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Letters to the Editor: Letters & Announcements

Anatomic Snuffbox Radial Artery Cannulation

Deepika, Krishnaprasad MD; Palaniappan, Dhamodaran MD; Fuhrman, Thomas MD; Saltzmanm, Bruce MD

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doi: 10.1213/ANE.0b013e3181ef343a
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To the Editor

Failure of radial artery cannulation at the wrist, although uncommon, is not infrequent and is secondary to vasospasm, hematoma formation, and intimal dissection or thickening. We describe an alternative successful ultrasound-guided approach to dorsal radial artery cannulation at the “anatomic snuffbox.” A 55-year-old woman, with a medical history significant for diabetes mellitus, coronary artery disease (postcoronary artery bypass surgery), and end-stage renal disease receiving hemodialysis via a left arm arteriovenous fistula, was scheduled for renal transplant. After induction of general anesthesia, several attempts to percutaneously insert a right radial artery catheter failed because of hematoma formation. Cannulation of the brachial and axillary arteries of the right arm was considered but might have precluded future surgical fistula formation. We decided not to cannulate the ulnar artery because of the radial artery hematoma. The radial artery was, however, palpable as the dorsal radial artery in the anatomic snuffbox. Using ultrasound guidance, the diameter of the dorsal radial artery was measured at 2.2 mm and a 22-gauge (0.9-mm outer diameter) cannula was inserted into the snuffbox radial artery.

In 1982, Pyles et al.1 published their clinical experience with cannulation of the dorsal radial artery. The cannulation site in the anatomic snuffbox is distal to the division of the radial artery that provides collateral flow to the hand through the superficial palmar (volar) arch (Fig. 1).2 Cannulation distal to that separation would be expected to reduce the potential for digital ischemia. The dorsal radial artery does provide arterial flow to the deep palmar arch and cannulation of the same may be preferable to a proximal site, which could interfere with both the deep and superficial palmar arch flows. For successful cannulation, we recommend semiprone position of hand (Fig. 2) and small-sized catheters. To conclude, cannulation of the dorsal radial artery is a viable alternative to the radial artery at the wrist and other possible arterial access sites.

Figure 1
Figure 1:
Arterial anatomy of the hand.
Figure 2
Figure 2:
Semiprone position of the hand for cannulation.

REFERENCES

1. 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
2. Gray H, Lewis WH. Gray's Anatomy of the Human Body. 20th US ed. Philadelphia: Lea & Febiger, originally published in 1918
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