Radial artery access site complications during cardiac procedures, clinical implications and potential solutions: The role of nitric oxide

Frequency of ventriculography during left heart catheterization for radial vs. femoral access

BACKGROUND

Radial artery access has been used for left heart catheterization (LHC) and percutaneous coronary intervention (PCI) for over 30 years. This method has gained popularity among operators due to superficial vessel anatomy, allowing for easy accessibility and compressibility, resulting in effective hemostasis.

METHODS

We conducted a retrospective analysis of patients who underwent PCI due to ST-elevation myocardial infarction (STEMI), non-ST-elevation acute coronary syndrome (NSTE-ACS), and chest pain (stable angina) from November 2013 to February 2023.

RESULTS

We analyzed validated registries and found 7714 PCIs. Of these, 1230 were STEMI patients, 5585 were NSTE-ACS patients, and 899 were stable angina patients, forming the basis of our final analysis. In STEMI patients, there was a trend toward a higher rate of ventriculography with femoral access compared to radial access (53.4 % vs. 47.5 %, p = 0.06), which was also observed in NSTE-ACS patients (34.2 % vs. 31.8 %, p = 0.07). The use of central venous access was more common with femoral access in all three diagnoses, with significantly higher rates seen in STEMI patients (36.2 % vs. 7.6 %, p < 0.001), NSTE-ACS patients (19.3 % vs. 2.8 %, p < 0.001), and chest pain patients (26.4 % vs. 2.7 %, p < 0.001).

CONCLUSIONS

The analysis revealed that operators may perform fewer ventriculography and RHC procedures when using radial access as compared to femoral access. While there is discrepancy in performing left ventriculography and RHC when using a radial artery, it is essential to emphasize that routinely performing ventriculography and hemodynamic assessment has not proven to impact outcomes, despite their contributions to proper decision-making and treatment.

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.

Complications of Radial vs Femoral Access for Coronary Angiography and Intervention: What Do the Data Tell Us?

In the last decades, radial access, as an alternative to femoral access, has rapidly evolved and emerged as the preferred vascular access for coronary angiography and percutaneous coronary intervention (PCI). The use of radial access for PCI can reduce access-site bleeding, particularly retroperitoneal bleeding, and risk of developing pseudoaneurysm, while also improving patient comfort after procedure (eg, early ambulation). However, radial access requires a longer learning curve to develop technical skills, and the data on radial artery graft for coronary artery bypass graft after radial access remain insufficient. Further, recent clinical trials have shown conflicts regarding whether radial access is associated with lower mortality in patients with ST-elevation myocardial infarction. Despite these recent investigations, it is still debated whether there are benefits associated with radial access over femoral access for PCI. In this review, we will evaluate radial access compared with femoral access for PCI on clinical outcomes and further discuss the usefulness of radial access.

Impact of Local Forearm Heating on Pain Intensity and Hemorrhage in Patients Undergoing Radial Artery Cardiac Catheterization: A Pilot Study

BACKGROUND

Radial artery cardiac catheterization is a common diagnostic and interventional procedure for cardiovascular conditions. Pain and hemorrhage at the access site can cause patient discomfort and complications. This pilot study investigates the potential of local forearm heating to reduce pain and hemorrhage in patients undergoing radial artery cardiac catheterization.

METHODS

We enrolled 100 patients scheduled for radial artery cardiac catheterization and randomly assigned them to the heating or control group. The heating group received local forearm heating before sheath removal, while the control group did not. Pain intensity was assessed with a visual analog scale, and hemorrhage was measured by assessing ecchymosis or hematoma size at the catheterization site. Hemodynamic parameters were also monitored. Statistical analysis compared outcomes between the groups.

RESULTS

Patients who received local forearm heating had significantly lower pain intensity (4.15 ± 2.73) compared to the control group (5.84 ± 3.34) (P =.009). Hemodynamic parameters and the extent of hemorrhage at the catheterization site did not significantly differ between the heating and control groups (P >.05). No adverse effects related to forearm heating were reported.

