Original article Herz DOI 10.1007/s00059-015-4321-4 Received: 13 January 2015 Revised: 13 March 2015 Accepted: 16 April 2015
Ahmet Çağrı Aykan1 · Ezgi Kalaycıoğlu1 · Tayyar Gökdeniz1 · Duygun Altıntaş Aykan2 · Engin Hatem1 · Regayip Zehir3
© Urban & Vogel 2015
3 Department of Cardiology, Siyami Ersek Education and Research Hospital, Istanbul, Turkey
1 Department of Cardiology, Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital,
Trabzon, Turkey 2 Department of Pharmacology, Karadeniz Technic University Faculty of Medicine, Trabzon, Turkey
Assessment of vascular dysfunction after transradial coronary angiography Is a single catheter better? The radial route is as popular alternative approach for transfemoral coronary angiography. Access site complications including bleeding, hematoma, and pseudoaneurysm formation were infrequent in transradial coronary angiography (TRCAG) [1, 2]. Patients prefer the transradial approach because of its comfort, shorter hospital stay, advantage of not being in the supine position during the procedure, and better physical and social functioning after the procedure [3, 4]. The blood supply to the hand is provided by a double arterial system consisting of the radial and ulnar arteries. The transradial approach may cause trauma to the radial artery. Flow-mediated vasodilatation (FMD) is the most widely accepted noninvasive standard method of assessing endothelial dysfunction. Several cardiovascular risk factors are related to acute and chronic FMD impairment [5, 6]. Physical damage to the vascular endothelium might also be a cause of functional impairment and might lead to arterial disease [7]. Narrowing and chronic impairment of FMD of the radial artery after transradial angiography was reported [8]. Additionally acute impairment of FMD in the brachial artery following TRCAG was shown [9]. However whether there are midterm effects of catheterization on the brachial artery and which factors determine the functional recovery of radial and brachial arteries are unclear. The present study
aimed to investigate the midterm effects of transradial catheterization on the radial and brachial artery diameters and the vasodilator characteristics as well as to assess the factors determining the functional recovery.
Patients and methods Study population This study included 136 consecutive patients (105 male and 31 female patients) who underwent TRCAG owing to suspected stable coronary artery disease between May and August 2013. The study protocol was approved by the institutional ethics committee. Patients with previous coronary revascularization, acute coronary syndrome, abnormal oximeter/plethysmography test results, moderate to severe valvular heart disease, hemodynamic impairment, uncontrolled hypertension, malignancy, heart rhythm other than sinus rhythm, heart failure, and radial artery obstruction were excluded from the study. An abnormal oximeter/plethysmography test result was a contraindication for TRCAG. It is impossible to evaluate radial FMD and nitroglycerin-mediated dilatation (NMD) in occluded arteries, and hence we excluded patients with radial artery occlusion. Blood pressure and hemodynamic impairment alter the arterial diameters, thus we excluded patients with
hemodynamic impairment and uncontrolled hypertension. Patients with atrial fibrillation were excluded because of the difficulty of evaluating arterial diameter in patients with this condition (at least seven cycles are required to sum a mean value). Chemotherapeutic agents may cause endothelial dysfunction, and therefore we excluded patients with cancer. Patients with heart failure were excluded since endothelial functions are impaired in heart failure.
