cannulation.16,112,113 Slogoff et al.16 evaluated the Modified Allen’s Test in 411 cardiovascular surgical patients reporting that 3.9% of patients had a recovery time of >15 s. Despite this, radial artery cannulation was performed in these patients without ischemic complications. Abu-Omar et al.109 reported radial artery harvesting without ischemic sequelae in 38 patients with an abnormal Modified Allen’s Test but normal Doppler ultrasound results (zero incidence in a small number of patients does not preclude a considerable risk of ischemic complications114). Consistent with these findings are those of Barbeau et al.102 who found that 80% of patients with an abnormal Modified Allen’s Test scheduled for transradial cardiac instrumentation had adequate collateral perfusion on plethysmography and oximetry tests. Ghuran et al.115 have even proposed that prescreening with the Modified Allen’s Test in the presence of palpable radial pulse is not required, because they reported no ischemic sequelae in 630 patients who underwent 662 transradial coronary interventions without prescreening. Conversely, hand ischemia after radial artery cannulation has been reported despite a normal Modified Allen’s Test before cannulation.104,116–119 Mangano and Hickey118 described development of progressive ischemic injury requiring amputation of the distal segments of 2 fingers in a patient with a normal Modified Allen’s Test and uncomplicated perioperative course. The authors hypothesized that an embolic event was the mechanism for digit ischemia. The predictive value of a normal precannulation Modified Allen’s Test was further questioned by Stead and Stirt120 who reported that digital perfusion was independent from the palmar perfusion as measured by the Modified Allen’s Test. Jarvis et al.103 compared the Modified Allen’s Test with Doppler ultrasound of the princeps pollicis artery in 93 hands of 47 patients before radial artery harvest and reported it to be a poor predictor of ulnar artery collateral flow. The diagnostic accuracy of the Modified Allen’s Test, compared with ultrasound, was only 80%, with a sensitivity of 76% and a specificity of 82% occurring with a 5-s recovery time.103 The authors concluded that the Modified Allen’s Test was unable to identify a cutoff point for determining adequate collateral blood flow to the hand. Glavin and Jones121 compared the Modified Allen’s Test with Doppler ultrasound in 75 patients (150 extremities) finding the former to have a sensitivity of 87% to correctly diagnose the presence of ulnar artery blood flow and a negative predictive value of only 0.18; i.e., 80% of all abnormal Modified Allen’s Test results in their study were incorrect.

Adjuncts to the Allen’s Test

Pulse oximetry has been used with the Modified Allen’s Test to make interpretation more objective102,122–130 and less dependent on the patient’s cooperation.127,129,130 The time for the oxygen saturation (measured on the thumb or finger) to return to baseline after release of the occlusion is measured for each artery. However, this method has been found to overdiagnose normal hand circulation compared with the Modified Allen’s Test65,102,122,126 (Web Supplement Table 2, see Supplemental Digital Content 2, https://links.lww.com/AA/A31). Cheng et al.122 reported that all patients with an indeterminate Modified Allen’s Test had a normal test using pulse oximetry. However, because blood flows as low as 4%–9% of baseline are associated with normal pulse oximetry values, the demonstration of normal pulse oximetry saturation may not ensure adequate tissue perfusion.131 Despite this theoretical concern,65 the Modified Allen’s Test using pulse oximetry has been used for selection of patients for radial artery harvest with no instances of vascular compromise in a series of 401 patients.125

The incorporation of plethysmography with the Modified Allen’s Test allows visualization of pulsatile flow and more objective assessment of reperfusion.132 Some consider it superior to pulse oximetry in evaluating the hand’s collateral perfusion.65 However, plethysmography suffers from the inability to quantify blood flow.133

The introduction of Doppler ultrasound in the assessment of collateral hand circulation allows for a comprehensive examination of the hand and forearm arteries47,63–65,68,69,77,100,104,134,135 (Web Supplement Table 3, see Supplemental Digital Content 3, https://links.lww.com/AA/A32). A Doppler ultrasound examination consists of 2 parts. The first evaluates the “static” anatomy and flow of the arteries77 and the second part incorporates the Modified Allen’s Test with “dynamic” radial and ulnar artery compressions to assess the response of the collateral circulation.68,69 It is performed with the Doppler ultrasound probe placed over the ulnar artery, radial artery, superior palmar arch, or dorsal digital thumb artery. There are no established standard criteria for Doppler ultrasound findings that define abnormal hand collateral perfusion. Accordingly, multiple definitions of inadequate collateral flow have been reported.63,64,68,69,77,100,101,103,104,134,136 Finally, Ruengsakulrach et al.68 suggested that no flow in the dorsal digital thumb artery with radial artery occlusion is the sole absolute contraindication for radial artery harvest.

Other tests for arterial collateral flow assessment of the hand include the “snuffbox test,”136,137 “squirt test,”138 postocclusive reactive circulatory hyperaemia test,139 measurement of the systolic thumb pressure,140–142 and the radial hyperemic response test.143 Even magnetic resonance angiography has been suggested for preoperative evaluation of hand circulation.144

Together, the literature suggests that a normal Modified Allen’s Test safely selects patients for radial artery harvest.53,68,97,109–111,145–147 In contrast, there is no proof that the Modified Allen’s Test can predict hand ischemia with radial artery cannulation.


Few studies have addressed the use of the ulnar artery for invasive arterial blood pressure monitoring reporting a safety and efficacy profile similar to that for radial artery cannulation.16,148–152 In a series of 50 patients, Karacalar et al.151 described a 100% success rate of cannulation in patients with strong ulnar pulse and 59% success rate in patients with a weak ulnar pulse without complications.151 Slogoff et al.16 reported no hand ischemia in 22 patients who had an ulnar artery catheter placed after a failed radial artery cannulation. However, digital ischemia after ulnar artery cannulation after unsuccessful radial artery catheterization has been reported.153 Hand ischemia has been reported in pediatric patients with prolonged ulnar artery cannulation in the setting of prior radial artery cannulation.149 Although there is a theoretical concern that ulnar artery cannulation could cause neural trauma to the ulnar nerve, the literature lacks evidence of such a complication.16,23,151,154–158 There is increasing interest in the use of the ulnar artery as an entry site for percutaneous coronary interventions when there are few other portal options.23,154–157,159 This approach has been safely used in patients with adequate radial artery flow,23,152,155,159 in those with compromised radial artery flow resulting from multiple punctures,156,157 and in those with known chronic radial artery occlusion.154 A randomized study of 431 patients found the transulnar approach for coronary angioplasty to be as safe and effective as the transradial artery approach.152 Similar rates of access success (transulnar 93.1% vs transradial 95.5%), complications, and asymptomatic artery occlusions (transulnar 5.7% vs transradial 4.7%) were reported. Mangin et al.157 evaluated the transulnar artery approach in 117 consecutive patients who underwent 122 percutaneous coronary interventions reporting puncture failure in only 9 of 122 attempts. Complications were noted in 7 patients (7.5%) including local (5 patients) or extended (1 patient) hematoma and false aneurysm (1 patient). The role of the Modified Allan’s Test in risk stratification before cannulation of the ulnar artery is poorly defined.154,156


Radial artery harvest for coronary artery bypass graft surgery provides a model for examination of the effects of radial artery occlusion. Removal of the radial artery is associated with a significant increase in ulnar artery diameter and blood flow velocity.160 Most investigators evaluating hand perfusion days to months after surgery using various methods (e.g., photoelectric plethysmography,160 laser Doppler flowmeter,161,162 venous occlusion plethysmography,163 digital-brachial indices,164 or pulsed wave Doppler165) have reported no significant decline in hand perfusion relative to the nonoperated hand (Web Supplement Table 4, see Supplemental Digital Content 4, https://links.lww.com/AA/A33). Early postoperative forearm blood flow has been reported to be similar to preoperative values during exercise-induced ischemic reperfusion.163 In contrast, Lee et al.166 reported a significant decline in digital blood flow 7 days after radial artery harvest. However, after 3 yr, blood flow increased to levels similar to those in the control arms.167 The long-term effects of radial artery harvest were examined in a series of 34 asymptomatic patients by Serricchio et al.168 who reported that ulnar artery peak systolic velocity was greater in the operated arm compared with the control arm 5 yr after radial artery harvest. Handgrip exercise stress led to a significant increase in ulnar artery diameter in both arms. Despite this increase, handgrip exercise was associated with a decrease in transcutaneous Pao2 and an increase in transcutaneous Paco2 in the operated hand.168 After 10 yr, a small degree of exercise-induced transcutaneous oxygen desaturation in the absence of symptoms was reported.169,170 Long-term follow-up data169,170 further suggest that the compensatory increase in ulnar artery blood flow after radial artery harvest may accelerate atherosclerosis (Fig. 3). Echo-Doppler evaluation performed in 39 patients 10 yr after radial artery harvest demonstrated greater intima-media thickness of the ulnar artery (Fig. 3), and a higher prevalence of atherosclerotic plaques compared with the nonoperated arm.169

Figure 3.:
Changes of the ulnar artery (UA) intima-media thickness (IMT) 10 yr after radial artery harvest. A, Variations of IMT with time in the operated versus control arm. There was an increase in IMT of the UA on the operated hand that reached statistical significance at 10-yr follow-up. B, In addition to changes in IMT, the UAs on the operated side demonstrated a significantly higher prevalence of atherosclerotic plaques (P = 0.03). This color Doppler echocardiographic picture shows turbulent flow in the UA, irregular artery wall, and atherosclerotic plaques in the UA of the operated arm 10 yr after surgical intervention marked by a white arrow. The white double arrow marks the radial artery lumen. (Reproduced from Gaudino et al.170 with permission.)

