Vascular dysfunction and its recovery after transradial coronary angioplasty- A serial observational study

OBJECTIVE

To serially evaluate the effect of trans-radial coronary angioplasty (TRA) on the vascular function of radial artery (RA) and upstream brachial artery (BA) and to find out the relative contribution of endothelial dependent flow-mediated vasodilatation (FMD) and endothelial independent nitrate mediated dilatation (NMD).

METHODS

Forty patients of chronic stable angina with successful TRA were studied. FMD and NMD of bilateral RA and BA were measured with high-resolution ultrasound, before and at 24 h and at 3 months, after catheterization.

RESULTS

FMD as well as NMD were significantly decreased in right RA (16.3 ± 3.6% to 5.7 ± 1.8%; p = 0.001, and 24.1 ± 5.3% to 9.7 ± 2.8%; p = 0.001, respectively) as well as in upstream BA (17.0 ± 1.6% to 9.4 ± 0.5%; p = 0.001,and 26.5 ± 6.8% to 20.5 ± 3.7%; p = 0.001, respectively) at 24 h. FMD/NMD ratio was also decreased in RA (70 ± 10% to 60 ± 10%; p = 0.04) and as well as in BA (70 ± 20% to 50 ± 10%; p = 0.03). The endothelial dysfunctions returned to normal at 3 months. Control arm did not show any change in vascular function at any point of time. Radial artery diameter/sheath ratio <1 and catheter exchanges >2 were the independent predictors for >50% decrease in FMD.

CONCLUSIONS

TRA results in reversible depression in FMD as well as NMD in the radial artery as well as upstream brachial artery. These vascular dysfunctions are limited to the catheterized arm only and return to normal after 3 months.

The effect of coronary angiography and femoral access on femoral artery distensibility and elasticity

AIM OF THE STUDY

The aim of this study was to evaluate the long-term effects of access to the femoral artery for the purposes of coronary angiography through the measurement of femoral artery distensibility and elasticity on the accessed and non-accessed sides.

MATERIAL AND METHODS

This cross-sectional study included patients who underwent femoral angiography at least 1 year previously. Those whose femoral artery was accessed once formed Group 1 (n = 59), those who were accessed twice formed Group 2 (n = 57), those accessed 3 times formed Group 3 (n = 55), and those with more than 3 accesses, Group 4 (n = 60). The groups were compared in respect of femoral artery elasticity and distensibility in the accessed and non-accessed sides.

RESULTS

No statistically significant difference was determined in respect of femoral distensibility and elasticity in Group 1 (9.40 ± 0.84 vs 9.48 ± 0.75, p = 0.107 and 0.23 ± 0.03 vs 0.23 ± 0.03, p = 0.433, respectively). However, a significant difference was observed between the two sides in terms of distensibility and elasticity in Group 2 (9.02 ± 0.81 vs 9.23 ± 0.75, and 0.21 ± 0.02 vs 0.22 ± 0.02), in Group 3 (8.49 ± 0.77 vs 9.18 ± 0.9 and 0.19 ± 0.02 vs 0.21 ± 0.02), and in Group 4 (8.14 ± 0.74 vs 9.03 ± 0.81 and 0.16 ± 0.01 vs 0.2 ± 0.02, p <0.001, for all comparisons).

CONCLUSION

While a single access in the femoral artery for coronary angiography does not affect femoral artery elasticity and distensibility, multiple accesses may have adverse effects.

Long-term endothelial dysfunction after trans-radial catheterization: A meta-analytic approach

BACKGROUND

Following cardiac catheterization using radial artery (RA) access, persistent endothelial dysfunction may limit the use of RA as a conduit during coronary artery bypass graft (CABG) surgery. We reviewed published literature to investigate the effects of transradial coronary catheterization on RA endothelial function.

METHODS

We searched PubMed from inception to April 2017 for published studies assessing RA endothelial function late (≥1 month) after coronary catheterization. A total of 12 eligible published studies (n = 490 patients) were included in the final quantitative synthesis. Statistical heterogeneity among studies was assessed by the I² . A random effects model was used to calculate the pooled estimate for standardized mean difference (SMD). Meta-regression analysis was used to explore predictors of change in RA endothelial function following catheterization.

RESULTS

In all studies, a significant reduction in endothelium dependent response was observed post-catheterization (SMD = -0.53, 95% confidence interval [CI]: -0.93 to -0.13, P = 0.01) and a marginal, non-significant, reduction in endothelium independent response (SMD = -0.38, 95%CI: -0.77, 0.01, P < 0.059). In controlled studies, using the contralateral RA as a control, a significant impairment in endothelial function was confirmed (SMD = -6.26, 95%CI: -9.71 to -2.81, P < 0.0001), while the change in endothelium-independent response was not significant (SMD = -4.46, 95%CI: -13.3 to 4.37, P = 0.32). In meta-regression analysis male gender (z = 2.36, P = 0.018) and increasing time following catheterization (z = 2.62, P = 0.009) were associated with less RA endothelial dysfunction.

