indian heart journal 67 (2015) 507–508
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ihj
Correspondence Transradial approach for coronary angiogram: Something not to be neglected
Keywords: Coronary angiography Transradial Anticoagulation Puncture technique
We read with great interest the article ‘‘How to do radial coronary angiogram’’ by Satheesh et al1 Transradial approach (TRA) for coronary procedures is gradually becoming popular worldwide and has become de facto standard of care. The advantage of TRA is well proven. There are three important issues which we feel should not be neglected and will enhance our knowledge and understanding of TRA for coronary angiograms. 1. Anticoagulation: The type and dose of anticoagulation during coronary angiography by TRA is an important issue and it varies among various operators. Unfractionated Heparin (UFH) is used most commonly for anticoagulation either intravenous or intra-arterial and the recommended dose is 50 U/Kg body weight or 5000 IU and if there is heparin-induced thrombocytopenia, then intravenous bivalirudin may be used at the dose of 0.75 U/Kg body weight.2 However, there is some controversy regarding the optimal dose of UFH for diagnostic coronary angiography and studies have shown that standard dose (5000 IU) of heparin significantly reduces the rate of radial artery occlusion as compared to low dose heparin (2500 IU).3 Recently, a study by Degirmencioglu et al has shown that low dose heparin (2500 U) as compared to high dose (5000 U) decreases the bleeding rate without increasing the radial artery occlusion rate.4 In our opinion, the optimal dose of heparin is 5000 IU as compression of radial artery in India is mostly achieved using manual compression followed by firm bandage rather than using hemostatic device. 2. Sheath size: Although the article has mentioned about the most commonly used catheter (5F TIG) for coronary
cannulation but regarding the radial sheath only the length is mentioned. In our view 5F sheath is sufficient in most of the diagnostic coronary angiograms and also in some non complex coronary interventions. The size of radial artery in Indians varies from 1.6 to 3.7 mm5 and the outer diameter of 5F sheath is 2.28 mm and 6F sheath is 2.52 mm, therefore using 5F system may help in reducing the chances of radial artery occlusion. After the coronary angiography if the patient is planned for ad hoc angioplasty, then 6F sheath can be exchanged. Routinely for exchange of 5F sheath, a 7 cm long 6F sheath is used using 0.025 inch straight glidewire but if the 5F sheath is to be exchanged with access to the ascending aorta retained with 0.03200 wire, then long sheath of 10 cm should be used as 7 cm sheath cannot accommodate 0.03200 wire. 3. Puncture technique: The radial artery is punctured most commonly by Seldinger technique but in our experience keeping the needle at 458 angle increases the chances that radial artery will slip away. Here, we describe a modified technique (Patel & Shah's modification) for successful radial artery puncture. In this technique, the 20-guage Tefloncoated angiocath needle is kept at around 60–708 to the skin which prevents rolling movement of the artery and fixes it better. Then, double wall puncture of radial artery is performed and stylet is removed. The Teflon-coated cannula is gradually pulled back parallel to the skin allowing its coaxial entry into the vessel lumen. This modified technique increases the chances of successful radial artery access especially in small caliber artery without increasing the local bleeding complications although no randomized trial has been done so far.
Conflicts of interest The authors have none to declare.
references
1. Satheesh S, Subramanian A. How to do radial coronary angiogram? Indian Heart J. 2015. http://dx.doi.org/10.1016/j. ihj.2015.04.009.
DOI of original article: http://dx.doi.org/10.1016/j.ihj.2015.04.009
508
indian heart journal 67 (2015) 507–508
2. Rao SV, Tremmel JA, Gilchrist IC, et al. Best practices for transradial angiography and intervention: a consensus statement from the society for cardiovascular angiography and intervention's transradial working group. Catheter Cardiovasc Interv. 2014;83:228–236. 3. Aykan AÇ, Gökdeniz T, Gül I, et al. Comparison of low dose versus standard dose heparin for radial approach in elective coronary angiography? Int J Cardiol. 2015;21:389–392. 4. Degirmencioglu A, Buturak A, Zencirci E, et al. Comparison of effects of low- versus high-dose heparin on access-site complications during transradial coronary angiography: a double-blind randomized study. Cardiology. 2015 Apr. 28;131:142–148. 5. Garg N, Madan BK, Khanna R. Incidence and predictors of radial artery occlusion after transradial coronary angioplasty: doppler-guided follow-up study. J Invasive Cardiol. 2015;27:106–112.
