Kintur Sanghvi Cezar Staniloae Sudhesh Srivastava John Coppola. Journal of Invasive Cardiology April 2006 ISSN: Volume 18 - Issue 4

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1 Nitroglycerine, Nitroprusside, or Both in Preventing Radial Artery Spasm During Transradial Artery Catheterization Kintur Sanghvi Cezar Staniloae Sudhesh Srivastava John Coppola Journal of Invasive April 2006 ISSN: Volume 18 - Issue 4

2 Disclosure None

3 Transradial Intervention

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11 Transradial Intervention Advantages. Nearly 0% local site complication. Better quality of life for the patients and the staff. Reduce cost. Same day discharge. All coronary and peripheral vascular interventions are possible except for few exceptions. Limitations: Technically difficult: Access failure. Radial spasm. Loops and tortuosity of Radial and Subclavian. Longer learning curve

12 Transradial Intervention Radial Vs Femoral approach for diagnostic and PCI procedures: Systemic overview and meta-analysis 12 randomized trials n = 3234 (J Am Coll Cardiol : )

13 Background Radial spasm: patient discomfort and failure to complete procedure. Intra-arterial vasodilator solutions containing a calcium channel blocker and Nitroglycerin have been proven to prevent or treat t spasm. Role of direct Nitric oxide donor is unknown.

14 Objective Primary: To compare the efficacy of three different intra-arterial vasodilating cocktails in reducing the incidence of radial artery spasm in patients undergoing transradial coronary angiogram. Secondary: To assess the predictors of arterial spasm in this large group of patients.

15 Methods Patients with standard indication for coronary angiogram were enrolled prospectively. Exclusion Abnormal Allen s test Allergy to study drug Previous transradial catheterization. Continuous infusion of any of the study drug except Heparin. Shock Primary endpoint Occurrence of radial artery spasm.

16 Methods Randomized to receive one of the three solutions : method of randomization. Ultrasound of radial artery to measure inner diameter. Operator was blinded for content of solution and ultrasound results. Solution A Solution B Solution C Heparin 2500 U 2500 U 2500 U Lidocaine 20 mg 20 mg 20 mg Diltiazem 5 mg 5 mg 5 mg Nitroglycerine 100 mcg mcg Nitroprusside mcg 100 mcg

17 Methods Clinical history/ demographics/ height and weight recorded. Duration of the procedure/ size of catheters/ complications were recorded. A single experienced operator subjectively determined the presence of spasm. The spasm was defined as inability to freely manipulate the catheter, difficulty to remove the sheath at the end of the procedure, or presence of fore-arm pain experienced by the patient.

18 Statistical Analysis. 25% improvement in the occurrence of spasm was considered significant. For 80% power number needed to study was calculated to be 100pts in each group. Statistical significance was considered for P< Data were expressed in mean ± standard deviation. Quantitative variables: the paired t test. Qualitative variables: the chi square test. Multigroup ANOVA to compare the 3 different groups. A backward regression multivariate analysis was performed to establish the predictors of radial artery spasm.

19 Results Clinical and Procedural variables

20 Results Occurrence of Spasm P = Total Pts Spasm Group A Group B Group C

21 Conclusion & Discussion The addition of a direct NO donor to Nitroglycerine, does not reduces the risk of radial artery spasm. Use of Nitroglycerine is as effective as the use of Nitroprusside. Inspite of infusing increasing number of local vasodilators, no significant improvement in the incidence of the radial artery spasm. (the concept that certain triggers of arterial spasm cannot be counteracted by the mere use of vasodilators ).

22 Results Univariate analysis for predictor of spasm

23 Results Multivariate analysis for predictor of spasm

24 Conclusion & Discussion Morphometric factors play a significant role in predicting the occurrence of radial artery spasm. The age or sex of the patient, presence of diabetes, BSA and smoking played no role in prediction of radial spasm as was suggested by some other studies. The relationship between the size of the radial artery, the body size, and the sheath size is more important in predicting arterial spasm, than each individual component separately.

25 Limitation Subjective evaluation of Radial artery spasm. Ideal would be Objective: Pull back, Sonogram, Angiogram Effect of Sedative / hypnotics was not evaluated. Important in predicting arterial spasm, than each individual component separately.

26 Radial Cocktail study II Multicenter radomization All pateints: Heparine Radial and Subclavian Angio Radial Cocktail (Verapaamil + NTG) + Sedation Radial Cocktail (Verapaamil + NTG) No sedation Sedation No Cocktail No Cocktail No Sedation.

27 Thank You