CONCLUSIONS

Transradial catheterization impairs endothelium dependent vasodilatory properties of the cannulated RA, which do not recover even several months post-catheterization. Non-recovery of vasomotor function of cannulated RAs may limit their use as arterial grafts during CABG surgery.

Endothelial Progenitor Cell Biology and Vascular Recovery Following Transradial Cardiac Catheterization

BACKGROUND

Transradial catheterization is associated with radial artery injury and vasomotor dysfunction and represents an accessible model of acute vascular injury in humans. We characterized vascular injury and functional recovery to understand the role of circulating endothelial progenitor cells in vascular repair.

METHODS AND RESULTS

In 50 patients (aged 64±10 years, 70% male) undergoing transradial cardiac catheterization, radial artery injury was assessed by optical coherence tomography and examination of explanted vascular sheaths. Flow- and nitrate-mediated dilatation of the radial artery was assessed in both arms at baseline, at 24 hours, and at 1, 4, and 12 weeks. Circulating endothelial progenitor cell populations were quantified using flow cytometry. Late endothelial outgrowth colonies were isolated and examined in vitro. Optical coherence tomography identified macroscopic injury in 12 of 50 patients (24%), but endothelial cells (1.9±1.2×104 cells) were isolated from all arterial sheaths examined. Compared with the noncatheterized radial artery, flow-mediated vasodilatation was impaired in the catheterized artery at 24 hours (9.9±4.6% versus 4.1±3.1%, P<0.0001) and recovered by 12 weeks (8.1±4.9% versus 10.1±4.9%, P=0.09). Although the number of CD133+ cells increased 24 hours after catheterization (P=0.02), the numbers of CD34+ cells and endothelial outgrowth colonies were unchanged. Migration of endothelial cells derived from endothelial outgrowth colonies correlated with arterial function before catheterization but was not related to recovery of function following injury.

CONCLUSIONS

Transradial cardiac catheterization causes endothelial denudation, vascular injury, and vasomotor dysfunction that recover over 12 weeks. Recovery of vascular function does not appear to be dependent on the mobilization or function of endothelial progenitor cells.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02147119.

Evaluation of endothelial dysfunction with flow-mediated dilatation after transradial coronary angiography

Objective Transradial coronary angiography (TRCA) may lead to endothelial dysfunction. Therefore, this study investigated the TRCA-related endothelial dysfunction and its relation to operator experience, the number of punctures and procedure duration. Methods and results A total of 57 patients (42 males and 17 females) who underwent TRCA were included in this single-centre study. Nine months after the procedure, all patients underwent radial artery B-mode ultrasound imaging, and flow-mediated dilatation (FMD) and nitroglycerin-mediated dilatation (NMD) techniques were employed. The non-intervened right radial artery was accepted as control. The percentage change in diameter after FMD was significantly greater in the right radial artery compared to the left radial artery (right 13.6% vs left 10.1%, P = 0.041). The percentage change in diameter after NMD was similar in both right and left radial arteries (right 23.8% vs left 23.4%, P = 0.932). According to the puncture numbers, the percentage change was significantly lower in the intervened artery among patients with more than one puncture (13.3% vs 7.8%, P = 0.005). According to the operator experience, the percentage change in the intervened artery was significantly higher in patients in whom the procedure was performed by experienced operators (13.7% vs 7.6%, P = 0.002). The procedure duration also showed a negative correlation with the percentage change in the intervened artery (r = -0.349, P = 0.008). Conclusions TRCA may lead to endothelial dysfunction represented by FMD. Moreover, higher puncture numbers for sheath insertion, longer procedure durations and less experience in radial interventions may have adverse effects on the endothelial function.

Preoperative Insight Into the Quality of Radial Artery Grafts

We investigated the impact of preoperative ultrasonography of the forearm circulation on radial artery conduit selection. Preoperative ultrasound of the forearm circulation was performed routinely in 536 patients planned for radial artery harvesting. The safety assessment of the harvest included the following algorithm of tests: the ultrasound, the Allen test, and pulse oximetry. The quality criteria that were used to exclude a radial artery from harvesting were small size of the artery, diffuse atherosclerosis, calcifications, and severe neointimal hyperplasia. The overall rejection rate due to safety reasons was 16.4%. Seventy-one (13.2%) radial arteries did not fulfill the conduit quality criteria and consequently these arteries were not harvested. In 13.4% of radial arteries, localized arterial wall disease was found in the distal third of the artery. The distal part of the artery was discarded and the rest was used as a conduit. Our results indicate that the ultrasound provides an accurate preoperative insight into the radial artery morphology, enabling selection of the arteries with favorable morphological features.