A growing body of literature examining microsurgery of radial artery flap transfer supports the long-term safety of radial artery harvest.171–175 Physiologic adaptation after radial artery harvest includes enlargement in the diameter of the remaining forearm arteries and a compensatory increase in blood flow velocity to the hand.168,170,172,173 During rest, these adaptations usually provide adequate perfusion, but with exercise insufficient perfusion can occur.169,168

Although a rare event, the most feared complication of radial artery harvest is acute hand ischemia. Nunoo-Mensah176 described a patient with acute hand ischemia despite a normal preharvest Modified Allen’s Test, normal pulse oximetry saturation during intraoperative radial artery occlusion, and good backflow from the distal radial artery stump. The patient was subsequently found to have a congenital absence of the ulnar artery and a large interosseous artery. The patient underwent successful cephalic vein to distal radial artery revascularization. Three other patients have been described to have experienced hand ischemia after radial artery harvest. Tatoulis et al.177 reported postoperative fingertip ischemia in 2 patients with scleroderma (0.08%) after radial artery harvest. Manabe et al.104 described 1 patient who, despite a normal Modified Allen’s Test, developed ischemia of the thumb several days after the operation.


The reported incidence of at least temporary radial artery occlusion after cannulation is between 1.5% and 88%.178,179 In a review of 78 publications involving 19,617 cannulations, Scheer et al.8 reported that the incidence of temporary radial artery occlusion was 19.7%. Temporary spasm can occur in up to 57% of radial arteries immediately after cannula insertion.148 Thrombotic occlusion has been described as early as 2 h after radial artery catheter insertion or as late as a week after catheter removal.16,180 In a study of 100 surgical patients undergoing radial artery cannulations, of which 40 developed radial artery occlusion, Bedford and Wollman85 found that at the time of decannulation, only 42% of these 40 occlusions were present. Another 30% of all occlusions occurred within 24 h of decannulation and another 28% occurred later than 1 day after decannulation. Symptoms of radial artery occlusion can persist for several days after catheter removal.16,181 Davis and Stewart,14 using Doppler ultrasound, reported a 24% incidence of complete occlusion 8 days after decannulation. Recannulation of an occluded radial artery as late as 75 days after catheter removal has been reported.85

Digital embolization, a major source of hand ischemia with radial artery cannulation,16,118,182,183 can lead to irreversible digital ischemia even in a setting of macroscopically and microscopically normal radial, ulnar, and superficial palmar arteries.183 Downs et al.,180 in a study of 32 patients, reported thrombotic embolization in 23% of patients after radial artery cannulation. Multiple emboli were seen not only in the radial artery but also in the other major arteries of the upper extremity including the brachial, ulnar, and interosseous arteries.180 Rapid manual “flushing” of an indwelling radial artery catheter has been found to produce retrograde flow in the brachial and axillary arteries on duplex ultrasound examination.184 Cerebral air embolization associated with manual flushing of a radial artery catheter185,186 is, however, a rare event.187 It has been suggested that local injury induced by an indwelling radial artery catheter, together with radial artery constriction at the time of decannulation, can promote thrombus formation.85

There are multiple reports of severe hand ischemia associated with radial artery cannulation.180–182,188–191 In the review by Scheer et al.,8 the incidence of permanent hand ischemic damage was 0.09%. However, the incidence of hand ischemia after radial artery cannulation is difficult to estimate because most cases are probably not reported. Hand ischemia requiring amputation as late as 10 days after decannulation has been reported.119

Other complications of radial artery cannulation include sepsis (0.13%), local infection (0.72%), pseudoaneurysm (0.09%), hematoma (14.4%), bleeding (0.5%), and skin necrosis proximal to the site of cannulation.8,192 It has been suggested that hyperextension of the wrist results in impairment of median nerve function.18,193 Data on the frequency of arterial catheter-related infections are inconsistent.194 Catheter-related bacterial colonization is reported to range from <1% to 22.5%.195–206 There is controversy as to whether radial artery cannulation is associated with a decreased incidence of infections compared with femoral artery cannulation.195,196,198,202,203,205,207 It is also unclear whether there is an increased risk of infection with increasing duration of the cannulation.196,201,204,205 A recent prospective study reported that arterial cannulation was associated with less than half the incidence of catheter-related bloodstream infection compared with central venous catheterization (0.92 [95% confidence interval {CI}, 0.13–6.44] vs 2.23 [95% CI, 1.12–4.44] per 1000 catheter days, respectively).205 However, both sites had the same incidence of catheter colonization (15.71 [95% CI, 9.5–25.9] vs 16.83 [95% CI, 13.3–21.3] per 1000 catheter days, respectively),205 emphasizing the importance of the arterial cannulation site as a potential source of sepsis.194,208 However, current guidelines from the Centers for Disease Control and Prevention209 and others194,205 do not recommend routine replacement of peripheral arterial catheters at fixed intervals to prevent infections. Immunocompromised patients, however, may benefit from routine catheter change every 4 days.201 An aseptic technique for radial artery catheter placement that includes skin cleansing with an antiseptic alcohol containing chlorhexidine solution is recommended.209,210 Maximal barrier precautions did not, however, reduce the risk of arterial catheter-related bloodstream infection in a randomized study.211


There remains considerable controversy over reliable predictors of radial artery occlusion and ischemic hand injury after direct cannulation.14,16,17,148,212,213 In a seminal study of 1699 patients from the Texas Heart Institute, Slogoff et al.16 were unable to identify any predictors of serious ischemic complications of direct radial artery blood pressure monitoring. However, analysis of the aggregate literature suggests that a combination of profound circulatory failure, hypotension, and high-dose vasopressor therapy may increase the risk of hand ischemia16,182,188,190,214 (Table 6). Signs of multiple digital emboli have been frequently reported in such instances.16,85,183,214,217 Hematoma at the puncture site has been associated with an increased incidence of occlusion.14,16,17,212 Other factors reported to be associated with radial artery injury are more controversial such as the number of puncture attempts,14,16 artery size,16,85,105,213,215 the composition of the catheter (teflon versus polypropylene),14,16,148,178,180,213,215,216 catheter diameter,16,85,105,213,215 the duration of cannulation,14,16,85,148,218,219 and gender.17,148 The method of puncture (direct puncture versus transfixation technique) has been reported to have no effect on risk for thrombosis,17,212 and recannulation of previously cannulated radial arteries did not increase the frequency of occlusions.14 The use of large sheaths (5F or 6F) for cannulation, as used in transradial coronary interventions, has been associated with vessel narrowing, occlusion, and subsequent failure to cannulate the radial artery.220 Finally, longer catheters (>2 inches) were associated with higher catheter patency221 and fewer incidences of occlusion after decannulation compared with shorter catheters (≤2 inches).222

Table 6:
Risk Factor Assessment Before Radial Artery Catheter Placement

A plethora of patient-specific (e.g., atherosclerosis), cannulation-related (e.g., thrombosis, vasospasm, emboli), and hospital course–related (e.g., hypotension, vasopressors) risk factors emphasizes the multifactorial nature of ischemic complications of indwelling radial artery cannulation making precannulation risk assessment challenging (Table 6).182 Any of these risk factors might override compensatory mechanisms protecting hand perfusion leading to ischemia despite adequate precannulation hand collateralization.182 Whether ultrasound-guided arterial cannulation can improve outcomes from radial artery cannulation is not yet clearly established.223–228Tables 6 and 7 provide a summary of risk factor assessment before radial artery cannulation (Table 6) and an algorithm for avoiding catheter-associated complications (Table 7).

