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Abdelazeem B, Abuelazm MT, Swed S, Gamal M, Atef M, Al-Zeftawy MA, Noori MA, Lutz A, Volgman AS. The efficacy of nitroglycerin to prevent radial artery spasm and occlusion during and after transradial catheterization: A systematic review and meta-analysis of randomized controlled trials. Clin Cardiol 2022; 45:1171-1183. [PMID: 36335609 DOI: 10.1002/clc.23906] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 11/07/2022] Open
Abstract
Radial artery spasm (RAS) is the most common cause of transradial access site crossover and is a common intra-procedural complication. RAS incidence can lead to radial artery occlusion (RAO) postprocedure, preventing the radial artery as a future access site. We evaluated the efficacy of nitroglycerin preventing RAS and RAO during transradial catheterization discussing the different routes of administration, including topical, subcutaneous, and intra-arterial. A systematic review and meta-analysis included all relevant articles until April 23, 2022. We searched six databases Google Scholar, Web of Science, SCOPUS, EMBASE, PubMed (MEDLINE), and CENTRAL. We registered our review protocol in PROSPERO with ID: CRD42022330356. We included 11 trials with 5814 patients. Compared to placebo, the pooled analysis favored subcutaneous nitroglycerin in preventing RAS (risk ratio [RR]: 0.57 with 95% confidence interval [CI] [0.43-0.77], p = .0003) and RAO (RR: 0.39 with 95% CI [0.16-0.98], p = .05). In contrast to the intra-arterial nitroglycerin that showed nonstatistically significant results in preventing RAS and RAO (RR: 0.8 with 95% CI [0.63-1.02], p = .07)- (RR: 0.78 with 95% CI [0.6-1.01], p = .06)), respectively. Also, topical nitroglycerin did not prevent RAS (RR: 0.73 with 95% CI [0.42-1.24], p = .24). Compared with placebo, subcutaneous nitroglycerin during transradial catheterization reduced the incidence of RAS and RAO. Meanwhile, Intra-arterial and topical nitroglycerin did not show statistically significant outcomes. Subcutaneous nitroglycerin may be a practical and cost-effective technique to facilitate transradial catheterization; however, more RCTs are needed to evaluate the subcutaneous versus intra-arterial nitroglycerin administration.
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Affiliation(s)
- Basel Abdelazeem
- McLaren Health Care, Flint, Michigan, USA
- Michigan State University, East Lansing, Michigan, USA
| | | | - Sarya Swed
- Faculty of Medicine, Aleppo University, Aleppo, Syria
| | | | - Mostafa Atef
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | | | - Anthony Lutz
- Michigan State University, East Lansing, Michigan, USA
- Division of Cardiology, Beaumont Hospital, Farmington Hills, Michigan, USA
| | - Annabelle S Volgman
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
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2
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da Silva RL, de Andrade PB, Dangas G, Joaquim RM, da Silva TRW, Vieira RG, Pereira VC, Sousa AGM, Feres F, Costa JR. Randomized Clinical Trial on Prevention of Radial Occlusion After Transradial Access Using Nitroglycerin: PATENS Trial. JACC Cardiovasc Interv 2022; 15:1009-1018. [PMID: 35331684 DOI: 10.1016/j.jcin.2022.02.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/10/2022] [Accepted: 02/15/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate whether administration of nitroglycerin at the beginning or end of a transradial approach (TRA) procedure would preserve radial patency. BACKGROUND The TRA is becoming the preferred vascular access route in coronary interventions. Radial artery occlusion (RAO) is the most frequent complication. Routine vasodilator treatment aims to reduce spasm and possibly prevent RAO. METHODS The authors designed a prospective, multicenter, randomized, double-blind, 2-by-2 factorial, placebo-controlled trial encompassing patients undergoing the TRA. Patients were randomized to either 500 μg nitroglycerin or placebo; each arm was also subrandomized to early (upon sheath insertion) or late (right before sheath removal) nitroglycerin administration to evaluate the superiority of nitroglycerin in the prevention of RAO with 24 hours on Doppler ultrasound. RESULTS A total of 2,040 patients were enrolled. RAO occurred in 49 patients (2.4%). Fifteen of these patients (30.6%) showed re-establishment of flow at 30 days. Nitroglycerin, compared with placebo, did not reduce the risk for RAO at either of the 2 time points (early, 2.5% vs 2.3% [P = 0.66]; late, 2.3% vs 2.5% [P = 0.66]). By multivariable analysis, the presence of spasm (OR: 3.53; 95% CI: 1.87-6.65; P < 0.001) and access achieved with more than 1 puncture attempt (OR: 2.58; 95% CI: 1.43-4.66; P = 0.002) were independent predictors of RAO. CONCLUSIONS The routine use of nitroglycerin was not associated with a reduction in the rate of RAO, regardless of the time of administration (at the beginning or end of the TRA procedure).