CONCLUSION

Local forearm heating is a promising intervention to reduce pain intensity without increasing hemorrhage or affecting hemodynamic parameters during radial artery cardiac catheterization. This simple, noninvasive approach has the potential to enhance patient comfort and safety post procedure.

Finger exercise could reduce painfulness and radial artery complications related to coronary artery angiography

OBJECTIVE

To estimate if applying a finger exercise during trans-radial coronary artery angiography (CAG) could help to reduce a patient's painfulness and evaluate its protective effects against radial artery complications.

METHODS

This is a prospective, controlled, single-center trial. Overall, 390 patients who underwent coronary angiography through radial path in our hospital during 2022 were randomized 1 : 1 to the following two groups: test group: finger exercise in addition to routine perioperative care; control group: routine care. The success rate of radial puncture, the incidence of procedural radial artery dissection (RAD) and radial artery spasm (RAS), change of wrist circumference, pain degree related to the operation, occurrence of access site hemorrhagic complications, hemostasis time and postprocedure occurrence of radial artery occlusion (RAO) before discharge were recorded and compared between two groups.

RESULTS

Compared to the control group, the test group had a higher success rate of radial puncture, lower incidence of RAS, RAD and RAO, slighter swelling of wrist and patients who felt less pain in the test group. There was no difference in prolonged hemostasis time or hemorrhagic complications between the two groups.

CONCLUSION

Finger exercise could help to make a patient more comfortable and reduce radial artery complications related to CAG.

Évaluation de la voie radiale distale dans les interventions coronaires percutanées. Essai contrôlé, randomisé de non infériorité

INTRODUCTION

The conventional radial approach (CRA), the gold standard approach for percutaneous coronary interventions (PCI), is associated with the risk of radial artery occlusion (RAO). The distal radial approach (DRA) is an effective alternative with fewer complications.

AIM

To evaluate the efficacy in terms of puncture success and safety by RAO rate of the DRA in elective PCI in Tunisian patients.

METHODS

It was a randomized controlled non-inferiority trial including patients hospitalized for elective PCI. The protocol was previously published (Tunis Med 2022; 100(3): 192-202). The primary endpoints were puncture success and RAO rate at 30 days.

RESULTS

Overall, 250 patients were included and the groups were comparable. The preprocedural examination of the radial pulse and the Barbeau test were similar. The majority of PCIs were coronary angiography (82%). In ITT, respectively in CRA versus DRA, puncture success rates were similar (97.6% versus 96.8%; p≤0.500). RAO rates were similar (2.4% versus 3.2%; p≤0.500). Crossovers were similar. PCI through DRA lasted longer but was not more irradiating, however it required more contrast. Overall bleeding and vascular complications were similar.

CONCLUSION

This study demonstrated the non-inferiority of DRA compared to CRA for elective PCIs in a Tunisian population regarding puncture success and RAO rate at 30 days. Multicenter trials including urgent PCI with systematic ultrasound screening for RAO are needed.

Cocoa flavanol supplementation preserves early and late radial artery function after transradial catheterization

Background: The transradial approach for coronary angiography is associated with fewer complications and preferred over the femoral approach. Injury to the radial artery (RA) endothelium elicits intimal hyperplasia, possibly resulting in total occlusion and limb functional decline. Flavanols are known to improve endothelial function. Effects on arterial remodeling after mechanical injury are unknown. Objective: To investigate the effects of cocoa flavanols on (a) intimal hyperplasia and (b) endothelial functional recovery after mechanical vascular wall injury through transradial coronary angiography (TCA). Methods: Primary endpoint in this double-blind, randomized, controlled trial was RA intima-media thickness (IMT) after 6 months follow-up (FU). Secondary endpoints were RA flow-mediated vasodilation (FMD) and fractional diameter change (Fdc). Further luminal diameter and circulating endothelial microparticles (EMP) were assessed. Thirty-six male patients undergoing elective TCA were included. Flavanol or matched placebo supplementation started 7 days prior TCA (cocoa flavanol 1000 mg day^-1) for 14 days. Four measurements spanned three periods over 6-moths-FU. Results: TCA induced sustained intimal hyperplasia in the placebo-, but not in the flavanol-group (IMT 0.44 ± 0.01 vs. 0.37 ± 0.01 mm, p = 0.01). FMD decreased after TCA in both groups, but recovered to baseline after 6 months in the flavanol group only. Fdc acutely decreased, EMPs increased in the placebo-, not in the flavanol -group. Luminal diameter remained unchanged in both groups. Conclusion: Peri-interventional cocoa flavanol supplementation prevents long-term intima media thickening and endothelial dysfunction 6 months after TCA opening the perspective for dietary interventions to mitigate endothelial cell damage and intimal hyperplasia after mechanical injury.