Table 7:
Algorithm for Minimizing Catheter Associated Complications in Patients with Multiple Risk Factors for Hand Ischemia8,16,17,85,188,218,221,229


Much debate has centered around the most appropriate solution for maintaining the patency of arterial catheters during continuous blood pressure monitoring. Heparinized solutions are considered advantageous by some investigations, but heparin exposure might promote antibody formation leading to heparin-induced thrombocytopenia.235–237 Continuous heparin flush solution has been reported to affect coagulation studies if drawn via arterial access.238–241

Several randomized controlled trials have compared heparin with nonheparinized solutions for maintaining arterial catheter patency221,238,242–244 (Table 8). The American Association of Critical-Care Nurses’ multicenter, randomized, controlled trial involving 5139 intensive care unit (ICU) patients at 198 sites found heparin superior for maintaining catheter patency compared with nonheparinized solutions.221 The data were collected at 4-h intervals for up to 72–96 h, or until the removal of the catheter.221 Of note, catheter insertion depth >2 inches, male gender, femoral cannulation site, and use of other anticoagulants or thrombolytics were identified to enhance arterial catheter patency.221 Other smaller studies performed in the ICU setting found no superiority,238 a trend toward superiority,243 or superiority242 with heparin- versus nonheparin-containing solutions. In patients requiring arterial catheter during the perioperative period, a randomized, controlled, double-blind trial in 200 patients failed to demonstrate any significant difference in the number of radial artery occlusions between heparinized catheter flush solution compared with normal saline.244 The optimal heparin concentrations have not been established, with the heparin concentrations used ranging from 1,238,244 2,243 4,242 and 5 U/mL.245 A study comparing 2 heparin concentrations, 0.25 and 1 U/mL, failed to demonstrate a significant difference in arterial catheter patency, suggesting that a low concentration is adequate in the adult population.246 In contrast, Butt et al.245 reported that a heparin concentration of 5 U/mL (154 catheters) led to prolonged catheter patency compared with 1 U/mL (164 catheters) in children admitted to the ICU.

Table 8:
Use of Heparin Versus Nonheparin Flush Solutions for Continuous Arterial Monitoring


There is no consensus on the optimal treatment for ischemic injuries resulting from radial artery cannulation (Table 9). Early recognition is likely the most important means to reduce permanent injury. An absent pulse, dampened waveform, blanched or mottled skin, delayed capillary refill, and painful and cold hand or fingers with motor weakness are presentations of hand ischemia.182,190,214 Blistering and skin ulceration are late findings.

Table 9:
Clinical Reports on Characteristics, Treatment Options, and Outcome of Ischemic Complications of Radial Artery Catheterization (RAC)
Table 9:

Arterial color flow Doppler ultrasound, angiography, or magnetic resonance imaging can be used to evaluate arterial flow in the arteries of the affected limb. Doppler ultrasound examination has the advantage of being noninvasive and easily performed, but it is limited by the inability to identify the mechanism of compromised blood flow. Immediate consultation with a vascular surgeon is imperative.183,217 The radial artery catheter should be removed to ensure that it is not contributing to flow obstruction if intraarterial drug administration or arteriography is not under consideration.

Treatment is aimed at the underlying mechanism (e.g., radial artery thrombus, ulnar artery or radial artery vasospasm, local radial artery trauma, reduced systemic arterial perfusion, digital embolization, or previously unrecognized congenital inadequate collateral hand circulation). Different management techniques for radial artery occlusion have been attempted and are summarized in Table 9.116–119,182,188–190,249–251 Aspiration of the thrombus at the catheter tip has been described to restore arterial pulsation in 60% of patients with suspected thrombosis.195 Intraarterial verapamil, prilocaine, and phentolamine have been successful to reverse ischemic symptoms.117,118,195,248,250 Other proposed treatments include low-molecular-weight dextran and low-dose heparin.182,183,190 Geschwind et al.214 reported angiographic flow restoration with <20% residual thrombus leading to clinical improvement in 5 of 7 patients treated with intraarterial urokinase for radial artery occlusion due to thrombosis.

Hot compresses to the involved extremity may resolve vasospasm251 (but could aggravate the ischemia if applied to the hand). Sympathetic nerve block14,252 or cervicodorsal sympathetic block190 should be considered for suspected arterial vasospasm.14,188,190,252,253 There is a growing body of literature on prevention and management of radial artery spasm during transradial artery cardiac catheterization demonstrating that intraarterially administered vasodilators (e.g., nitrates, calcium channel blockers, lidocaine, and molsidomine) are safe and effective in preventing radial artery spasm.254–256 Radial artery spasm after an initial failed attempt can be reversed with subcutaneously administered nitroglycerin alone257 or in combination with 2% lidocaine.258

Surgical exploration is often necessary for patients with absent radial artery blood flow and severe hand ischemia as a complication of radial artery cannulation. Despite successful cases being reported, operative therapy has not been conclusively demonstrated to be superior to medical therapy.217,247 In a retrospective analysis of treatment of 8 patients with hand ischemia after radial artery cannulation, surgical revascularization was attempted in 5 patients.182 Of the 5, 1 patient died; all patients who survived developed gangrene of the first or second digit, with 2 patients requiring finger amputation. In contrast, only 1 of 3 patients treated conservatively developed gangrene and underwent amputation.182 Unsuccessful surgical exploration has been reported by others.118

Note added in proof:

A crucial reference (Pyles et al.260) originally published by Anesthesia & Analgesia was added during the proof review process.


The authors acknowledge the administrative and editorial assistance of John Rukkila, ELS.


