Endothelial dysfunction and the occurrence of radial artery spasm during transradial coronary procedures: the ACRA-Spasm study

Radial Artery Spasm-A Review on Incidence, Prevention and Treatment

Radial artery spasm (RAS) is a common complication associated with transradial access (TRA) for coronary interventions, particularly affecting elderly patients in whom radial access is preferred due to its benefits in reducing bleeding complications, improving clinical outcomes, and lowering long-term costs. This review examines the incidence, prevention, and treatment of RAS. Methods included an online search of PubMed and other databases in early 2024, analyzing meta-analyses, reviews, studies, and case reports. RAS is characterized by a sudden narrowing of the radial artery due to psychological and mechanical factors with incidence reports varying up to 51.3%. Key risk factors include patient characteristics like female sex, age, and small body size as well as procedural factors such as emergency procedures and the use of multiple catheters. Preventive measures include using distal radial access, hydrophilic sheaths, and appropriate catheter sizes. Treatments involve the intraarterial administration of nitroglycerine and verapamil as well as mechanical methods like balloon-assisted tracking. This review underscores the need for standardizing RAS definitions and emphasizes the importance of operator experience and patient management in reducing RAS incidence and improving procedural success.

Extremity Dysfunction After Large-Bore Radial and Femoral Arterial Access

Background

The use of large‐bore (LB) arterial access and guiding catheters has been advocated for complex percutaneous coronary intervention. However, the impact of LB transradial access (TRA) and transfemoral access (TFA) on extremity dysfunction is currently unknown.

Methods and Results

The predefined substudy of the COLOR (Complex Large‐Bore Radial PCI) trial aimed to assess upper and lower‐extremity dysfunction after LB radial and femoral access. Upper‐extremity function was assessed in LB TRA‐treated patients by the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire and lower‐extremity function in LB TFA‐treated patients by the Lower Extremity Functional Scale questionnaire. Extremity pain and effect of access site complications and risk factors on extremity dysfunction was also analyzed. There were 343 patients who completed analyzable questionnaires. Overall, upper and lower‐extremity function did not decrease over time when LB TRA and TFA were used for complex percutaneous coronary intervention, as represented by the median Quick Disabilities of the Arm, Shoulder, and Hand score (6.8 at baseline and 2.1 at follow‐up, higher is worse) and Lower Extremity Functional Scale score (56 at baseline and 58 at follow‐up, lower is worse). Clinically relevant extremity dysfunction occurred in 6% after TRA and 9% after TFA. A trend for more pronounced upper‐limb dysfunction was present in female patients after LB TRA (P=0.05). Lower‐extremity pain at discharge was significantly higher in patients with femoral access site complications (P=0.02).

Conclusions

Following LB TRA and TFA, self‐reported upper and lower‐limb function did not decrease over time in the majority of patients. Clinically relevant limb dysfunction occurs in a small minority of patients regardless of radial or femoral access.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03846752.

Diagnosis of coronary artery spasm by ergonovine provocation test of radial artery

We investigated the sensitivity, specificity and safety of ergonovine provocation test of radial artery in the diagnosis of coronary artery spasm (CAS). The patients who came to our hospital for chest pain from January to June 2020 as well as had coronary stenosis < 50% and no radial artery stenosis, were enrolled in this study. These patients were divided into CAS group and control group after intracoronary ergonovine provocation test. All patients underwent ergonovine provocation test of radial artery, the inner diameter (D₀ and D₁) and the peak systolic velocities (PSV₀ and PSV₁) of the radial artery were measured by ultrasound before and after ergonovine provocation. The predictive value of ergonovine provocation test of radial artery for the diagnosis of CAS was analyzed using receiver operator characteristic (ROC) curve. There were 19 patients in the CAS group and 28 patients in the control group. Low density lipoprotein cholesterol and smoking rate were significantly higher in the CAS group than in the control group (all P < 0.05), but there were no significant differences in other items (P > 0.05) between the two groups. In the ergonovine provocation test of radial artery, degree of radial artery stenosis was significantly higher in the CAS group [41.50% (35.60%, 50.00%)] than in the control group [11.25% (5.15%, 23.00%)] (P = 0.000), but there were no siginificant differences in D₀, PSV₀ and PSV₁ between the two groups (P > 0.05). The area under ROC curve of ergonovine (120 µg) provocation test of radial artery for the diagnosis of CAS was 0.912 with 95%CI: 0.792-0.975, P = 0.001, cut-off of 31%, specificity of 92.86% and sensitivity of 84.21%. The ergonovine (120 µg) provocation test of radial artery did not cause any adverse reactions. We concluded that the ergonovine provocation test of radial artery has high sensitivity, specificity and safety in the diagnosis of CAS.