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Affiliation(s)
- Roberto L da Silva
- Department of Interventional Cardiology, Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil; Department of Interventional Cardiology, Instituto de Cardiologia de Santa Catarina, São José, Brazil; Department of Cardiology, Hospital Universitário Prof Polydoro Ernani de São Thiago, Florianópolis, Brazil.
| | - Pedro B de Andrade
- Department of Interventional Cardiology, Santa Casa de Marília, Marília, Brazil
| | - George Dangas
- Department of Interventional Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Rodrigo M Joaquim
- Department of Interventional Cardiology, Instituto de Cardiologia de Santa Catarina, São José, Brazil; Department of Cardiology, Hospital Universitário Prof Polydoro Ernani de São Thiago, Florianópolis, Brazil
| | - Thaís R W da Silva
- Department of Cardiology, Hospital Universitário Prof Polydoro Ernani de São Thiago, Florianópolis, Brazil
| | - Ramiro G Vieira
- Department of Interventional Cardiology, Instituto de Cardiologia de Santa Catarina, São José, Brazil
| | - Vanderlei C Pereira
- Department of Interventional Cardiology, Instituto de Cardiologia de Santa Catarina, São José, Brazil
| | - Amanda G M Sousa
- Department of Interventional Cardiology, Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | - Fausto Feres
- Department of Interventional Cardiology, Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | - José R Costa
- Department of Interventional Cardiology, Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
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Chen Y, Ke Z, Xiao J, Lin M, Huang X, Yan C, Ye S, Tan X. Subcutaneous Injection of Nitroglycerin at the Radial Artery Puncture Site Reduces the Risk of Early Radial Artery Occlusion After Transradial Coronary Catheterization: A Randomized, Placebo-Controlled Clinical Trial. Circ Cardiovasc Interv 2019; 11:e006571. [PMID: 30002088 DOI: 10.1161/circinterventions.118.006571] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 06/08/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Transradial coronary catheterization is widely used as a diagnostic or interventional procedure for coronary disease. However, it can lead to adverse complications, such as radial artery occlusion. We sought to determine whether preprocedural injection of nitroglycerin at the radial artery puncture site reduces radial artery occlusion. METHODS AND RESULTS A total of 188 patients undergoing transradial coronary catheterization were randomized in a single-blind fashion to receive subcutaneous injection of 0.5 mL 0.1% nitroglycerin or a placebo at the radial artery puncture site. The participants underwent ultrasound examinations of the radial artery before and at 24 hours after the procedure. Of the 188 patients enrolled, 182 completed the study, as the procedure failed in 2 participants in the nitroglycerin-treated group and 4 in the placebo group. Baseline demographic and clinical characteristics were similar between 2 groups. Comparing the radial artery diameters before and after the operation, there was a statistically significant increase in the nitroglycerin-treated group (2.48±0.45 versus 2.45±0.46 mm; P=0.003) but a decrease in the placebo control group (2.41±0.50 versus 2.46±0.49 mm; P<0.001). Importantly, the incidence of radial arterial occlusion was substantially lower in the nitroglycerin-treated group than in the placebo control group (5.4% versus 14.4%; P=0.04). There was not significant difference in other complications (forearm hematoma and radial artery pseudoaneurysm, respectively), and there was no incidence of cause hypotension or an intolerable headache. CONCLUSIONS Subcutaneous injection of nitroglycerin at the radial artery puncture site dilates the radial artery and reduces the incidence of early radial artery occlusion post-catheterization. CLINICAL TRIAL REGISTRATION URL: https://www.chictr.org.cn. Unique identifier: ChiCTR-IPR-15006559.
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Affiliation(s)
- Yequn Chen
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, China (Y.C., Z.K., J.X., M.L., X.H., C.Y., X.T.)
| | - Zhiquan Ke
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, China (Y.C., Z.K., J.X., M.L., X.H., C.Y., X.T.)
| | - Jiaxin Xiao
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, China (Y.C., Z.K., J.X., M.L., X.H., C.Y., X.T.)
| | - Mengyue Lin
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, China (Y.C., Z.K., J.X., M.L., X.H., C.Y., X.T.)
| | - Xiru Huang
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, China (Y.C., Z.K., J.X., M.L., X.H., C.Y., X.T.)
| | - Chunyin Yan
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, China (Y.C., Z.K., J.X., M.L., X.H., C.Y., X.T.)
| | - Shu Ye
- Cardiovascular Genetics Laboratory, Shantou University Medical College, China (S.Y.). .,Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, United Kingdom (S.Y.)
| | - Xuerui Tan
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, China (Y.C., Z.K., J.X., M.L., X.H., C.Y., X.T.).
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Dharma S, Gilchrist IC. Vasodilators and Radial Artery Occlusion: A Concept to Reduce Radial Artery Occlusion? Circ Cardiovasc Interv 2019; 11:e007011. [PMID: 30002090 DOI: 10.1161/circinterventions.118.007011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Surya Dharma
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, Jawa Barat, Indonesian Cardiovascular Research Center, National Cardiovascular Center Harapan Kita, Jakarta (S.D.)
| | - Ian C Gilchrist
- College of Medicine, Pennsylvania State University, Hershey (I.C.G.).