1. Statement on Intravascular Catheterization Procedures. Atlanta, Georgia: ASA House of Delegates, 2005:1–2
2. Gidlund A. Development of apparatus and methods for roentgen studies in haemodynamics. Acta Radiol Suppl 1956;130:7–70
3. Peterson LH, Dripps RD, Risman GC. A method for recording the arterial pressure pulse and blood pressure in man. Am Heart J 1949;37:771–82
4. Peirce EC II. Percutaneous femoral artery catheterization in man with special reference to aortography. Surg Gynecol Obstet 1951;93:56–74
5. Peirce EC II. Percutaneous arterial catheterization in dogs with special reference to aortography. Ann Surg 1951;133:544–7
6. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta Radiol 1953;39:368–76
7. Barr PO. Percutaneous puncture of the radial artery with a multi-purpose Teflon catheter for indwelling use. Acta Physiol Scand 1961;51:343–7
8. Scheer BV, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care 2002;6:198–204
9. Ryan JF, Raines J, Dalton BC, Mathieu A. Arterial dynamics of radial artery cannulation. Anesth Analg 1973;52:1017–25
10. Vogelzang RL. Arteriography of the hand and wrist. Hand Clin 1991;7:63–86
11. Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet 1961;113:409–24
12. Shah N, Bedford RF. Invasive and noninvasive blood pressure monitoring. In: Lake CL, Hines RL, Blitt CD, eds. Clinical monitoring practical applications for anesthesia and critical care. 1st ed. Philadelphia: W.B. Saunders Company, 2001:181–203
13. Gardner R. Direct arterial pressure monitoring. Curr Anaesth Crit Care 1990;1:239–46
14. Davis FM, Stewart JM. Radial artery cannulation. A prospective study in patients undergoing cardiothoracic surgery. Br J Anaesth 1980;52:41–7
15. Hausmann D, Schulte am Esch J, Fischdick G. [Radial artery cannulation—a prospective study on its complication rate by clinical and sonographic evaluation (author’s transl)]. Anasth Intensivther Notfallmed 1981;16:269–73
16. Slogoff S, Keats AS, Arlund C. On the safety of radial artery cannulation. Anesthesiology 1983;59:42–7
17. Cederholm I, Sorensen J, Carlsson C. Thrombosis following percutaneous radial artery cannulation. Acta Anaesthesiol Scand 1986;30:227–30
18. Chowet AL, Lopez JR, Brock-Utne JG, Jaffe RA. Wrist hyperextension leads to median nerve conduction block: implications for intra-arterial catheter placement. Anesthesiology 2004; 100:287–91
19. Acar C, Jebara VA, Portoghese M, Beyssen B, Pagny JY, Grare P, Chachques JC, Fabiani JN, Deloche A, Guermonprez JL. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652–9
20. Carpentier A, Guermonprez JL, Deloche A, Frechette C, DuBost C. The aorta-to-coronary radial artery bypass graft. A technique avoiding pathological changes in grafts. Ann Thorac Surg 1973;16:111–21
21. Rockwell WB, Smith SM, Tolliston T, Valnicek SM. Arterial conduits for extremity microvascular bypass surgery. Plast Reconstr Surg 2003;112:829–34
22. Edwards EA. Organization of the small arteries of the hand and digits. Am J Surg 1960;99:837–46
23. Dashkoff N, Dashkoff PB, Zizzi JA Sr, Wadhwani J, Zizzi JA Jr. Ulnar artery cannulation for coronary angiography and percutaneous coronary intervention: case reports and anatomic considerations. Catheter Cardiovasc Interv 2002;55:93–6
24. Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn 1989;16:3–7
25. Nagai Y, Metter EJ, Earley CJ, Kemper MK, Becker LC, Lakatta EG, Fleg JL. Increased carotid artery intimal-medial thickness in asymptomatic older subjects with exercise-induced myocardial ischemia. Circulation 1998;98:1504–9
26. Kamiya H, Ushijima T, Kanamori T, Ikeda C, Nakagaki C, Ueyama K, Watanabe G. Use of the radial artery graft after transradial catheterization: is it suitable as a bypass conduit? Ann Thorac Surg 2003;76:1505–9
27. Johnson D, Ellis H. Pectoral girdle and upper limb. In: Standring S, ed. Gray’s anatomy. New York: Elsevier Churchill Livingstone, 2005:799–942
28. McCormack LJ, Cauldwell EW, Anson BJ. Brachial and antebrachial arterial patterns; a study of 750 extremities. Surg Gynecol Obstet 1953;96:43–54
29. Sargon M, Celik HH. Proximal origins of radial and common interosseous arteries. Kaibogaku Zasshi 1994;69:406–9
30. Uglietta JP, Kadir S. Arteriographic study of variant arterial anatomy of the upper extremities. Cardiovasc Intervent Radiol 1989;12:145–8
31. Durgun B, Yucel AH, Kizilkanat ED, Dere F. Multiple arterial variation of the human upper limb. Surg Radiol Anat 2002;24:125–8
32. Yucel AH. Unilateral variation of the arterial pattern of the human upper extremity with a muscle variation of the hand. Acta Med Okayama 1999;53:61–5
33. Alameddine AK, Alimov VK, Englelman RM, Rousou JA, Flack JE III, Deaton DW, Englelman DT. Anatomic variations of the radial artery: significance when harvesting for coronary artery bypass grafting. J Thorac Cardiovasc Surg 2004; 127:1825–7
34. Sargon MF, Tanyeli E, Surucu HS, Yazar F, Arifoglu Y. A complicated variation of the upper extremity vascularisation. Kaibogaku Zasshi 1996;71:211–4
35. Kumar MR. Multiple arterial variations in the upper limb of a South Indian female cadaver. Clin Anat 2004;17:233–5
36. Porter CJ, Mellow CG. Anatomically aberrant forearm arteries: an absent radial artery with co-dominant median and ulnar arteries. Br J Plast Surg 2001;54:727–8
37. Poteat WL. Report of a rare human variation: absence of the radial artery. Anat Rec 1986;214:89–95
38. Yoo BS, Yoon J, Ko JY, Kim JY, Lee SH, Hwang SO, Choe KH. Anatomical consideration of the radial artery for transradial coronary procedures: arterial diameter, branching anomaly and vessel tortuosity. Int J Cardiol 2005;101:421–7
39. Karlsson S, Niechajev IA. Arterial anatomy of the upper extremity. Acta Radiol Diagn (Stockh) 1982;23:115–21
40. Rodriguez-Niedenfuhr M, Vazquez T, Nearn L, Ferreira B, Parkin I, Sanudo JR. Variations of the arterial pattern in the upper limb revisited: a morphological and statistical study, with a review of the literature. J Anat 2001;199:547–66
41. Kadanoff D, Balkansky G. [2 cases with rare variations of arteries of the upper extremities]. Anat Anz 1966;118:289–96
42. Yokoyama N, Takeshita S, Ochiai M, Koyama Y, Hoshino S, Isshiki T, Sato T. Anatomic variations of the radial artery in patients undergoing transradial coronary intervention. Catheter Cardiovasc Interv 2000;49:357–62
43. Moore KL, Dalley AF. Upper limb. Clinically oriented anatomy. 4 ed. Philadelphia: Lippincott Williams & Wilkins, 1999:665–810
44. Haerle M, Hafner HM, Dietz K, Schaller HE, Brunelli F. Vascular dominance in the forearm. Plast Reconstr Surg 2003;111:1891–8
45. Keen JA. A study of the arterial variations in the limbs, with special reference to symmetry of vascular patterns. Am J Anat 1961;108:245–61
46. Haerle M, Hafner HM, Schaller HE, Brunelli F. Dominances in finger arteries. J Hand Surg Br 2002;27:526–9
47. Little JM, Zylstra PL, West J, May J. Circulatory patterns in the normal hand. Br J Surg 1973;60:652–5
48. Bilge O, Pinar Y, Ozer MA, Govsa F. A morphometric study on the superficial palmar arch of the hand. Surg Radiol Anat 2006;28:343–50
49. Fazan VP, Borges CT, Da Silva JH, Caetano AG, Filho OA. Superficial palmar arch: an arterial diameter study. J Anat 2004;204:307–11
50. Riekkinen HV, Karkola KO, Kankainen A. The radial artery is larger than the ulnar. Ann Thorac Surg 2003;75:882–4
51. Tonks AM, Lawrence J, Lovie MJ. Comparison of ulnar and radial arterial blood-flow at the wrist. J Hand Surg Br 1995;20:240–2
52. Gellman H, Botte MJ, Shankwiler J, Gelberman RH. Arterial patterns of the deep and superficial palmar arches. Clin Orthop Relat Res 2001;383:41–6
53. Kohonen M, Teerenhovi O, Terho T, Laurikka J, Tarkka M. Is the Allen test reliable enough? Eur J Cardiothorac Surg 2007; 32:902–5
54. Loh YJ, Nakao M, Tan WD, Lim CH, Tan YS, Chua YL. Factors influencing radial artery size. Asian Cardiovasc Thorac Ann 2007;15:324–6
55. Ruengsakulrach P, Eizenberg N, Fahrer C, Fahrer M, Buxton BF. Surgical implications of variations in hand collateral circulation: anatomy revisited. J Thorac Cardiovasc Surg 2001;122:682–6
56. Al-Turk M, Metcalf WK. A study of the superficial palmar arteries using the Doppler Ultrasonic Flowmeter. J Anat 1984;138(Pt 1):27–32
57. Callow A. Vascular disorders of the upper extremity. In: Jupiter J, ed. Flynn’s hand surgery. Baltimore: Williams & Wilkins, 1991:629–47
58. Jelicic N, Gajisin S, Zbrodowski A. Arcus palmaris superficialis. Acta Anat (Basel) 1988;132:187–90
59. Jaschtschinski S. Morphologie und Topologie des Arcus volaris sublimes und profundus des Menschen. Anat Heft 1897;7:161–88
60. Loukas M, Holdman D, Holdman S. Anatomical variations of the superficial and deep palmar arches. Folia Morphol (Warsz) 2005;64:78–83