Surender Deora* Assistant Professor, Department of Cardiology, PGIMER Dr RML Hospital, New Delhi 110001, India Sanjay Shah Associate Professor, Department of Cardiology, Sheth V.S. General Hospital, Smt. N.H.L. Municipal Medical College,
Ahmedabad 380006, India Tejas Patel Professor & Head, Department of Cardiology, Sheth V.S. General Hospital, Smt. N.H.L. Municipal Medical College, Ahmedabad 380006, India *Corresponding author at: Department of Cardiology, PGIMER Dr RML Hospital, Baba Kharak Singh Marg, New Delhi 110001, India. Tel.: +91 9413063063 E-mail address: [email protected] (S. Deora) 27 May 2015 Available online 30 July 2015
http://dx.doi.org/10.1016/j.ihj.2015.05.023 0019-4832/ # 2015 Published by Elsevier B.V. on behalf of Cardiological Society of India.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ihj
Correspondence Transradial approach for coronary angiogram: Something not to be neglected
Keywords: Coronary angiography Transradial Anticoagulation Puncture technique
We read with great interest the article ‘‘How to do radial coronary angiogram’’ by Satheesh et al1 Transradial approach (TRA) for coronary procedures is gradually becoming popular worldwide and has become de facto standard of care. The advantage of TRA is well proven. There are three important issues which we feel should not be neglected and will enhance our knowledge and understanding of TRA for coronary angiograms. 1. Anticoagulation: The type and dose of anticoagulation during coronary angiography by TRA is an important issue and it varies among various operators. Unfractionated Heparin (UFH) is used most commonly for anticoagulation either intravenous or intra-arterial and the recommended dose is 50 U/Kg body weight or 5000 IU and if there is heparin-induced thrombocytopenia, then intravenous bivalirudin may be used at the dose of 0.75 U/Kg body weight.2 However, there is some controversy regarding the optimal dose of UFH for diagnostic coronary angiography and studies have shown that standard dose (5000 IU) of heparin significantly reduces the rate of radial artery occlusion as compared to low dose heparin (2500 IU).3 Recently, a study by Degirmencioglu et al has shown that low dose heparin (2500 U) as compared to high dose (5000 U) decreases the bleeding rate without increasing the radial artery occlusion rate.4 In our opinion, the optimal dose of heparin is 5000 IU as compression of radial artery in India is mostly achieved using manual compression followed by firm bandage rather than using hemostatic device. 2. Sheath size: Although the article has mentioned about the most commonly used catheter (5F TIG) for coronary
cannulation but regarding the radial sheath only the length is mentioned. In our view 5F sheath is sufficient in most of the diagnostic coronary angiograms and also in some non complex coronary interventions. The size of radial artery in Indians varies from 1.6 to 3.7 mm5 and the outer diameter of 5F sheath is 2.28 mm and 6F sheath is 2.52 mm, therefore using 5F system may help in reducing the chances of radial artery occlusion. After the coronary angiography if the patient is planned for ad hoc angioplasty, then 6F sheath can be exchanged. Routinely for exchange of 5F sheath, a 7 cm long 6F sheath is used using 0.025 inch straight glidewire but if the 5F sheath is to be exchanged with access to the ascending aorta retained with 0.03200 wire, then long sheath of 10 cm should be used as 7 cm sheath cannot accommodate 0.03200 wire. 3. Puncture technique: The radial artery is punctured most commonly by Seldinger technique but in our experience keeping the needle at 458 angle increases the chances that radial artery will slip away. Here, we describe a modified technique (Patel & Shah's modification) for successful radial artery puncture. In this technique, the 20-guage Tefloncoated angiocath needle is kept at around 60–708 to the skin which prevents rolling movement of the artery and fixes it better. Then, double wall puncture of radial artery is performed and stylet is removed. The Teflon-coated cannula is gradually pulled back parallel to the skin allowing its coaxial entry into the vessel lumen. This modified technique increases the chances of successful radial artery access especially in small caliber artery without increasing the local bleeding complications although no randomized trial has been done so far.
Conflicts of interest The authors have none to declare.
references
1. Satheesh S, Subramanian A. How to do radial coronary angiogram? Indian Heart J. 2015. http://dx.doi.org/10.1016/j. ihj.2015.04.009.
DOI of original article: http://dx.doi.org/10.1016/j.ihj.2015.04.009
508
indian heart journal 67 (2015) 507–508
2. Rao SV, Tremmel JA, Gilchrist IC, et al. Best practices for transradial angiography and intervention: a consensus statement from the society for cardiovascular angiography and intervention's transradial working group. Catheter Cardiovasc Interv. 2014;83:228–236. 3. Aykan AÇ, Gökdeniz T, Gül I, et al. Comparison of low dose versus standard dose heparin for radial approach in elective coronary angiography? Int J Cardiol. 2015;21:389–392. 4. Degirmencioglu A, Buturak A, Zencirci E, et al. Comparison of effects of low- versus high-dose heparin on access-site complications during transradial coronary angiography: a double-blind randomized study. Cardiology. 2015 Apr. 28;131:142–148. 5. Garg N, Madan BK, Khanna R. Incidence and predictors of radial artery occlusion after transradial coronary angioplasty: doppler-guided follow-up study. J Invasive Cardiol. 2015;27:106–112.
Surender Deora* Assistant Professor, Department of Cardiology, PGIMER Dr RML Hospital, New Delhi 110001, India Sanjay Shah Associate Professor, Department of Cardiology, Sheth V.S. General Hospital, Smt. N.H.L. Municipal Medical College,
Ahmedabad 380006, India Tejas Patel Professor & Head, Department of Cardiology, Sheth V.S. General Hospital, Smt. N.H.L. Municipal Medical College, Ahmedabad 380006, India *Corresponding author at: Department of Cardiology, PGIMER Dr RML Hospital, Baba Kharak Singh Marg, New Delhi 110001, India. Tel.: +91 9413063063 E-mail address: [email protected] (S. Deora) 27 May 2015 Available online 30 July 2015
http://dx.doi.org/10.1016/j.ihj.2015.05.023 0019-4832/ # 2015 Published by Elsevier B.V. on behalf of Cardiological Society of India.