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Mamas MA, Fraser DG, Ratib K, Fath-Ordoubadi F, El-Omar M, Nolan J, Neyses L. Minimising radial injury: prevention is better than cure. EUROINTERVENTION 2015; 10:824-32. [PMID: 24472679 DOI: 10.4244/eijv10i7a142] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Transradial (TR) coronary intervention is associated with fewer access-site-related bleeding complications and is independently associated with a lower risk of mortality following PCI compared to procedures undertaken through the femoral route. However, recent studies that have undertaken imaging of the radial artery through the use of IVUS and OCT, as well as histological studies, suggest that TR cardiac catheterisation is associated with significant injury to the radial artery wall resulting in significant endothelial cell dysfunction. The vascular endothelium plays a central role in the regulation of vascular tone, angiogenesis and vascular remodelling through the release of vasoactive mediators in response to a variety of stimuli. Hence, trauma to the vascular endothelium and subsequent changes in endothelial cell function may contribute to patterns of injury such as intimal hyperplasia and radial artery occlusion observed following TR cardiac catheterisation. Such injury patterns to the radial artery following TR procedures may limit the success and future utility of the TR approach. Minimisation of radial artery injury should be a key procedural component of procedures undertaken through the transradial approach.
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Affiliation(s)
- Mamas A Mamas
- Manchester Heart Centre, Manchester Royal Infirmary, Biomedical Research Centre, Manchester, United Kingdom
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Sobolewski P, El Fray M. Cardiac catheterization: consequences for the endothelium and potential for nanomedicine. WILEY INTERDISCIPLINARY REVIEWS-NANOMEDICINE AND NANOBIOTECHNOLOGY 2014; 7:458-73. [PMID: 25429858 DOI: 10.1002/wnan.1316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 09/15/2014] [Accepted: 10/11/2014] [Indexed: 12/19/2022]
Abstract
Cardiac catheterization results in interactions between the catheter and surfaces and the artery lumen, which is lined by the endothelium. These interactions can range from minor rubbing to severe mechanical injury. Further, in the case of radial access, even atraumatic interactions have consequences ranging from clinical complications, such as radial spasm and radial occlusion, to lasting endothelial cell dysfunction. These consequences may be underappreciated; however, endothelial cells play a central role in maintaining vascular homeostasis via nitric oxide production. Existing treatment paradigms do not address endothelial dysfunction or damage and, thus, novel therapeutic approaches are needed. Nanomedicine, in particular, offers great potential in the form of targeted drug delivery, via functionalized coatings or nanocarriers, aimed at increased nitric oxide bioavailability or reduced inflammation.
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Affiliation(s)
- Peter Sobolewski
- Division of Biomaterials and Microbiological Technologies, West Pomeranian University of Technology, Szczecin, Poland
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Dharma S, Kedev S, Patel T, Kiemeneij F, Gilchrist IC. A novel approach to reduce radial artery occlusion after transradial catheterization: Postprocedural/prehemostasis intra-arterial nitroglycerin. Catheter Cardiovasc Interv 2014; 85:818-25. [DOI: 10.1002/ccd.25661] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 08/29/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Surya Dharma
- Department of Cardiology and Vascular Medicine; Faculty of Medicine; University of Indonesia, National Cardiovascular Center Harapan Kita Jakarta; Indonesia
| | - Sasko Kedev
- Department of Cardiology; Faculty of Medicine; University Clinic of Cardiology, University of St Cyril & Methodius; Vodnjanska 17 Skopje Macedonia
| | - Tejas Patel
- Department of Cardiovascular Science; Apex Heart Institute; Ahmedabad Gujarat India
| | | | - Ian C. Gilchrist
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine; Hershey Pennsylvania USA
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A Review of JACC Journal Articles on the Topic of Interventional Cardiology: 2011–2012. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Alef MJ, Tzeng E, Zuckerbraun BS. Nitric oxide and nitrite-based therapeutic opportunities in intimal hyperplasia. Nitric Oxide 2012; 26:285-94. [PMID: 22504069 DOI: 10.1016/j.niox.2012.03.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 03/27/2012] [Accepted: 03/30/2012] [Indexed: 12/22/2022]
Abstract
Vascular intimal hyperplasia (IH) limits the long term efficacy of current surgical and percutaneous therapies for atherosclerotic disease. There are extensive changes in gene expression and cell signaling in response to vascular therapies, including changes in nitric oxide (NO) signaling. NO is well recognized for its vasoregulatory properties and has been investigated as a therapeutic treatment for its vasoprotective abilities. The circulating molecules nitrite (NO(2)(-)) and nitrate (NO(3)(-)), once thought to be stable products of NO metabolism, are now recognized as important circulating reservoirs of NO and represent a complementary source of NO in contrast to the classic L-arginine-NO-synthase pathway. Here we review the background of IH, its relationship with the NO and nitrite/nitrate pathways, and current and future therapeutic opportunities for these molecules.
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Affiliation(s)
- Matthew J Alef
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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10
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Affiliation(s)
- Mark A. Kotowycz
- From the Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Vladimír Džavík
- From the Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
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