Radial artery vasomotor function following transradial cardiac catheterisation

Aims

To determine the reproducibility of flow-mediated dilation (FMD) and nitrate-mediated dilation (NMD) in the assessment of radial artery vasomotor function, and to examine the effect of transradial catheterisation on radial artery injury and recovery.

Methods

Radial artery FMD and NMD were examined in 20 volunteers and 20 patients on four occasions (two visits at least 24 hours apart, with two assessments at each visit). In a further 10 patients, radial artery FMD was assessed in the catheterised arm prior to, at 24 hours and 3 months following cardiac catheterisation.

Results

There were no differences in baseline radial artery diameter (2.7±0.4 mm vs 2.7±0.4 mm), FMD (13.4±6.4 vs 12.89±5.5%) or NMD (13.6±3.8% vs 10.1±4.3%) between healthy volunteers and patients (p>0.05 for all comparisons). Mean differences for within and between day FMD were 2.53% (95% CIs −15.5% to 20.5%) and −4.3% (−18.3% to 9.7%) in patients. Compared to baseline, radial artery FMD was impaired at 24 hours (8.7±4.1% vs 3.9±2.9%, p=0.015) but not 3 months (8.7±4.1% vs 6.2±4.4, p=0.34) following transradial catheterisation.

Conclusions

Radial FMD is impaired early after transradial catheterisation but appears to recover by 3 months. While test–retest variability was demonstrated, our findings suggest that transradial access for cardiac catheterisation may afford a potential model of vascular injury and repair in vivo in man.

The effect of transradial coronary catheterization on upper limb function

OBJECTIVES

The aim of this study was to analyze the change of upper limb function when percutaneous coronary procedures were performed through the radial artery.

BACKGROUND

It is currently unknown if upper limb function is affected by transradial (TR) catheterization.

METHODS

Between January 2013 and February 2014, upper limb function was assessed in a total of 338 patients undergoing coronary catheterization in an ambulatory setting (85% radial approach, 15% femoral approach). Upper limb function was assessed with the self-reported shortened version of the Disabilities of Arm, Shoulder, and Hand questionnaire. The presence and severity of upper extremity cold intolerance was assessed with the self-reported Cold Intolerance Symptom Severity questionnaire. Both questionnaires were completed before the catheterization and at 30-day follow-up. Higher scores represent worse upper limb functionality or symptoms. The nonparametric Wilcoxon signed-rank test was used to assess the change of upper limb function and symptoms over time.

RESULTS

Upper limb function did not change significantly over time when catheterization was performed through the radial artery (p=0.06). The number of procedure-related extremity complaints that persisted during 30-day follow-up were not different between both access groups (TR access 10.5%, transfemoral access 11.5%; p=0.82). The upper extremity was not affected by cold intolerance after TR access at 30-day follow-up (p=0.91).

CONCLUSIONS

Upper limb function was not affected when coronary catheterizations and interventions were performed through the radial artery.

Cardiac catheterization: consequences for the endothelium and potential for nanomedicine

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.

Radial access during percutaneous interventions in patients with acute coronary syndromes: should we routinely monitor radial artery patency by ultrasonography promptly after the procedure and in long-term observation?

Access-site vascular complications in patients undergoing transradial coronary procedures are rare but may have relevant clinical consequences. The aim of the study was to evaluate: (1) radial artery's (RA) patency immediately after the procedure and in long-term observation, (2) factors influencing the frequency of radial artery's occlusion (RAO) after percutaneous coronary intervention (PCI) procedures performed via transradial access in the group of 220 patients with acute coronary syndromes (ACS). RA ultrasound was performed 48-72 h after the procedure and in those who were diagnosed with RAO-again after 6-12 months. According to the ultrasonographic findings, the patients were divided into two sub-groups: 187 pts (85 %) with patent RA after PCI and 33 pts (15 %) with RAO. Both sub-groups significantly statistically differed with regard to the frequency of local hematomas-15 versus 27.3 % (p = 0.02), the frequency of applying IIbIIIa inhibitors in PCI-6.4 versus 15.1 % (p = 0.015) and procedure duration-0.59 ± 0.37 versus 0.77 ± 0.38 (p = 0.014), respectively. In a multifactorial analysis the only factor influencing RA patency promptly after the procedure was PCI duration (p < 0.05, r = -0.22). In the follow-up, right RA remained still obstructed in 28 patients (12.7 %) whereas in five patients (2.3 %) the regular flow in RA was resumed. The chronic RAO was clinically silent. Due to insignificant frequency of the occurrence of RAO after PCI procedure in patients with ACS as well as practically lack of clinical consequences of this artery's occlusion in long-term observation, we do not see any implications to routine ultrasound periprocedural RA evaluation.