Impact of Opioid Analgesia and Inhalation Sedation Kalinox on Pain and Radial Artery Spasm during Transradial Coronary Angiography

With respect to the transfemoral approach, transradial procedures enable a drastic reduction of bleeding events and are associated with a reduction of mortality. Radial artery spasm (RAS) is one of the most common complications and may lead to patient discomfort and procedural failure. Currently, there is no consensus on the optimal sedation protocol to avoid RAS. The aim of this study was to investigate the respective impact of opioids analgesia and inhalation sedation with a 50% nitrous oxide/oxygen premix (Kalinox) on pain and occurrence of RAS during transradial coronary procedures. Consecutive patients undergoing transradial coronary angiography were prospectively enrolled in one, single center observational study (Nouvel Hôpital Civil, Strasbourg, France). Patients received opioids analgesia or inhalation sedation with Kalinox. The primary endpoints of the study were the incidence of a pain scale ≥5/10 and the occurrence of RAS. The secondary endpoints were the incidence of side effects. A total of 325 patients were enrolled (185 in the opioids analgesia group, 140 in the Kalinox group). RAS and pain scale ≥5 rates were not significantly different in the opioids analgesia and Kalinox groups (respectively 13.5% vs. 10.0% and 16.2% vs. 11.4%). Headache was more frequently observed in the Kalinox group (6.4% vs. 0.0%; p = 0.002). By multivariate analysis, female gender, BMI <25 kg/m², puncture difficulty, the use of plastic needle and 6F sheath were identified as independent predictors of RAS. Procedural inhalation sedation by Kalinox is as safe as opioids analgesia during transradial coronary angiography.

A novel predictor of radial spasm: arterial stiffness

OBJECTIVE

In this study, we aimed to assess the relationship between radial artery spasm (RAS) and arterial stiffness (AS) measured by the oscillometric method.

MATERIALS AND METHODS

A total of 123 consecutive patients scheduled for elective coronary angiography in a single default radial center were enrolled for the study. AS [namely, augmentation pressure; augmentation index (AIx); and pulse wave velocity] was assessed using a validated oscillometric device (Mobil-O-Graph NG 24 h PWA). Central arterial pressures were also recorded. In the cath lab, the number of puncture attempts, total procedural time (TPT), and largest catheter size were noted. If greater than two catheters were required to complete imaging, it was additionally specified. RAS was considered to exist if two or more of predefined clinical features were present.

RESULTS

RAS was observed in 20 (16.3%) patients. Patients were divided into two distinct groups in terms of the occurence of RAS. In the RAS(+) group, the proportion of hypertensive individuals was significantly higher, whereas there were fewer smokers. With respect to operational data, TPT (24.3±9.8 vs. 29.3±9.1 mins; P=0.038) and procedures carried out with more than one puncture attempts were significantly higher in the RAS(+) group. Among all oscillometric parameters, augmentation pressure, AIx, and PR were found to be higher in the RAS(+) group. According to multivariate analysis, TPT (P=0.029) and AIx (odds ratio: 1.044, 95% confidence interval=0.977-1.117; P=0.009) were found to be independent predictors of RAS.

CONCLUSION

Along with conventional risk factors, AS assessment, as a practical, noninvasive method, may help to predict RAS in angiographic procedures.

Novel treatment of severe radial artery spasm using "homemade sheathless technique": A case report

RATIONALE

Transradial access (TRA) is common for cardiac catheterization, but radial artery spasm (RAS) is suggested to be highlighted. Severe radical artery spasm could be solved by a relative novel approach called "sheathless technique," using a Tiger diagnostic catheter.

PATIENT CONCERNS

A 73-year-old woman presented to our institution with a recurrent feeling of discomfort in her chest. Her electrocardiogram showed ST segment depression. Her medical history indicated arterial hypertension, diabetes, and chronic renal failure. She was on hemodialysis for 5 years for the management of renal problems. Five stents were implanted from femoral access in another hospital via 2 percutaneous coronary interventions. The patient agreed to angiography this time and wanted a more comfortable solution.

DIAGNOSIS

Recurrent exertional angina was confirmed based on the chief complaint, electrocardiogram, and history.

INTERVENTIONS

After a successful radial artery puncture, a 6F arterial sheath pipe and a 5F Tiger diagnostic ductus could only advance slightly because of the RAS. Glonoin and verapamil functioned with the help of the radial sheath, and systemic nitroglycerin was applied later but had a negative outcome. Warm covers were positioned on the antebrachium, but no relief was reported.The "homemade sheathless technique" was applied. The 5F tube was held, and the 6F sheath was withdrawn. A blade was used to damage the sheath in reverse, and the excess sheath tube was removed.

OUTCOMES

The diagnostic catheter was successfully advanced to the ascending aorta, enabling left main and right coronary engagement and angiography. No significant coronary lesion was observed. The patient was discharged 3 days after angiography. Moreover, no complications were observed. A follow-up for 1 month after discharge also showed no complications.