61. Ruengsakulrach P, Buxton BF, Eizenberg N, Fahrer M. Anatomic assessment of hand circulation in harvesting the radial artery. J Thorac Cardiovasc Surg 2001;122:178–80
62. Ikeda A, Ugawa A, Kazihara Y, Hamada N. Arterial patterns in the hand based on a three-dimensional analysis of 220 cadaver hands. J Hand Surg Am 1988;13:501–9
63. Doscher W, Viswanathan B, Stein T, Margolis IB. Physiologic anatomy of the palmar circulation in 200 normal hands. J Cardiovasc Surg (Torino) 1985;26:171–4
64. Doscher W, Viswanathan B, Stein T, Margolis IB. Hemodynamic assessment of the circulation in 200 normal hands. Ann Surg 1983;198:776–9
65. Fuhrman TM, Pippin WD, Talmage LA, Reilley TE. Evaluation of collateral circulation of the hand. J Clin Monit 1992;8:28–32
66. Mezzogiorno A, Passiatore C, Mezzogiorno V. Anatomic variations of the deep palmar arteries in man. Acta Anat (Basel) 1994;149:221–4
    67. Olave E, Prates JC. Deep palmar arch patterns in Brazilian individuals. Surg Radiol Anat 1999;21:267–71
    68. Ruengsakulrach P, Brooks M, Hare DL, Gordon I, Buxton BF. Preoperative assessment of hand circulation by means of Doppler ultrasonography and the modified Allen test. J Thorac Cardiovasc Surg 2001;121:526–31
    69. Pola P, Serricchio M, Flore R, Manasse E, Favuzzi A, Possati GF. Safe removal of the radial artery for myocardial revascularization: a Doppler study to prevent ischemic complications to the hand. J Thorac Cardiovasc Surg 1996;112:737–44
    70. Stary HC, Blankenhorn DH, Chandler AB, Glagov S, Insull W Jr, Richardson M, Rosenfeld ME, Schaffer SA, Schwartz CJ, Wagner WD. A definition of the intima of human arteries and of its atherosclerosis-prone regions. A report from the Committee on Vascular Lesions of the Council on Arteriosclerosis, American Heart Association. Circulation 1992;85:391–405
    71. Stary HC, Chandler AB, Dinsmore RE, Fuster V, Glagov S, Insull W Jr, Rosenfeld ME, Schwartz CJ, Wagner WD, Wissler RW. A definition of advanced types of atherosclerotic lesions and a histological classification of atherosclerosis. A report from the Committee on Vascular Lesions of the Council on Arteriosclerosis, American Heart Association. Circulation 1995;92:1355–74
    72. Proudfoot D, Shanahan CM. Biology of calcification in vascular cells: intima versus media. Herz 2001;26:245–51
    73. Gaudino M, Tondi P, Serricchio M, Spatuzza P, Santoliquido A, Flora R, Girola F, Nasso G, Pola P, Possati G. Atherosclerotic involvement of the radial artery in patients with coronary artery disease and its relation with midterm radial artery graft patency and endothelial function. J Thorac Cardiovasc Surg 2003;126:1968–71
    74. Ruengsakulrach P, Brooks M, Sinclair R, Hare D, Gordon I, Buxton B. Prevalence and prediction of calcification and plaques in radial artery grafts by ultrasound. J Thorac Cardiovasc Surg 2001;122:398–9
    75. Oshima A, Takeshita S, Kozuma K, Yokoyama N, Motoyoshi K, Ishikawa S, Honda M, Oga K, Ochiai M, Isshiki T. Intravascular ultrasound analysis of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 2005;79:99–103
    76. Hosono M, Suehiro S, Shibata T, Sasaki Y, Kumano H, Kinoshita H. Duplex scanning to assess radial artery suitability for coronary artery bypass grafting. Jpn J Thorac Cardiovasc Surg 2000;48:217–21
    77. Rodriguez E, Ormont ML, Lambert EH, Needleman L, Halpern EJ, Diehl JT, Edie RN, Mannion JD. The role of preoperative radial artery ultrasound and digital plethysmography prior to coronary artery bypass grafting. Eur J Cardiothorac Surg 2001;19:135–9
    78. Nicolosi AC, Pohl LL, Parsons P, Cambria RA, Olinger GN. Increased incidence of radial artery calcification in patients with diabetes mellitus. J Surg Res 2002;102:1–5
    79. Kane-ToddHall SM, Taggart SP, Clements-Jewery H, Roskell DE. Pre-existing vascular disease in the radial artery and other coronary artery bypass conduits. Eur J Med Res 1999;4:11–4
    80. Ruengsakulrach P, Sinclair R, Komeda M, Raman J, Gordon I, Buxton B. Comparative histopathology of radial artery versus internal thoracic artery and risk factors for development of intimal hyperplasia and atherosclerosis. Circulation 1999; 100:II139–44
    81. Kaufer E, Factor SM, Frame R, Brodman RF. Pathology of the radial and internal thoracic arteries used as coronary artery bypass grafts. Ann Thorac Surg 1997;63:1118–22
    82. Ozkan S, Akay TH, Gultekin B, Aslim E, Arslan A, Ozdemir BH, Becit N, Tasdelen A. Atherosclerosis of radial and internal thoracic arteries used in coronary bypass: atherosclerosis in arterial grafts. J Card Surg 2007;22:385–9
    83. Chowdhury UK, Airan B, Mishra PK, Kothari SS, Subramaniam GK, Ray R, Singh R, Venugopal P. Histopathology and morphometry of radial artery conduits: basic study and clinical application. Ann Thorac Surg 2004;78:1614–21
    84. Kim YO, Song HC, Yoon SA, Yang CW, Kim NI, Choi YJ, Lee EJ, Kim WY, Chang YS, Bang BK. Preexisting intimal hyperplasia of radial artery is associated with early failure of radiocephalic arteriovenous fistula in hemodialysis patients. Am J Kidney Dis 2003;41:422–8
    85. Bedford RF, Wollman H. Complications of percutaneous radial-artery cannulation: an objective prospective study in man. Anesthesiology 1973;38:228–36
    86. Madssen E, Haere P, Wiseth R. Radial artery diameter and vasodilatory properties after transradial coronary angiography. Ann Thorac Surg 2006;82:1698–702
    87. Nagai S, Abe S, Sato T, Hozawa K, Yuki K, Hanashima K, Tomoike H. Ultrasonic assessment of vascular complications in coronary angiography and angioplasty after transradial approach. Am J Cardiol 1999;83:180–6
    88. Wakeyama T, Ogawa H, Iida H, Takaki A, Iwami T, Mochizuki M, Tanaka T. Intima-media thickening of the radial artery after transradial intervention. An intravascular ultrasound study. J Am Coll Cardiol 2003;41:1109–14
    89. Edmundson A, Mann T. Nonocclusive radial artery injury resulting from transradial coronary interventions: radial artery IVUS. J Invasive Cardiol 2005;17:528–31
    90. Goldberg S. There’s no free lunch? J Invasive Cardiol 2005;17:532
    91. Hall JJ, Arnold AM, Valentine RP, McCready RA, Mick MJ. Ultrasound imaging of the radial artery following its use for cardiac catheterization. Am J Cardiol 1996;77:108–9
    92. Stella PR, Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. Incidence and outcome of radial artery occlusion following transradial artery coronary angioplasty. Cathet Cardiovasc Diagn 1997;40:156–8
    93. Cable DG, Mullany CJ, Schaff HV. The Allen test. Ann Thorac Surg 1999;67:876–7
    94. Allen E. Thromboangiitis obliterans: methods of diagnosis of chronic occlusive arterial lesions distal to the wrist with illustrative cases. Am J Med Sci 1929;178:237–44
    95. Ejrup B, Fischer B, Wright IS. Clinical evaluation of blood flow to the hand. The false-positive Allen test. Circulation 1966;33:778–80
    96. Wright IS. Vascular diseases in clinical practice. 2 ed. Chicago: The Year Book Publishers Inc., 1952
    97. Asif M, Sarkar PK. Three-digit Allen’s test. Ann Thorac Surg 2007;84:686–7
    98. Gandhi SK, Reynolds AC. A modification of Allen’s test to detect aberrant ulnar collateral circulation. Anesthesiology 1983;59:147–8
    99. Greenhow DE. Incorrect performance of Allen’s test—ulnar-artery follow erroneously presumed inadequate. Anesthesiology 1972;37:356–7
    100. Kamienski RW, Barnes RW. Critique of the Allen test for continuity of the palmar arch assessed by doppler ultrasound. Surg Gynecol Obstet 1976;142:861–4
    101. Agrifoglio M, Dainese L, Pasotti S, Galanti A, Cannata A, Roberto M, Parolari A, Biglioli P. Preoperative assessment of the radial artery for coronary artery bypass grafting: is the clinical Allen test adequate? Ann Thorac Surg 2005;79:570–2
    102. Barbeau GR, Arsenault F, Dugas L, Simard S, Lariviere MM. Evaluation of the ulnopalmar arterial arches with pulse oximetry and plethysmography: comparison with the Allen’s test in 1010 patients. Am Heart J 2004;147:489–93
    103. Jarvis MA, Jarvis CL, Jones PR, Spyt TJ. Reliability of Allen’s test in selection of patients for radial artery harvest. Ann Thorac Surg 2000;70:1362–5
    104. Manabe S, Tabuchi N, Toyama M, Kuriu K, Mizuno T, Sunamori M. Measurement of ulnar flow is helpful in predicting ischemia after radial artery harvest. Thorac Cardiovasc Surg 2002;50:325–8
    105. Bedford RF. Radial arterial function following percutaneous cannulation with 18- and 20-gauge catheters. Anesthesiology 1977;47:37–9
    106. Phillips CS, Murphy MS. Vascular problems of the upper extremity: a primer for the orthopaedic surgeon. J Am Acad Orthop Surg 2002;10:401–8