Transradial coronary angiography After assessing the permeability of the palmar arch, sterile preparation was made and local anesthesia with 1 ml of 2 % prilocaine was used. The radial artery was cannulated with 6-Fr hydrophilic 10-cmlong sheaths (Terrumo Radifocus® Introducer II, Terumo, Leuven, Belgium). After sheath insertion, a radial cocktail containing 2 mg of diltiazem, 200 mcg of nitroglycerin, and 5,000 IU of heparin diluted in a 10-ml syringe was injected gradually through the sheath side arm into the radial artery. Coronary angiography was performed using 6-Fr catheters (Boston Scientific, Natick, MA). On completion of the diagnostic procedure, the radial sheaths were removed and an inflatable hemostatic device was applied at the access site. After the patient was transferred to the recovery room, the initial compression was further reduced to maintain raHerz
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Original article Table 1 Patient characteristics Male, n (%) Age, years Body mass index, kg/m2 Hypertension, n (%) Diabetes mellitus, n (%) Dyslipidemia, n (%) Current smoking, n (%) Low-density lipoprotein cholesterol, mg/dl High-density lipoprotein cholesterol, mg/dl Triglyceride, mg/dl Creatinine, mg/dl Glomerular filtration rate, ml/min Glucose, mg/dl Hemoglobin, g/dl Systolic blood pressure, mmHg Diastolic blood pressure, mmHg Pulse pressure, mmHg Left ventricular ejection fraction, % Left ventricular mass index, g/m2 Percutaneous coronary intervention, n (%) Number of catheters, n (%) 1 2 3 ≥ 4 Pain score Compression time, min
105 (77.2 %) 61.88 ± 9.51 28.58 ± 3.15 71 (52.2 %) 37 (27.2 %) 86 (63.2 %) 51 (37.5 %) 149.14 ± 40.24 41.01 ± 9.96 164 (115.25) 0.87 ± 0.21 95.16 ± 24.47 103.33 ± 12.06 13.99 ± 1.50 144.24 ± 12.19 87.93 ± 9.62 56.30 ± 9.22 62.00 ± 5.51 101.90 ± 32.82 50 (36.8 %) 31 (22.8 %) 39 (28.7 %) 32 (23.5 %) 34 (25 %) 4.72 ± 1.47 150 (60)
Table 2 Medications taken by the patients Therapy Acetyl salicylic acid, n (%) Clopidogrel, n (%) ACE inhibitor/ARB, n (%) Diuretic, n (%) Beta blocker, n (%) Calcium channel blocker, n (%) Nitrate, n (%) Statin, n (%)
n (%) 136 (100 %) 50 (36.8 %) 59 (43.4 %) 54 (39.7 %) 53 (39 %) 19 (14 %) 23 (16.9 %) 86 (63.2 %)
Table 3 Radial and brachial artery diameters Variable Radial artery diameter, mm Radial artery FMD diameter, mm Radial artery NMD diameter, mm Radial artery FMD, % Radial artery NMD, % Brachial artery diameter, mm Brachial artery FMD diameter, mm Brachial artery NMD diameter, mm Brachial artery FMD, % Brachial artery NMD, %
Basal 2.97 ± 0.46 3.18 ± 0.45 3.32 ± 0.45 7.50 ± 3.62 12.42 ± 4.96 4.41 ± 0.58 4.61 ± 0.60 4.75 ± 0.63 4.53 ± 2.29 7.84 ± 2.83
First month 2.82 ± 0.51 2.99 ± 0.54 3.11 ± 0.54 5.89 ± 3.04 10.54 ± 4.47 4.40 ± 0.58 4.59 ± 0.59 4.75 ± 0.62 4.33 ± 2.56 7.98 ± 2.74
FMD flow-mediated dilatation, NMD nitroglycerin-mediated dilatation
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Ahmet Çağrı Aykan1 · Ezgi Kalaycıoğlu1 · Tayyar Gökdeniz1 · Duygun Altıntaş Aykan2 · Engin Hatem1 · Regayip Zehir3
© Urban & Vogel 2015
3 Department of Cardiology, Siyami Ersek Education and Research Hospital, Istanbul, Turkey
1 Department of Cardiology, Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital,
Trabzon, Turkey 2 Department of Pharmacology, Karadeniz Technic University Faculty of Medicine, Trabzon, Turkey
Assessment of vascular dysfunction after transradial coronary angiography Is a single catheter better? The radial route is as popular alternative approach for transfemoral coronary angiography. Access site complications including bleeding, hematoma, and pseudoaneurysm formation were infrequent in transradial coronary angiography (TRCAG) [1, 2]. Patients prefer the transradial approach because of its comfort, shorter hospital stay, advantage of not being in the supine position during the procedure, and better physical and social functioning after the procedure [3, 4]. The blood supply to the hand is provided by a double arterial system consisting of the radial and ulnar arteries. The transradial approach may cause trauma to the radial artery. Flow-mediated vasodilatation (FMD) is the most widely accepted noninvasive standard method of assessing endothelial dysfunction. Several cardiovascular risk factors are related to acute and chronic FMD impairment [5, 6]. Physical damage to the vascular endothelium might also be a cause of functional impairment and might lead to arterial disease [7]. Narrowing and chronic impairment of FMD of the radial artery after transradial angiography was reported [8]. Additionally acute impairment of FMD in the brachial artery following TRCAG was shown [9]. However whether there are midterm effects of catheterization on the brachial artery and which factors determine the functional recovery of radial and brachial arteries are unclear. The present study
aimed to investigate the midterm effects of transradial catheterization on the radial and brachial artery diameters and the vasodilator characteristics as well as to assess the factors determining the functional recovery.