LESSONS

Severe RAS causing failure of TRA is frequent in the transradial catheterization procedure. The sheathless technique may be useful in relieving spasm when other measures fail.

Effect of transient ulnar artery compression on radial artery diameter

The transradial approach is widely preferred in coronary procedures. A small radial artery diameter (RAD) is the most important factor affecting successful access. Various maneuvers and medications have been used to increase the RAD and thereby facilitate RA cannulation. Ulnar artery compression (UAC) for 30 min has been indicated to be effective in increasing the RAD and facilitating RA access. The aim of the present preliminary study was to assess the effect of transient UAC for 1 min on the RAD. A total of 151 patients were included in the present study. RA ultrasonography was performed at the level of the wrist. The UA was compressed for 1 min. The RAD was measured at baseline, at the end of UAC and at 1 min thereafter. The results indicated that the RAD was significantly smaller in diabetic vs. non-diabetic patients (2.35±0.43 vs. 2.50±0.39 mm, P=0.024) and in women vs. men (2.25±0.38 vs. 2.56±0.38 mm, P<0.001). At the end of UAC, the RAD was increased compared with that at baseline (2.45±0.41 vs. 2.62±0.41 mm, P<0.001), but it started to decrease thereafter, and the RAD measured at 1 min after stopping UAC was significantly smaller (2.62±0.41 vs. 2.55±0.40 mm, P<0.001), while remaining significantly larger than that at baseline (P<0.001). The RA peak systolic flow velocity also increased significantly during UAC (35.3±8.9 vs. 60.3±19.2 cm/sec; P<0.001). In conclusion, Transient UAC for 1 min significantly increased the RAD and the peak systolic flow velocity. Further studies with clinical endpoints are required for further exploration of the feasibility of this approach.

Transradial access for coronary diagnostic and interventional procedures: Consensus statement and recommendations for India: Advancing Complex CoronariES Sciences through TransRADIAL intervention in India - ACCESS RADIAL™: Clinical consensus recommendations in collaboration with Cardiological Society of India (CSI)

Radial access for cardiac catheterization and intervention in India has been growing steadily over the last decade with favorable clinical outcomes. However, its usage by interventional cardiologists varies greatly among Indian operators and hospitals due to large geographic disparities in health care delivery systems and practice patterns. It also remains unclear whether the advantages, as well as limitations of transradial (TR) intervention (as reported in the western literature), are applicable to developing countries like India or not. An evidence-based review involving various facets of radial procedure for cardiac catheterization, including practical, patient-related and technical issues was conducted by an expert committee that formed a part of Advancing Complex CoronariES Sciences through TransRADIAL intervention (ACCESS RADIAL™) Advisory Board. Emerging challenges in redefining TR management based on evidence supporting practices were discussed to formulate these final recommendations through consensus.

Body Mass Index Is Associated With Microvascular Endothelial Dysfunction in Patients With Treated Metabolic Risk Factors and Suspected Coronary Artery Disease

BACKGROUND

Obesity is key feature of the metabolic syndrome and is associated with high cardiovascular morbidity and mortality. Obesity is associated with macrovascular endothelial dysfunction, a determinant of outcome in patients with coronary artery disease. Here, we compared the influence of obesity on microvascular endothelial function to that of established cardiovascular risk factors such as diabetes mellitus, hypertension, hypercholesterolemia, and smoking in patients with suspected coronary artery disease.

METHODS AND RESULTS

Endothelial function was assessed during postocclusive reactive hyperemia of the brachial artery and downstream microvascular beds in 108 patients who were scheduled for coronary angiography. In all patients, microvascular vasodilation was assessed using peripheral arterial tonometry; laser Doppler flowmetry and digital thermal monitoring were performed. Body mass index was significantly associated with decreased endothelium-dependent vasodilatation measured with peripheral arterial tonometry (r=0.23, P=0.02), laser Doppler flowmetry (r=0.30, P<0.01), and digital thermal monitoring (r=0.30, P<0.01). In contrast, hypertension, hypercholesterolemia, and smoking had no influence on microvascular vasodilatation. Especially in diabetic patients, endothelial function was not significantly reduced (control versus diabetes mellitus, mean±SEM or median [interquartile range], peripheral arterial tonometry: 1.90±0.20 versus 1.67±0.20, P=0.19, laser Doppler flowmetry: 728% [interquartile range, 427-1110] versus 589% [interquartile range, 320-1067] P=0.28, and digital thermal monitoring: 6.6±1.0% versus 2.5±1.7%, P=0.08). In multivariate linear regression analysis, body mass index was the only risk factor that significantly attenuated endothelium-dependent vasodilatation using all 3 microvascular function tests.

CONCLUSIONS

Higher body mass index is associated with reduced endothelial function in patients with suspected coronary artery disease, even after adjustment for treated diabetes mellitus, hypertension, hypercholesterolemia, and smoking.