Efficacy Assessment of Phentolamine Accompanied by Lidocaine Subcutaneously under Ultrasound Guidance on Radial Artery Catheterization in Pediatric Patients

Objective

Pediatric patients are facing greater difficulties in radial catheterization for anatomic variation and smaller diameter. This study is to investigate the efficacy of phentolamine accompanied by lidocaine subcutaneously under ultrasound guidance on radial catheterization in pediatric patients.

Methods

66 pediatric patients were enrolled and randomly divided into saline group, phentolamine group, and phentolamine+lidocaine group. Baseline characteristics and surgical types were collected. Relevant solutions were subcutaneously injected, and catheterization was subsequently conducted under ultrasound guidance. Radial artery diameter and depth were measured, the success rate of catheterization and procedure time were calculated, and the complications were evaluated with ultrasonography.

Results

No significant differences were observed in age, sex, weight, American Society of Anesthesiologists' classification, systolic blood pressure, diastolic blood pressure, heart rate, hemoglobin, and surgical types among three groups. Subcutaneously, the diameter in phentolamine and phentolamine+lidocaine groups increased significantly compared with the saline group. Moreover, the diameter also increased significantly after injection compared with that before injection both in the phentolamine and phentolamine+lidocaine groups. The first-attempt success rates were significantly higher while the procedure times of cannulation were shorter in the phentolamine and phentolamine+lidocaine groups than that in the saline group. Kaplan–Meier analysis showed that the overall procedure time was shorter in the phentolamine and phentolamine+lidocaine groups than the saline group. Overall complications and vasospasm incidence were lower in the phentolamine and phentolamine+lidocaine groups than the saline group.

Conclusion

Phentolamine accompanied by lidocaine subcutaneous injection under ultrasound guidance improved the first-attempt success rate and reduced the complication of radial artery catheterization in pediatric patients.

Impact of skin tone on photoacoustic oximetry and tools to minimize bias

The major optical absorbers in tissue are melanin and oxy/deoxy-hemoglobin, but the impact of skin tone and pigmentation on biomedical optics is still not completely understood or adequately addressed. Melanin largely governs skin tone with higher melanin concentration in subjects with darker skin tones. Recently, there has been extensive debate on the bias of pulse oximeters when used with darker subjects. Photoacoustic (PA) imaging can measure oxygen saturation similarly as pulse oximeters and could have value in studying this bias. More importantly, it can deconvolute the signal from the skin and underlying tissue. Here, we studied the impact of skin tone on PA signal generation, depth penetration, and oximetry. Our results show that subjects with darker skin tones exhibit significantly higher PA signal at the skin surface, reduced penetration depth, and lower oxygen saturation compared to subjects with lighter skin tones. We then suggest a simple way to compensate for these signal differences.

Standardized Forearm Angiography Increases Procedural Success Rates of Coronary Angiography and PCI: A Retrospective Analysis of an all-Comers Patient Cohort in a Real-Life Scenario

Background

There is a consensus, that Transradial-Access (TRA) for coronary procedures should be preferred over Transfemoral-Access (TFA). Previously, Forearm-Artery-Angiography (FA) was mainly performed when difficulties during the advancement of the guidewire/-catheter were encountered. We explored the implication of a Standardized Forearm-Angiography (SFA) on procedural success rates of TRA under real-world conditions.