Patients and methods Study population This study included 136 consecutive patients (105 male and 31 female patients) who underwent TRCAG owing to suspected stable coronary artery disease between May and August 2013. The study protocol was approved by the institutional ethics committee. Patients with previous coronary revascularization, acute coronary syndrome, abnormal oximeter/plethysmography test results, moderate to severe valvular heart disease, hemodynamic impairment, uncontrolled hypertension, malignancy, heart rhythm other than sinus rhythm, heart failure, and radial artery obstruction were excluded from the study. An abnormal oximeter/plethysmography test result was a contraindication for TRCAG. It is impossible to evaluate radial FMD and nitroglycerin-mediated dilatation (NMD) in occluded arteries, and hence we excluded patients with radial artery occlusion. Blood pressure and hemodynamic impairment alter the arterial diameters, thus we excluded patients with
hemodynamic impairment and uncontrolled hypertension. Patients with atrial fibrillation were excluded because of the difficulty of evaluating arterial diameter in patients with this condition (at least seven cycles are required to sum a mean value). Chemotherapeutic agents may cause endothelial dysfunction, and therefore we excluded patients with cancer. Patients with heart failure were excluded since endothelial functions are impaired in heart failure.
Transradial coronary angiography After assessing the permeability of the palmar arch, sterile preparation was made and local anesthesia with 1 ml of 2 % prilocaine was used. The radial artery was cannulated with 6-Fr hydrophilic 10-cmlong sheaths (Terrumo Radifocus® Introducer II, Terumo, Leuven, Belgium). After sheath insertion, a radial cocktail containing 2 mg of diltiazem, 200 mcg of nitroglycerin, and 5,000 IU of heparin diluted in a 10-ml syringe was injected gradually through the sheath side arm into the radial artery. Coronary angiography was performed using 6-Fr catheters (Boston Scientific, Natick, MA). On completion of the diagnostic procedure, the radial sheaths were removed and an inflatable hemostatic device was applied at the access site. After the patient was transferred to the recovery room, the initial compression was further reduced to maintain raHerz
1
Original article Table 1 Patient characteristics Male, n (%) Age, years Body mass index, kg/m2 Hypertension, n (%) Diabetes mellitus, n (%) Dyslipidemia, n (%) Current smoking, n (%) Low-density lipoprotein cholesterol, mg/dl High-density lipoprotein cholesterol, mg/dl Triglyceride, mg/dl Creatinine, mg/dl Glomerular filtration rate, ml/min Glucose, mg/dl Hemoglobin, g/dl Systolic blood pressure, mmHg Diastolic blood pressure, mmHg Pulse pressure, mmHg Left ventricular ejection fraction, % Left ventricular mass index, g/m2 Percutaneous coronary intervention, n (%) Number of catheters, n (%) 1 2 3 ≥ 4 Pain score Compression time, min
105 (77.2 %) 61.88 ± 9.51 28.58 ± 3.15 71 (52.2 %) 37 (27.2 %) 86 (63.2 %) 51 (37.5 %) 149.14 ± 40.24 41.01 ± 9.96 164 (115.25) 0.87 ± 0.21 95.16 ± 24.47 103.33 ± 12.06 13.99 ± 1.50 144.24 ± 12.19 87.93 ± 9.62 56.30 ± 9.22 62.00 ± 5.51 101.90 ± 32.82 50 (36.8 %) 31 (22.8 %) 39 (28.7 %) 32 (23.5 %) 34 (25 %) 4.72 ± 1.47 150 (60)
Table 2 Medications taken by the patients Therapy Acetyl salicylic acid, n (%) Clopidogrel, n (%) ACE inhibitor/ARB, n (%) Diuretic, n (%) Beta blocker, n (%) Calcium channel blocker, n (%) Nitrate, n (%) Statin, n (%)
n (%) 136 (100 %) 50 (36.8 %) 59 (43.4 %) 54 (39.7 %) 53 (39 %) 19 (14 %) 23 (16.9 %) 86 (63.2 %)
Table 3 Radial and brachial artery diameters Variable Radial artery diameter, mm Radial artery FMD diameter, mm Radial artery NMD diameter, mm Radial artery FMD, % Radial artery NMD, % Brachial artery diameter, mm Brachial artery FMD diameter, mm Brachial artery NMD diameter, mm Brachial artery FMD, % Brachial artery NMD, %
Basal 2.97 ± 0.46 3.18 ± 0.45 3.32 ± 0.45 7.50 ± 3.62 12.42 ± 4.96 4.41 ± 0.58 4.61 ± 0.60 4.75 ± 0.63 4.53 ± 2.29 7.84 ± 2.83
First month 2.82 ± 0.51 2.99 ± 0.54 3.11 ± 0.54 5.89 ± 3.04 10.54 ± 4.47 4.40 ± 0.58 4.59 ± 0.59 4.75 ± 0.62 4.33 ± 2.56 7.98 ± 2.74
FMD flow-mediated dilatation, NMD nitroglycerin-mediated dilatation
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