Transradial catheterization may decrease the radial artery luminal diameter and impair the vasodilatation response in the access site at late term: an observational study

The Effect of Previous Transradial Catheterization on Radial Forearm Free Flaps

Radial forearm free flaps (RFFF) are a versatile option for the reconstruction of a wide variety of soft tissue defects and are particularly common in head and neck surgery. Benefits of RFFF include a relatively short operating time, a long pedicle, and a thinner, more pliable flap. However, in addition to its role in reconstructive surgery, the radial artery may be utilized for a number of other procedures including coronary angiography and percutaneous coronary interventions. Concern has previously been raised that prior catheterization may deleteriously affect the function of the radial artery and in the field of cardiothoracic surgery, individuals are increasingly advising against its use as a graft for coronary artery bypass graft surgery in such circumstances. Despite this, little is known about the effect on RFFF. In this review article, we concisely consider the available evidence of the effect of previous transradial catheterization on the radial artery and discuss the implications for reconstructive surgery. We then summarize the key considerations regarding their use in current practice.

The distal radial artery: Versatile vascular access for transcatheter interventions

Conventional transradial access has been established as the gold standard for invasive coronary angiography and percutaneous interventions by the current European and American guidelines. The distal or snuffbox radial artery access represents an alternative transradial access site that allows radial sheath insertion with the patient's hand pronated. Firstly described 40 years ago, it exploded in popularity only recently. Promising additional benefits, the distal radial access is increasingly being adopted in various types of percutaneous interventions, being preferred by many interventional cardiologists and radiologists for its reduced vascular complications and time to hemostasis, and improvement of patient and operator comfort. Other centers consider it a fad, waiting for solid clear evidence and benefits. The evidence is dynamic and discrepant, depending on the center, the operator, and how it was collected (randomized controlled vs observational studies). Another essential aspect raised by "skeptics" was whether distal radial access, by its smaller diameter and more angled course, can support all types of interventions. The aim of this review is to gather all the scenarios where distal radial access has been utilized and to conclude whether this vascular access is feasible across all transcatheter interventions.

Expert systematic review on the choice of conduits for coronary artery bypass grafting: endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS)

PREAMBLE

The finalized document was endorsed by the EACTS Council and STS Executive Committee before being simultaneously published in the European Journal of Cardio-thoracic Surgery (EJCTS) and The Annals of Thoracic Surgery (The Annals) and the Journal of Thoracic and Cardiovascular Surgery (JTCVS).

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.

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

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.

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.

Access-site complications of transradial percutaneous coronary intervention using sheathless guiding catheters for acute coronary syndrome: a prospective cohort study with radial ultrasound follow-up

The advantages of sheathless guiding catheters over the conventional approach using sheaths in percutaneous coronary intervention (PCI) regarding access-site complications, particularly ultrasound-diagnosed radial artery occlusion (RAO), remain unknown. The present study investigated the incidence of access-site complications of transradial primary PCI using sheathless guiding catheters in acute coronary syndrome (ACS). This prospective study evaluated access-site complications in 500 patients with ACS undergoing sheathless transradial primary PCI. Doppler ultrasound evaluation of the radial arteries was performed 2 and 30 days after the procedure. Sheathless guiding catheters (7.5-Fr) were used in 91.0% of the patients. The procedural success rate was 98.4%. Ultrasound-diagnosed RAO rates were 2.0% and 3.8% at 2- and 30-day follow-ups, respectively. Logistic regression analysis identified that the sheath-to-artery ratio (per 0.1) (odds ratio [OR] 5.71; 95% confidence interval [CI] 1.18-27.71; p = 0.001) was associated with more frequent RAO and that hypertension (OR 0.22; 95% CI 0.06-0.81; p = 0.023) was associated with less frequent RAO. Receiver operating characteristic curve analysis revealed that a sheath-to-artery ratio of 1.47 was the cutoff for 30-day post-procedural RAO (sensitivity 72%, specificity 81%). Sheathless transradial primary PCI for ACS was associated with a low incidence of access-site complications and a higher sheath-to-artery ratio cutoff for RAO than that expected from conventional PCI using sheaths based on historical data, demonstrating the access-site safety of sheathless guiding catheters and their benefit in PCI for ACS (University Hospital Medical Information Network-Clinical Trial Registry Number UMIN000019931).

Impact of Transradial Catheterization on Vascular Function of the Brachial Artery Assessed by Flow-Mediated Dilatation

Background

Few studies have evaluated long-term vascular function after radial access catheterization. Furthermore, the impact of repeated catheterization remains unknown. We investigated flow-mediated dilatation (FMD) of the brachial artery after transradial catheterization.

Methods

We prospectively enrolled 50 patients with suspected coronary artery disease referred for diagnostic coronary angiography. No ad-hoc percutaneous coronary interventions (PCI) had been performed at the time of the index procedure. In 30 patients (63.8%), PCI and/or repeated follow-up diagnostic catheterization were subsequently performed via the radial artery used at the index catheterization. FMD was successfully measured before catheterization, at 24 h after catheterization, and after long-term follow-up (mean, 32 months; range, 24-43) in 47 patients. FMD at follow-up was compared between patients receiving only one procedure and those receiving multiple procedures via the same arteries.