Methods

In a single-center study, an all-comers-cohort of 1191 consecutive cases during 1/2020-12/2020 were assessed retrospectively. Primary TFA rates, crossover to TFA, reasons for Forearm-Artery-Access (FAA) failure, the prevalence of kinking at the level of the forearm and the occurrence of vascular complications were analyzed. Major forearm side branches including the common interosseus artery were assessed via SFA.

Results

In 1191 consecutive procedures, primary FAA access was attempted in 97.9% of cases. Crossover to TFA after a primary or secondary FAA attempt was necessary in 2.8%. Severe kinking was the most frequent cause of FAA failure and occurred in 3.0% of attempts. A second or third FAA attempt to avoid TFA was successful in 81%. Severe kinking at the level of the forearm was reported in 1.8% of procedures.

Conclusion

This is the first study to provide detailed success rates of a primary FAA strategy combined with a Standardized-Forearm-Angiography (SFA) in an all-comers-cohort. While severe kinking proved to be a rare but relevant challenge for FAA success, the prevalence of arterial spasm was marginal. Multiple attempts of FAA to avoid TFA might be safe possibly due to collateral blood supply by the common interosseus artery.

Patent hemostasis of radial artery: Comparison of two methods

BACKGROUND

Radial artery obstruction is the most common complication of coronary angiography performed via transradial access. Patent hemostasis can significantly reduce the risk of radial artery occlusion. Previous studies utilized sophisticated methods to evaluate radial artery patency. Simplified and easily applicable methods for successful patent hemostasis are currently lacking.

AIM

To determine which method (pulse oximeter vs the traditional radial artery palpation) is better to achieve patent hemostasis.

METHODS

This prospective, single center study included 299 consecutive patients who underwent coronary angiography or percutaneous coronary intervention between November 2017 and July 2019. Patients less than 18 years old, with a history of radial artery disease, or no palpable artery pulse were excluded from the study. Patients were randomly assigned to two groups. In the first group, radial artery flow was assessed by palpation of the artery during hemostasis (traditional method). In the second group, radial artery patency was estimated with the use of a pulse oximeter. Two different compression devices were used for hemostasis (air chamber and pressure valve). The primary study endpoint was the achievement of successful patent hemostasis.

RESULTS

The two groups (pulse oximeter vs artery palpation) had no significant differences in age, sex, body mass index, risk factors, or comorbidities except for supraventricular arrhythmias. The percentage of patients with successful patent hemostasis was significantly higher in the pulse oximeter group (82.2% vs 68.1%, P = 0.005). A lower percentage of patients with spasm was recorded in the pulse oximeter group (9.9% vs 19.0%, P = 0.024). The incidence of local complications, edema, bleeding, hematoma, vagotonia, or pain did not differ between the two groups. In the multivariate analysis, the use of a pulse oximeter (OR: 2.35, 95%CI: 1.34-4.13, P = 0.003) and advanced age (OR: 1.04, 95%CI: 1.01-1.07, P = 0.006), were independently associated with an increased probability of successful patent hemostasis. The type of hemostatic device did not affect patent hemostasis (P = 0.450).

CONCLUSION

Patent hemostasis with the use of pulse oximeter is a simple, efficient, and safe method that is worthy of further investigation. Larger randomized studies are required to consider its clinical implications.

Efficacy and safety of distal radial approach for cardiac catheterization: A systematic review and meta-analysis

BACKGROUND

The traditional radial approach (RA) is recommended as the standard method for coronary angiography (CAG), while a distal RA (DRA) has been recently used for CAG.

AIM

To assess the efficacy and safety of the DRA vs RA during CAG.