    107. Yokoyama N, Takeshita S, Ochiai M, Hoshino S, Koyama Y, Oshima A, Isshiki T, Sato T. Direct assessment of palmar circulation before transradial coronary intervention by color Doppler ultrasonography. Am J Cardiol 2000;86:218–21
    108. Benit E, Vranckx P, Jaspers L, Jackmaert R, Poelmans C, Coninx R. Frequency of a positive modified Allen’s test in 1,000 consecutive patients undergoing cardiac catheterization. Cathet Cardiovasc Diagn 1996;38:352–4
    109. Abu-Omar Y, Mussa S, Anastasiadis K, Steel S, Hands L, Taggart DP. Duplex ultrasonography predicts safety of radial artery harvest in the presence of an abnormal Allen test. Ann Thorac Surg 2004;77:116–9
    110. Sajja LR, Mannam MG, Sompalli S. Is Allen’s test not reliable in the selection of patients for radial artery harvest? Ann Thorac Surg 2002;74:296
    111. Meharwal ZS, Trehan N. Functional status of the hand after radial artery harvesting: results in 3,977 cases. Ann Thorac Surg 2001;72:1557–61
    112. Wilkins RG. Radial artery cannulation and ischaemic damage: a review. Anaesthesia 1985;40:896–9
    113. McGregor A. The Allen test—an investigation of its accuracy by fluorescein angiography. J Hand Surg 1986;12:82–5
    114. Hanley JA, Lippman-Hand A. If nothing goes wrong, is everything all right? Interpreting zero numerators. JAMA 1983;249:1743–5
    115. Ghuran AV, Dixon G, Holmberg S, de Belder A, Hildick-Smith D. Transradial coronary intervention without pre-screening for a dual palmar blood supply. Int J Cardiol 2007;121:320–2
    116. Arthurs GJ. Case report: digital ischaemia following radial artery cannulation. Anaesth Intensive Care 1978;6:54–5
    117. Gallacher BP. Intra-arterial verapamil to reverse acute ischaemia of the hand after radial artery cannulation. Can J Anaesth 1991;38:138
    118. Mangano DT, Hickey RF. Ischemic injury following uncomplicated radial artery catheterization. Anesth Analg 1979;58:55–7
    119. Mangar D, Laborde RS, Vu DN. Delayed ischaemia of the hand necessitating amputation after radial artery cannulation. Can J Anaesth 1993;40:247–50
    120. Stead SW, Stirt JA. Assessment of digital blood flow and palmar collateral circulation. Allen’s test vs. photoplethysmography. Int J Clin Monit Comput 1985;2:29–34
    121. Glavin RJ, Jones HM. Assessing collateral circulation in the hand—four methods compared. Anaesthesia 1989;44:594–5
    122. Cheng EY, Lauer KK, Stommel KA, Guenther NR. Evaluation of the palmar circulation by pulse oximetry. J Clin Monit 1989;5:1–3
    123. Greenwood MJ, Della-Siega AJ, Fretz EB, Kinloch D, Klinke P, Mildenberger R, Williams MB, Hilton D. Vascular communications of the hand in patients being considered for transradial coronary angiography: is the Allen’s test accurate? J Am Coll Cardiol 2005;46:2013–7
    124. Hovagim AR, Katz RI, Poppers PJ. Pulse oxymetry for evaluation of radial and ulnar arterial blood flow (abstract). Anesth Analg 1988;67:S94
    125. Johnson WH III, Cromartie RS III, Arrants JE, Wuamett JD, Holt JB. Simplified method for candidate selection for radial artery harvesting. Ann Thorac Surg 1998;65:1167
    126. Lauer KK, Cheng EY, Stommel KA, Guenther NR, Kay J. Pulse oximetry evaluation of the palmar circulation (abstract). Anesth Analg 1988;67:S129
    127. Nowak GS, Moorthy SS, McNiece WL. Use of pulse oximetry for assessment of collateral arterial flow. Anesthesiology 1986;64:527
    128. Oettle AC, van Niekerk A, Boon JM, Meiring JH. Evaluation of Allen’s test in both arms and arteries of left and right-handed people. Surg Radiol Anat 2006;28:3–6
    129. Raju R. The pulse oximeter and the collateral circulation. Anaesthesia 1986;41:783–4
    130. Rozenberg B, Rosenberg M, Birkhan J. Allen’s test performed by pulse oximeter. Anaesthesia 1988;43:515–6
    131. Lawson D, Norley I, Korbon G, Loeb R, Ellis J. Blood flow limits and pulse oximeter signal detection. Anesthesiology 1987;67:599–603
    132. Brodsky JB. A simple method to determine patency of the ulnar artery intraoperatively prior to radial-artery cannulation. Anesthesiology 1975;42:626–7
    133. Fuhrman TM, Reilley TE, Pippin WD. Comparison of digital blood pressure, plethysmography, and the modified Allen’s test as means of evaluating the collateral circulation to the hand. Anaesthesia 1992;47:959–61
    134. Mozersky DJ, Buckley CJ, Hagood CO Jr, Capps WF Jr, Dannemiller FJ Jr. Ultrasonic evaluation of the palmar circulation. A useful adjunct to radial artery cannulation. Am J Surg 1973;126:810–2
    135. McSwain GR, Ameriks JA. Doppler-improved Allen test. South Med J 1979;72:1620–1
    136. Kochi K, Orihashi K, Sueda T. The snuffbox technique: a reliable color Doppler method to assess hand circulation. J Thorac Cardiovasc Surg 2003;125:821–5
    137. Kochi K, Sueda T, Orihashi K, Matsuura Y. New noninvasive test alternative to Allen’s test: snuff-box technique. J Thorac Cardiovasc Surg 1999;118:756–8
    138. Birdi I, Ritchie AJ. Intraoperative confirmation of ulnar collateral blood flow during radial artery harvesting using the “squirt test”. Ann Thorac Surg 2002;74:271–2
    139. Vaghadia H, Schechter MT, Sheps SB, Jenkins LC. Evaluation of a postocclusive reactive circulatory hyperaemia (PORCH) test for the assessment of ulnar collateral circulation. Can J Anaesth 1988;35:591–8
    140. Husum B, Berthelsen P. Allen’s test and systolic arterial pressure in the thumb. Br J Anaesth 1981;53:635–7
    141. Husum B, Palm T. Before cannulation of the radial artery: collateral arterial supply evaluated by strain-gauge plethysmography. Acta Anaesthesiol Scand 1980;24:412–4
    142. Husum B, Palm T. Before cannulation of the radial artery. Br J Anaesth 1979;51:71–2
    143. Roberts N, Ghosh S, Boehm M, Galinanes M. The radial hyperaemic response: a new and objective assessment of ulnar collateral supply to the hand. Eur J Cardiothorac Surg 2002;21:549–52
    144. Winterer JT, Ennker J, Scheffler K, Rosendahl U, Schafer O, Wanner M, Laubenberger J, Langer M. Gadolinium-enhanced elliptically reordered three-dimensional MR angiography in the assessment of hand vascularization before radial artery harvest for coronary artery bypass grafting: first experience. Invest Radiol 2001;36:501–8
    145. Ronald A, Patel A, Dunning J. Is the Allen’s test adequate to safely confirm that a radial artery may be harvested for coronary arterial bypass grafting? Interact Cardiovasc Thorac Surg 2005;4:332–40
    146. Barner HB. Allen’s test. Ann Thorac Surg 2008;85:690
    147. Unlu Y. Is the Allen test reliable enough? Eur J Cardiothorac Surg 2008;33:754
    148. Kim JM, Arakawa K, Bliss J. Arterial cannulation: factors in the development of occlusion. Anesth Analg 1975;54:836–41
    149. Kahler AC, Mirza F. Alternative arterial catheterization site using the ulnar artery in critically ill pediatric patients. Pediatr Crit Care Med 2002;3:370–4
    150. Green JA, Tonkin MA. Ischaemia of the hand in infants following radial or ulnar artery catheterisation. Hand Surg 1999;4:151–7
    151. Karacalar S, Ture H, Baris S, Karakaya D, Sarihasan B. Ulnar artery versus radial artery approach for arterial cannulation: a prospective, comparative study. J Clin Anesth 2007;19:209–13
    152. Aptecar E, Pernes JM, Chabane-Chaouch M, Bussy N, Catarino G, Shahmir A, Bougrini K, Dupouy P. Transulnar versus transradial artery approach for coronary angioplasty: the PCVI-CUBA study. Catheter Cardiovasc Interv 2006;67:711–20
    153. Maston M, Van Oldenbeek C. Digital ischaemia after ulnar artery cannulation. Br J Anaesth 2003;90:111
    154. Lanspa TJ, Reyes AP, Oldemeyer JB, Williams MA. Ulnar artery catheterization with occlusion of corresponding radial artery. Catheter Cardiovasc Interv 2004;61:211–3
    155. Terashima M, Meguro T, Takeda H, Endoh N, Ito Y, Mitsuoka M, Ohtomo T, Murai O, Fujiwara S, Honda H, Miyazaki Y, Kuhara R, Kawashima O, Isoyama S. Percutaneous ulnar artery approach for coronary angiography: a preliminary report in nine patients. Catheter Cardiovasc Interv 2001;53:410–4
    156. Lanspa TJ, Williams MA, Heirigs RL. Effectiveness of ulnar artery catheterization after failed attempt to cannulate a radial artery. Am J Cardiol 2005;95:1529–30
    157. Mangin L, Bertrand OF, De La Rochelliere R, Proulx G, Lemay R, Barbeau G, Gleeton O, Rodes-Cabau J, Nguyen CM, Roy L. The transulnar approach for coronary intervention: a safe alternative to transradial approach in selected patients. J Invasive Cardiol 2005;17:77–9
    158. Buxton BF, Chan AT, Dixit AS, Eizenberg N, Marshall RD, Raman JS. Ulnar artery as a coronary bypass graft. Ann Thorac Surg 1998;65:1020–4