Results

FMD was significantly decreased after catheterization and recovered well in long-term follow-up (3.7 ± 1.6%, 3.0 ± 1.7%, and 3.9 ± 1.6%). There was no significant difference in follow-up FMD between the patients undergoing single catheterization and those with multiple procedures (3.4 ± 1.3 vs. 4.3 ± 1.7, p = 0.06). When the patients were divided into two groups according to the median follow-up FMD value, no significant predictive factor was identified for worse FMD.

Conclusions

After transradial catheterization, FMD of the brachial artery temporarily decreased but recovered in long-term follow-up. Recovery of FMD was not jeopardized by repeated catheterization, which suggests the potential of the brachial artery to recover endothelial function after repeated transradial procedures.

Radial Access for Lower Extremity Peripheral Arterial Interventions: Do We Have the Tools?

The benefits of transradial arterial access (TRA) versus transfemoral arterial access (TFA) have been extensively described in the literature; however, TFA remains the predominant access site choice in the management of peripheral arterial disease (PAD). There are still significant unmet needs for operators wishing to provide the same effective interventions for lower extremity PAD via TRA as with TFA. This article provides an up-to-date review of the literature and devices currently available for operators wishing to treat lower extremity PAD via TRA and the limitations they may face.

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

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.

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.

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.

Effect of Long-Term Administration of Nicorandil on Endothelial Function of the Radial Artery in Patients With Angina Undergoing Transradial Percutaneous Coronary Intervention

We evaluated the effect of long-term administration of nicorandil on endothelial function of the radial artery in patients with angina undergoing elective transradial coronary intervention (TRI). A total of 127 patients were randomly assigned to nicorandil (standard medication plus nicorandil 5 mg twice daily, n = 64) or control group (standard medication except nicorandil, n = 63) immediately after TRI procedure. Radial artery diameter (RAD), flow-mediated dilation (FMD), and nitroglycerin-mediated dilation (NMD) of radial artery were measured 1 day before TRI as well as 1 day and 3 months after TRI by Ultrasound-Doppler. No significant difference was observed in the baseline RAD, FMD, and NMD between the 2 groups (all P > .05). In cannulated arm, at 3-month follow-up, RAD in nicorandil group was much larger than that in the control group (2.78 ± 0.27 mm vs 2.61 ± 0.30 mm, P = .001). Besides, FMD and NMD were much higher in nicorandil group than those in the control group (10.38% ± 2.43% vs 6.81% ± 1.86%; 15.94% ± 6.28% vs 10.46% ± 5.37%, respectively, all Ps < .001). In conclusion, long-term administration of nicorandil after TRI could improve the endothelial function of the cannulated radial artery.

Impact of catheter size on reliability of quantitative coronary angiographic measurements (comparison of 4Fr and 6Fr catheters)

To evaluate the feasibility of catheter down sizing for QCA, the reliability of a 4Fr catheter as a calibration device was evaluated. Repeated coronary angiograms of 9 lesions were obtained using 4Fr and 6Fr catheters under otherwise identical conditions. The calibration factor was measured 10 times by 4Fr and 6Fr catheters. QCA measurements including minimal lumen diameter (MLD), interpolated normal reference (Int N), percent diameter stenosis (%DS), and lesion length (LL) were performed by two technicians twice with a 3-month interval. The intraobserver and interobserver variability of each parameter was evaluated using intraclass correlation coefficients (ICCs). Mean of mean SD of calibration factor was significantly larger in 4Fr than in 6Fr in 9 lesions. The mean of mean coefficient of variance was significantly larger in 4Fr catheters vs in 6Fr catheters. A 6Fr catheter showed excellent reliability for both intraobserver and interobserver variability in MLD, Int N, %DS, and LL. In contrast, 4Fr showed that reliability in intraobserver variability depended on the analyst. Although reliability of interobserver variability in Int N measured by the 4Fr catheter was >0.80, the value was less than that by the 6Fr catheter. Taking these results into consideration, 4Fr catheters are less reliable than 6Fr catheters when measuring QCA data especially for follow-up data that need most accurate measurements of MLD and %DS. It would be better to use a 6Fr catheter to evaluate QCA measurements such as acute gain, late loss, restenosis rate, and device size.

Does Previous Transradial Catheterization Preclude Use of the Radial Artery as a Conduit in Coronary Artery Bypass Surgery?

The radial artery (RA) is a commonly used conduit for coronary artery bypass grafting, and recent studies have demonstrated that it provides superior long-term patency rates to the saphenous vein in most situations. In addition, the RA is also being used with increasing frequency as the access point for coronary angiography and percutaneous coronary interventions. However, there has been concern for many years that these transradial procedures may have a detrimental impact on the function of RA grafts used in coronary artery bypass grafting, and there is now comprehensive evidence that such interventions cause morphologic and functional damage to the artery in situ. Despite this, there remain remarkably few studies investigating the use of previously cannulated RAs as grafts in coronary artery bypass surgery, and there are no clear guidelines on the use of the RA in coronary artery bypass grafting after its catheterization. This article will review concisely the evidence that transradial procedures cause damage to the RA, and discuss the impact this could have on previously cannulated RAs used as coronary artery bypass grafting conduits. On the basis of the evidence assessed, we make a number of recommendations to both surgeons and cardiologists regarding use of the RA in cardiovascular procedures.