METHODS

The following databases were searched through December 2020: MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, the World Health Organization International Clinical Trials Platform Search Portal, and ClinicalTrials.gov. Individual randomized-controlled trials for adult patients undergoing cardiac catheterization were included. The primary outcomes were the successful cannulation rate and the incidence of radial artery spasm (RAS) and radial artery occlusion (RAO). Study selection, data abstraction and quality assessment were independently performed using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

Three randomized control trials and 13 registered trials were identified. The two approaches showed similar successful cannulation rates [risk ratio (RR) 0.90, 95% confidence interval (CI): 0.72-1.13]. The DRA did not decrease RAS (RR 0.43, 95%CI: 0.08-2.49) and RAO (RR 0.48, 95%CI: 0.18-1.29). Patients with the DRA had a shorter hemostasis time in comparison to those with the RA (mean difference -6.64, 95%CI: -10.37 to -2.90). The evidence of certainty was low.

CONCLUSION

For CAG, the DRA would be safer than the RA with comparable cannulation rates. Given the limited data, additional research, including studies with standard protocols, is necessary.

Effect of intra-arterial vasodilator administration during radial artery access on systemic blood pressure in patients receiving moderate sedation

PURPOSE

The hemodynamic effects of intra-arterial vasodilator administration for the prevention of radial artery spasm during transradial access have not been well characterized. This study evaluates the effect of intra-arterial Verapamil and Nitroglycerine administration on systemic blood pressure and its correlation with timing of moderate sedation administration.

MATERIALS AND METHODS

Institutional review board approval was granted. Patients who underwent transradial access from 4/2018 to 4/2019 and received both intra-arterial vasodilators and moderate sedation were identified and their electronic medical records reviewed. Patients were divided into three cohorts based on the timing of sedation and intra-arterial vasodilator administration. Decrease in systolic blood pressure (SBP) was expressed as means with standard deviation which were then compared using Student's t-test.

RESULTS

A total of 84 patients who met inclusion criteria demonstrated an overall mean decrease in SBP of 16.45 mmHg ± 15.45 mmHg. Patients receiving sedation and intra-arterial vasodilators within their expected peak SBP effect times had similar SBP change following the intra-arterial vasodilators as those in whom the interval was greater than 10 min (4.2 mmHg; 95% CI (-4.11 to 12.52), p = 0.3171). Two patients experienced asymptomatic hypotension.

CONCLUSIONS

Patients undergoing transradial access for procedures utilizing moderate sedation can safely receive intra-arterial Verapamil and Nitroglycerine for prevention of radial artery spasm.

Implementation of a radial long sheath protocol for radial artery spasm reduces access site conversions in neurointerventions

BACKGROUND

Many neurointerventionalists have transitioned to transradial access (TRA) as the preferred approach for neurointerventions as studies continue to demonstrate fewer access site complications than transfemoral access. However, radial artery spasm (RAS) remains one of the most commonly cited reasons for access site conversions. We discuss the benefits, techniques, and indications for using the long radial sheath in RAS and present our experience after implementing a protocol for routine use.

METHODS

A retrospective review of all patients undergoing neurointerventions via TRA at our institution from July 2018 to April 2020 was performed. In November 2019, we implemented a long radial sheath protocol to address RAS. Patient demographics, RAS rates, radial artery diameter, and access site conversions were compared before and after the introduction of the protocol.

RESULTS

747 diagnostic cerebral angiograms and neurointerventional procedures in which TRA was attempted as the primary access site were identified; 247 were performed after the introduction of the long radial sheath protocol. No significant differences in age, gender, procedure type, sheath sizes, and radial artery diameter were seen between the two cohorts. Radial anomalies and small radial diameters were more frequently seen in patients with RAS. Patients with clinically significant RAS more often required access site conversion (p<0.0001), and in our multivariable model use of the long sheath was the only covariate protective against radial failure (OR 0.061, 95% CI 0.007 to 0.517; p=0.0103).

CONCLUSION

In our experience, we have found that the use of long radial sheaths significantly reduces the need for access site conversions in patients with RAS during cerebral angiography and neurointerventions.