    159. Limbruno U, Rossini R, De Carlo M, Amoroso G, Ciabatti N, Petronio AS, Micheli A, Mariani M. Percutaneous ulnar artery approach for primary coronary angioplasty: safety and feasibility. Catheter Cardiovasc Interv 2004;61:56–9
    160. Brodman RF, Hirsh LE, Frame R. Effect of radial artery harvest on collateral forearm blood flow and digital perfusion. J Thorac Cardiovasc Surg 2002;123:512–6
    161. Knobloch K, Lichtenberg A, Pichlmaier M, Tomaszek S, Krug A, Haverich A. Palmar microcirculation after harvesting of the radial artery in coronary revascularization. Ann Thorac Surg 2005;79:1026–30
    162. Knobloch K, Lichtenberg A, Tomaszek S, Hagl C, Khaladj N, Klima U, Haverich A. Long-term physical activity and neurologic function after harvesting of the radial artery as T-graft or free graft in coronary revascularization. Ann Thorac Surg 2005;80:918–21
    163. Chong WC, Ong PJ, Hayward CS, Collins P, Moat NE. Effects of radial artery harvesting on forearm function and blood flow. Ann Thorac Surg 2003;75:1171–4
    164. Dumanian GA, Segalman K, Mispireta LA, Walsh JA, Hendrickson MF, Wilgis EF. Radial artery use in bypass grafting does not change digital blood flow or hand function. Ann Thorac Surg 1998;65:1284–7
    165. Royse AG, Royse CF, Maleskar A, Garg A. Harvest of the radial artery for coronary artery surgery preserves maximal blood flow of the forearm. Ann Thorac Surg 2004;78:539–42
    166. Lee HS, Chang BC, Heo YJ. Digital blood flow after radial artery harvest for coronary artery bypass grafting. Ann Thorac Surg 2004;77:2071–4
    167. Lee HS, Heo YJ, Chang BC. Long-term digital blood flow after radial artery harvesting for coronary artery bypass grafting. Eur J Cardiothorac Surg 2005;27:99–103
    168. Serricchio M, Gaudino M, Tondi P, Gasbarrini A, Gerardino L, Santoliquido A, Pola P, Possati G. Hemodynamic and functional consequences of radial artery removal for coronary artery bypass grafting. Am J Cardiol 1999;84:1353–6, A8
    169. Gaudino M, Glieca F, Luciani N, Losasso G, Tondi P, Serricchio M, Pola P, Possati G. Ten-year Echo-Doppler evaluation of forearm circulation following radial artery removal for coronary artery bypass grafting. Eur J Cardiothorac Surg 2006; 29:71–3
    170. Gaudino M, Serricchio M, Tondi P, Gerardino L, Di Giorgio A, Pola P, Possati G. Chronic compensatory increase in ulnar flow and accelerated atherosclerosis after radial artery removal for coronary artery bypass. J Thorac Cardiovasc Surg 2005; 130:9–12
    171. Richardson D, Fisher SE, Vaughan ED, Brown JS. Radial forearm flap donor-site complications and morbidity: a prospective study. Plast Reconstr Surg 1997;99:109–15
    172. Ciria-Llorens G, Gomez-Cia T, Talegon-Melendez A. Angiologic observations following radial artery flap elevation: a case report. Surg Radiol Anat 1998;20:377–81
    173. Ciria-Llorens G, Gomez-Cia T, Talegon-Melendez A. Analysis of flow changes in forearm arteries after raising the radial forearm flap: a prospective study using colour duplex imaging. Br J Plast Surg 1999;52:440–4
    174. Meland NB, Core GB, Hoverman VR. The radial forearm flap donor site: should we vein graft the artery? A comparative study. Plast Reconstr Surg 1993;91:865–70; discussion 871
    175. Bardsley AF, Soutar DS, Elliot D, Batchelor AG. Reducing morbidity in the radial forearm flap donor site. Plast Reconstr Surg 1990;86:287–92
    176. Nunoo-Mensah J. An unexpected complication after harvesting of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1998;66:929–31
    177. Tatoulis J, Buxton BF, Fuller JA, Royse AG. Total arterial coronary revascularization: techniques and results in 3,220 patients. Ann Thorac Surg 1999;68:2093–9
    178. Brown AE, Sweeney DB, Lumley J. Percutaneous radial artery cannulation. Anaesthesia 1969;24:532–6
    179. Soderstrom CA, Wasserman DH, Dunham CM, Caplan ES, Cowley RA. Superiority of the femoral artery of monitoring. A prospective study. Am J Surg 1982;144:309–12
    180. Downs JB, Rackstein AD, Klein EF Jr, Hawkins IF Jr. Hazards of radial-artery catheterization. Anesthesiology 1973;38:283–6
    181. Little JM, Clarke B, Shanks C. Effects of radial artery cannulation. Med J Aust 1975;2:791–3
    182. Valentine RJ, Modrall JG, Clagett GP. Hand ischemia after radial artery cannulation. J Am Coll Surg 2005;201:18–22
    183. Lee KL, Miller JG, Laitung G. Hand ischaemia following radial artery cannulation. J Hand Surg Br 1995;20:493–5
    184. Murphy GS, Szokol JW, Marymont JH, Avram MJ, Vender JS, Kubasiak J. Retrograde blood flow in the brachial and axillary arteries during routine radial arterial catheter flushing. Anesthesiology 2006;105:492–7
    185. Lowenstein E, Little JW III, Lo HH. Prevention of cerebral embolization from flushing radial-artery cannulas. N Engl J Med 1971;285:1414–5
    186. Chang C, Dughi J, Shitabata P, Johnson G, Coel M, McNamara JJ. Air embolism and the radial arterial line. Crit Care Med 1988;16:141–3
    187. Murphy GS, Szokol JW, Marymont JH, Avram MJ, Vender JS. Retrograde air embolization during routine radial artery catheter flushing in adult cardiac surgical patients: an ultrasound study. Anesthesiology 2004;101:614–9
    188. Wallach SG. Cannulation injury of the radial artery: diagnosis and treatment algorithm. Am J Crit Care 2004;13:315–9
    189. Wong AY, O’Regan AM. Gangrene of digits associated with radial artery cannulation. Anaesthesia 2003;58:1034–5
    190. Baker RJ, Chunprapaph B, Nyhus LM. Severe ischemia of the hand following radial artery catheterization. Surgery 1976;80:449–57
    191. Bartlett RH, Munster AM. An improved technic for prolonged arterial cannulation. N Engl J Med 1968;279:92–3
    192. Wyatt R, Glaves I, Cooper DJ. Proximal skin necrosis after radial-artery cannulation. Lancet 1974;1:1135–8
    193. Kuo MH, Leong CP, Cheng YF, Chang HW. Static wrist position associated with least median nerve compression: sonographic evaluation. Am J Phys Med Rehabil 2001; 80:256–60
    194. Rijnders BJ. Catheter-related infection can be prevented if we take the arterial line seriously too! Crit Care Med 2005;33:1437–9
    195. Frezza EE, Mezghebe H. Indications and complications of arterial catheter use in surgical or medical intensive care units: analysis of 4932 patients. Am Surg 1998;64:127–31
    196. Furfaro S, Gauthier M, Lacroix J, Nadeau D, Lafleur L, Mathews S. Arterial catheter-related infections in children. A 1-year cohort analysis. Am J Dis Child 1991;145:1037–43
    197. Leroy O, Billiau V, Beuscart C, Santre C, Chidiac C, Ramage C, Mouton Y. Nosocomial infections associated with long-term radial artery cannulation. Intensive Care Med 1989;15:241–6
    198. Lorente L, Santacreu R, Martin MM, Jimenez A, Mora ML. Arterial catheter-related infection of 2,949 catheters. Crit Care 2006;10:R83
    199. Lorente L, Villegas J, Martin MM, Jimenez A, Mora ML. Catheter-related infection in critically ill patients. Intensive Care Med 2004;30:1681–4
    200. Raad II, Hohn DC, Gilbreath BJ, Suleiman N, Hill LA, Bruso PA, Marts K, Mansfield PF, Bodey GP. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol 1994;15:231–8
    201. Raad I, Umphrey J, Khan A, Truett LJ, Bodey GP. The duration of placement as a predictor of peripheral and pulmonary arterial catheter infections. J Hosp Infect 1993;23:17–26
    202. Rijnders BJ, Van Wijngaerden E, Peetermans WE. Catheter-tip colonization as a surrogate end point in clinical studies on catheter-related bloodstream infection: how strong is the evidence? Clin Infect Dis 2002;35:1053–8
    203. Thomas F, Burke JP, Parker J, Orme JF Jr, Gardner RM, Clemmer TP, Hill GA, MacFarlane P. The risk of infection related to radial vs femoral sites for arterial catheterization. Crit Care Med 1983;11:807–12
    204. Traore O, Liotier J, Souweine B. Prospective study of arterial and central venous catheter colonization and of arterial- and central venous catheter-related bacteremia in intensive care units. Crit Care Med 2005;33:1276–80
    205. Koh DB, Gowardman JR, Rickard CM, Robertson IK, Brown A. Prospective study of peripheral arterial catheter infection and comparison with concurrently sited central venous catheters. Crit Care Med 2008;36:397–402
    206. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006;81:1159–71
    207. Singh S, Nelson N, Acosta I, Check FE, Puri VK. Catheter colonization and bacteremia with pulmonary and arterial catheters. Crit Care Med 1982;10:736–9
    208. Mermel LA. Arterial catheters are not risk-free spigots. Crit Care Med 2008;36:620–2
    209. O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A, Weinstein RA. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 2002;30:476–89
