A commentary on “Factors Influencing Forearm Swelling after Transradial Artery Intervention and Establishment of a Predictive Model”

This invited commentary refers to ‘Factors influencing forearm swelling after transradial artery intervention and establishment of a predictive model: a prospective study’ by J. Duan et al., https://doi.org/10.1093/eurjcn/zvae183.

The invasive management of coronary artery disease includes, among other approaches, percutaneous coronary intervention.^1,2 Current guidelines recommend transradial access as the standard approach for diagnostic coronary angiography and intervention.³ This approach is associated with lower rates of vascular complications and a reduced length of hospital stay compared with the transfemoral approach.^4,5

Nevertheless, complications and postoperative care challenges may still arise following transradial access. Among these, forearm swelling, wound pain, bleeding, and limb numbness are commonly observed. The most common complication is forearm swelling.^6,7 The study ‘Factors Influencing Forearm Swelling after Transradial Artery Intervention and Establishment of a Predictive Model’ by Duan et al., published in the European Journal of Cardiovascular Nursing, addresses this significant, yet often overlooked complication of transradial interventions.⁸ If not properly managed, forearm swelling can cause patient discomfort and may lead to more severe complications, such as compartment syndrome. Therefore, early detection is crucial to prevent progression to major complications.⁹

Previously research found patient-related and procedural factors associated with forearm swelling. However, factors related to tourniquet compression after transradial coronary intervention have not been explored. Consequently, the predictors of forearm swelling are not known. Duan et al.⁸ have undertaken a prospective study to identify risk factors and develop a predictive model for forearm swelling, which is a commendable effort towards improving patient outcomes.

In this prospective, single-centre, observational cohort study, 209 patients were included. Participants were divided into two groups: those who developed forearm swelling post-procedure (n = 27) and those who did not (n = 182). The incidence of forearm swelling on the operative side of was found to be 13%. The analysis yielded a predictive model with an overall accuracy of 81%, suggesting that the model is highly reliable in identifying patients at risk of developing forearm swelling.⁸ These findings provide valuable insights for clinicians and healthcare providers in daily practice.

Three factors related to the management of radial artery tourniquets were identified: irregular tourniquet compression, the number of compressions, and the time to first tourniquet deflation. Additional risk factors for forearm swelling included inappropriate wrist movement, radial artery access, prolonged operation time, and body mass index.⁸

Factors related to the management of radial artery tourniquets are particularly suitable for nurse-led improvements, as nurses are often responsible for applying tourniquets after invasive coronary procedures. Education on tourniquet application is essential to raise awareness of the palmar arch collaterals. If compression of the radial artery is not applied both proximally and distally to the puncture site, retrograde flow from the palmar arch collaterals may occur, increasing the risk of forearm swelling.¹⁰ In some cases, proximal repositioning of the tourniquet or the addition of a proximal compression device is required.¹¹ Correct tourniquet placement may also reduce the number of compressions needed, which, according to the model by Duan et al.,⁸ could further decrease the incidence of forearm swelling.

Duan et al.⁸ recommend an initial tourniquet deflation time of 2 h. This recommendation is based on their own data as well as previously conducted research. Currently, no specific guideline exists for the optimal first deflation time of radial artery tourniquets, particularly for the TR band. According to the manufacturer, a total deflation time of 2 h is recommended, during which air is gradually removed in multiple steps.¹² The recommendation by Duan et al. is based on a meta-analysis of Maqsood et al.¹³ However, one study included in this meta-analysis describes a total TR band compression time of 2 h with intermitted deflation during that period.¹⁴ This raises the question of whether the impact of the first deflation time on forearm swelling should be reconsidered. Furthermore, shorter haemostatic compression durations have been associated with a lower incidence of radial artery occlusion, without an increased risk of bleeding complications.¹⁵

Another risk factor for forearm swelling is inappropriate wrist movement, as described by Duan et al.⁸ This is a factor that nurses can influence through proper education for both nurses and patients, as well as the use of supportive aids such as a sling.

In summary, the clinical implications of this study are profound. Utilizing the predictive model enables healthcare providers to identify high-risk patients and implement targeted preventive measures. This proactive approach has the potential to enhance patient care by reducing the incidence of forearm swelling, thereby improving patient comfort and potentially shortening hospital stays and associated healthcare costs.

The strengths of this study lie in its prospective design and the use of a well-defined patient cohort. However, its single-centre setting and relatively small sample size may limit the generalizability and robustness of the predictive model. Therefore, multicentre studies with larger sample sizes would be valuable to validate and further strengthen the findings presented in this manuscript.

In conclusion, this study makes a significant contribution to the field of interventional cardiology by identifying risk factors for forearm swelling and developing a highly accurate predictive model. The application of this model has the potential to improve patient outcomes by preventing a common and discomforting complication associated with transradial artery interventions. Yet, further research is needed to validate and refine this model, ensuring its broad applicability and effectiveness in diverse clinical settings.

Author contributions

Marjo J.A.G. De Ronde-Tillmans (Conceptualization [equal], Validation [equal]) and Diekje R. Schouten (Writing—original draft [equal])

Funding

Not applicable.

Data availability

Not applicable.

References

Author notes