Incidence and Predictors of Radial Artery Occlusion

Dear Editor:

We read with great interest the article by Garg et al.¹ The authors investigated the incidence and predictors of radial artery occlusion after transradial coronary angioplasty with the guidance of Doppler ultrasonography. We have some comments about the present study.

Radial artery occlusion is the most common complication of transradial interventions, with an estimated occurrence of 2%-10%. Although radial artery occlusion is usually an asymptomatic complication, it can rarely cause serious hand ischemia.² In previous studies, certain factors such as body weight,³ female gender,⁴ use and dose of anticoagulants,⁵ and type⁶ and duration⁷ of access-site compression were found to have influences on radial artery occlusion.

Anticoagulation is the cornerstone therapy in the prevention of radial artery occlusion. Various agents were used and compared as means of preventing radial artery occlusion in different studies.^3,5,8 Spaulding et al showed the importance of heparin dose in their study.⁵ But in the study by Garg et al, there are conflicting data about the absolute dose of heparin because the authors used the term for heparin dose “at least 5000 IU” and we cannot know whether there were any differences in terms of heparin dose between the occlusion group and non-occlusion group. When we analyze the patient characteristics in Table 1, 54.5% of patients in the study had acute coronary syndrome and there is no information about the duration and dose of heparin therapy in this group, which may have influenced radial artery occlusion and radial artery recanalization that was seen at month 3 with Doppler evaluation. In addition, 58.6% of patients were treated with glycoprotein IIb/IIIa inhibitors and there is no information about the effects of glycoprotein IIb/IIIa inhibitors, which may affect the occlusion and recanalization rates.

In a study by Dharma et al,⁹ the administration of postprocedural/prehemostasis intra-arterial nitroglycerin reduced the incidence of radial artery occlusion. However, there is no information in the study by Garg et al about the use and dose of nitroglycerin before or after the procedure. Finally, although previous studies^7,9 haven’t shown any relationship between total procedural time and radial artery occlusion, there are no data about total procedural time in the study by Garg et al. 

References

1. Garg N, Madan BK, Khanna R, et al. Incidence and predictors of radial artery occlusion after transradial coronary angioplasty: Doppler-guided follow-up study. J Invasive Cardiol. 2015;27:106-112.
2. Rademakers LM, Laarman GJ. Critical hand ischaemia after transradial cardiac catheterisation: an uncommon complication of a common procedure. Neth Heart J. 2012;20:372-375.
3. Plante S, Cantor WJ, Goldman L, et al. Comparison of bivalirudin versus heparin on radial artery occlusion after transradial catheterization. Catheter Cardiovasc Interv. 2010;76:654-658.
4. Tunçez A, Kaya Z, Aras D, et al. Incidence and predictors of radial artery occlusion associated transradial catheterization. Int J Med Sci. 2013;10:1715-1719.
5. Spaulding C, Lefèvre T, Funck F, et al. Left radial approach for coronary angiography: results of a prospective study. Cathet Cardiovasc Diagn. 1996;39:365-370.
6. Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of radial artery occlusion-patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv. 2008;72:335-340.
7. Pancholy SB, Patel TM. Effect of duration of hemostatic compression on radial artery occlusion after transradial access. Catheter Cardiovasc Interv. 2012;79:78-81.
8. Feray H, Izgi C, Cetiner D, Men EE, Saltan Y, Baltay A, Kahraman R. Effectiveness of enoxaparin for prevention of radial artery occlusion after transradial cardiac catheterization. J Thromb Thrombolysis. 2010;29:322-325.
9. 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. 2015;85:818-825. Epub 2014 Sep 13.

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From the Faculty of Medicine, Department of Cardiology, Selçuk University, Selçuklu/Konya.

Address for correspondence: Selçuk Üniversitesi Tıp Fakültesi, Kardiyoloji Anabilimdalı, 42000, Selçuklu/Konya. Email: drtuncez@yahoo.com

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Authors’ Response:

We would like to thanks the authors for their interest in our study¹ and for reiterating our view that radial artery occlusion is the most common but usually asymptomatic complication of transradial interventions. 