    210. Mimoz O, Pieroni L, Lawrence C, Edouard A, Costa Y, Samii K, Brun-Buisson C. Prospective, randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients. Crit Care Med 1996;24:1818–23
    211. Rijnders BJ, Van Wijngaerden E, Wilmer A, Peetermans WE. Use of full sterile barrier precautions during insertion of arterial catheters: a randomized trial. Clin Infect Dis 2003;36:743–8
    212. Jones RM, Hill AB, Nahrwold ML, Bolles RE. The effect of method of radial artery cannulation on postcannulation blood flow and thrombus formation. Anesthesiology 1981;55:76–8
    213. Davis FM. Radial artery cannulation: influence of catheter size and material on arterial occlusion. Anaesth Intensive Care 1978;6:49–53
    214. Geschwind JF, Dagli MS, Lambert DL, Kobeiter H. Thrombolytic therapy in the setting of arterial line-induced ischemia. J Endovasc Ther 2003;10:590–4
    215. Evans PJ, Kerr JH. Proceedings: complications of arterial cannulation and thermographic assessment of sequelae. Br J Anaesth 1974;46:318–9
    216. Bedford RF, Major MC. Percutaneous radial-artery cannulation— increased safety using teflon catheters. Anesthesiology 1975; 42:219–22
    217. Lee MK, Lee IO, Kong MH, Han SK, Lim SH. Surgical treatment of digital ischemia occurred after radial artery catheterization. J Korean Med Sci 2001;16:375–7
    218. Bedford RF. Long-term radial artery cannulation: effects on subsequent vessel function. Crit Care Med 1978;6:64–7
    219. Hasse J, Pusterla C, Cloeren S, Gigon JP. [Angiographic studies following prolonged catheterization of the radial artery]. Schweiz Med Wochenschr 1971;101:1057–61
    220. Sakai H, Ikeda S, Harada T, Yonashiro S, Ozumi K, Ohe H, Ochiai M, Miyahara Y, Kohno S. Limitations of successive transradial approach in the same arm: the Japanese experience. Catheter Cardiovasc Interv 2001;54:204–8
    221. Evaluation of the effects of heparinized and nonheparinzed flush solutions on the patency of arterial pressure monitoring lines: the AACN thunder project. By the American Association of Critical-Care Nurses. Am J Crit Care 1993;2:3–15
    222. Dahl MR, Smead WL, McSweeney TD. Radial artery cannulation: a comparison of 15.2- and 4.45-cm catheters. J Clin Monit 1992;8:193–7
    223. Levin PD, Sheinin O, Gozal Y. Use of ultrasound guidance in the insertion of radial artery catheters. Crit Care Med 2003;31:481–4
    224. Maher JJ, Dougherty JM. Radial artery cannulation guided by Doppler ultrasound. Am J Emerg Med 1989;7:260–2
    225. Sandhu NS, Patel B. Use of ultrasonography as a rescue technique for failed radial artery cannulation. J Clin Anesth 2006;18:138–41
    226. Schindler E, Kowald B, Suess H, Niehaus-Borquez B, Tausch B, Brecher A. Catheterization of the radial or brachial artery in neonates and infants. Paediatr Anaesth 2005;15:677–82
    227. Schwemmer U, Arzet HA, Trautner H, Rauch S, Roewer N, Greim CA. Ultrasound-guided arterial cannulation in infants improves success rate. Eur J Anaesthesiol 2006;23:476–80
    228. Shiver S, Blaivas M, Lyon M. A prospective comparison of ultrasound-guided and blindly placed radial arterial catheters. Acad Emerg Med 2006;13:1275–9
    229. Martin C, Saux P, Papazian L, Gouin F. Long-term arterial cannulation in ICU patients using the radial artery or dorsalis pedis artery. Chest 2001;119:901–6
    230. Johnstone RE, Greenhow DE. Catheterization of the dorsalis pedis artery. Anesthesiology 1973;39:654–5
    231. Bazaral MG, Welch M, Golding LA, Badhwar K. Comparison of brachial and radial arterial pressure monitoring in patients undergoing coronary artery bypass surgery. Anesthesiology 1990;73:38–45
    232. Moran KT, Halpin DP, Zide RS, Oberfield RA, Jewell ER. Long-term brachial artery catheterization: ischemic complications. J Vasc Surg 1988;8:76–8
    233. Clouse ME, Ahmed R, Ryan RB, Oberfield RA, McCaffrey JA. Complications of long term transbrachial hepatic arterial infusion chemotherapy. AJR Am J Roentgenol 1977;129:799–803
    234. Nichani S, Luyt D. Brachial artery catheterisation in paediatric intensive care. Anaesthesia 1997;52:608–9
    235. Greinacher A, Warkentin TE. Recognition, treatment, and prevention of heparin-induced thrombocytopenia: review and update. Thromb Res 2006;118:165–76
    236. Heeger PS, Backstrom JT. Heparin flushes and thrombocytopenia. Ann Intern Med 1986;105:143
    237. Ling E, Warkentin TE. Intraoperative heparin flushes and subsequent acute heparin-induced thrombocytopenia. Anesthesiology 1998;89:1567–9
    238. Del Cotillo M, Grane N, Llavore M, Quintana S. Heparinized solution vs. saline solution in the maintenance of arterial catheters: a double blind randomized clinical trial. Intensive Care Med 2008;34:339–43
    239. Alzetani A, Vohra HA, Patel RL. Can we rely on arterial line sampling in performing activated plasma thromboplastin time after cardiac surgery? Eur J Anaesthesiol 2004;21:384–8
    240. Heap MJ, Ridley SA, Hodson K, Martos FJ. Are coagulation studies on blood sampled from arterial lines valid? Anaesthesia 1997;52:640–5
    241. Hoste EA, Roels NR, Decruyenaere JM, Colardyn FA. Significant increase of activated partial thromboplastin time by heparinization of the radial artery catheter flush solution with a closed arterial catheter system. Crit Care Med 2002;30:1030–4
    242. Clifton GD, Branson P, Kelly HJ, Dotson LR, Record KE, Phillips BA, Thompson JR. Comparison of normal saline and heparin solutions for maintenance of arterial catheter patency. Heart Lung 1991;20:115–8
    243. Kulkarni M, Elsner C, Ouellet D, Zeldin R. Heparinized saline versus normal saline in maintaining patency of the radial artery catheter. Can J Surg 1994;37:37–42
    244. Tuncali BE, Kuvaki B, Tuncali B, Capar E. A comparison of the efficacy of heparinized and nonheparinized solutions for maintenance of perioperative radial arterial catheter patency and subsequent occlusion. Anesth Analg 2005;100:1117–21
    245. Butt W, Shann F, McDonnell G, Hudson I. Effect of heparin concentration and infusion rate on the patency of arterial catheters. Crit Care Med 1987;15:230–2
    246. Bolgiano CS, Subramaniam PT, Montanari JM, Minick L. The effect of two concentrations of heparin on arterial catheter patency. Crit Care Nurse 1990;10:47–57
    247. Crossland SG, Neviaser RJ. Complications of radial artery catheterization. Hand 1977;9:287–90
    248. Burrell AR. Treatment of ischaemia after radial artery cannulation. Anaesth Intensive Care 1977;5:388
    249. Sarma VJ. Intra-arterial prilocaine for ischeamia due to radial artery cannulation. Anaesthesia 1992;47:719
    250. Bright E, Baines DB, French BG, Cartmill TB. Upper limb amputation following radial artery cannulation. Anaesth Intensive Care 1993;21:351–3
    251. English LA, Maye JP, Dalton-Link MT. Hand ischemia associated with profound hypotension and radial artery catheterization in a pediatric patient: a case report. AANA J 2003;71:41–3
    252. Mehta Y, Juneja R. Continuous axillary block for ischemia following failed radial artery cannulation. J Cardiothorac Vasc Anesth 1994;8:257
    253. Weiss BM, Gattiker RI. Complications during and following radial artery cannulation: a prospective study. Intensive Care Med 1986;12:424–8
    254. Kiemeneij F. Prevention and management of radial artery spasm. J Invasive Cardiol 2006;18:159–60
    255. Varenne O, Jegou A, Cohen R, Empana JP, Salengro E, Ohanessian A, Gaultier C, Allouch P, Walspurger S, Margot O, El Hallack A, Jouven X, Weber S, Spaulding C. Prevention of arterial spasm during percutaneous coronary interventions through radial artery: the SPASM study. Catheter Cardiovasc Interv 2006;68:231–5
    256. Coppola J, Patel T, Kwan T, Sanghvi K, Srivastava S, Shah S, Staniloae C. Nitroglycerin, nitroprusside, or both, in preventing radial artery spasm during transradial artery catheterization. J Invasive Cardiol 2006;18:155–8
    257. Pancholy SB, Coppola J, Patel T. Subcutaneous administration of nitroglycerin to facilitate radial artery cannulation. Catheter Cardiovasc Interv 2006;68:389–91
    258. Bertrand OF, Larose E, Rodes-Cabau J. Sub-cutaneous nitroglycerin: good example of the “KISS” rule! Catheter Cardiovasc Interv 2007;70:161
    259. Manabe S, Tabuchi N, Toyama M, Yoshizaki T, Kato M, Wu H, Kotani M, Sunamori M. Oxygen pressure measurement during grip exercise reveals exercise intolerance after radial harvest. Ann Thorac Surg 2004;77:2066–7
    260. Pyles ST, Scher KS, Vega ET, Harrah JD, Rubis LJ. Cannulation of the dorsal radial artery: a new technique. Anesth Analg 1982;61:876–8

    Supplemental Digital Content

    © 2009 International Anesthesia Research Society