We are in total agreement with the authors that the previous studies have shown body weight,² female gender,³ use and dose of anticoagulants,⁴ and type and duration of radial artery compression⁵ as predictors of radial artery occlusion. We are also in agreement with their comment that anticoagulation is the cornerstone therapy for the prevention of radial artery occlusion.^2,4,6 For the anticoagulation in the present study, we followed our catheterization laboratory protocol; weight-adjusted heparin in doses of 100 units/kg was used. If the procedure was prolonged for more than 1 hour, activated clotting time (ACT) was checked every 30 minutes and additional boluses of heparin were used as per requirement. Total dose of heparin in the present study varied between 5000-9000 U. Unfortunately, total dose used in individual patients was not recorded, so was neither analyzed nor mentioned in the manuscript. However, ACT was kept >250 seconds at all times. We are of the view that it is not the absolute dose of heparin but rather the persistent proper level of anticoagulation that can affect radial artery patency rates. This factor was uniformly taken care of in each patient and therefore was unlikely to have any bearing on the occurrence of radial artery occlusion.

All acute coronary syndrome patients were given either low-molecular-weight heparin or plain heparin. Low-molecular-weight heparin was stopped at least 12 hours before the procedure, while plain heparin was stopped 6 hours before the procedure. After completion of the procedure, no further dose of low-molecular-weight heparin or plain heparin was given to any patient. We are of the view that doses and duration of anticoagulation before the procedure are unlikely to affect radial artery occlusion rates. As we have not used any type of heparin postprocedurally in any patient, irrespective of their baseline diagnosis of acute coronary syndrome or stable coronary artery disease, heparin dose used for treating patients of acute coronary syndrome before angioplasty is unlikely to be associated with the radial artery occlusion rates. 

Glycoprotein IIb/IIIa inhibitors were used in 58.6% of patients. On univariate analysis of glycoprotein IIb/IIIa inhibitor administration as the predictor for radial artery occlusion, it was found to be non-significant (odds ratio, 0.79; 95% confidence interval, 0.31-1.97; P=.61). 

We also agree with the authors that the administration of postprocedural/prehemostasis intra-arterial nitroglycerin reduces the incidence of radial artery occlusion.⁷ As per the protocol in our catheterization laboratory, we always give a cocktail of 100 µm nitroglycerin, 100 µg diltiazem, and 1 mg lignocaine in all patients just after the insertion of the introducer sheath as well as postprocedurally just before removing the sheath and applying the TR band. In addition, we always give this cocktail at each catheter exchange and during radial artery spasm if encountered. This protocol was uniformly followed in each patient, and was therefore unlikely to have any bearing on the occurrence of radial artery occlusion.

Finally, we also agree with the authors that total procedure time can have a bearing on radial artery occlusion rate. In fact, fluoroscopy time was analyzed but was not found to be associated with radial artery occlusion rate; this may be a result of strict ACT monitoring and keeping the ACT >250 seconds throughout the procedure in all patients.

Sincerely,

• Naveen Garg, MD, DM, DNB
• B.K. Madan, MD, DM
• Roopali Khanna, MD, DM
• Aditya Kapoor, MD, DM
• Satendra Tewari, MD, DM
• Sudeep Kumar, MD, DM
• Pravin Kumar Goel, MD, DM

Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

References

1. Garg N, Madan BK, Khanna R, et al. Incidence and predictors of radial artery occlusion after transradial coronary angioplasty: Doppler-guided follow-up study. J Invasive Cardiol. 2015;27:106-112.
2. Plante S, Cantor WJ, Goldman L, et al. Comparison of bivalirudin versus heparin on radial artery occlusion after transradial catheterization. Catheter Cardiovasc Interv. 2010;76:654-658. 
3. Tunçez A, Kaya Z, Aras D, et al. Incidence and predictors of radial artery occlusion associated transradial catheterization. Int J Med Sci. 2013;10:1715-1719.
4. Spaulding C, Lefèvre T, Funck F, et al. Left radial approach for coronary angiography: results of a prospective study. Cathet Cardiovasc Diagn. 1996;39:365-370.
5. Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of radial artery occlusion-patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv. 2008;72:335-340.
6. Feray H, Izgi C, Cetiner D, et al. Effectiveness of enoxaparin for prevention of radial artery occlusion after transradial cardiac catheterization. J Thromb Thrombolysis. 2010;29:322-325. 
7. 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. 2015;85:818-825. Epub 2014 Sep 13.