Review
Intra-arterial vasodilators to prevent radial artery spasm: a systematic review and pooled analysis of clinical studies

https://doi.org/10.1016/j.carrev.2015.08.008Get rights and content

Highlights

  • Radial artery spasm (RAS) causes procedural failure in transradial catheterization.

  • RAS may complicate 10–15% procedures undertaken through the radial approach.

  • We reviewed the efficacy of vasodilators that have been used to minimize RAS.

  • The pooled RAS rate was lowest with 5 mg of verapamil (4%) compared to placebo (12%).

  • The best combination of drugs to minimize RAS is nitroglycerine and verapamil.

Abstract

Objectives

The aim of this study is to review the available literature on the efficacy and safety of agents used for prevention of RAS.

Background

Different vasodilator agents have been used to prevent radial artery spasm (RAS) in patients undergoing transradial cardiac catheterization.

Methods

We included studies that evaluated any intra-arterial drug administered in the setting cardiac catheterization that was undertaken through the transradial access site (TRA). We also compared studies for secondary outcomes of major bleeding, procedure time, and procedure failure rate in setting of RAS prevention, patent hemostasis and radial artery occlusion.

Results

22 clinical studies met the inclusion criteria. For placebo, RAS rate was 12% (4 studies, 638 participants), which was similar to 2.5 mg of verapamil 12% (3 studies, 768 participants) but greater than 5 mg of verapamil (4%, 2 studies, 497 participants). For nicorandil, there was a much higher RAS rate compared to placebo (16%, 3 studies, 447 participants). The lowest rates of RAS was found for nitroglycerin at both 100 μg (4%) and 200 μg (2%) doses, isosorbide mononitrate (4%) and nicardipine (3%). We found no information regarding the procedure failure rates, patent hemostasis, and radial artery occlusion in these studies.

Conclusions

In this largest and up-to-date review on intra-arterial vasodilators use to reduce RAS, we have found that the verapamil at a dose of 5 mg or verapamil in combination with nitroglycerine are the best combinations to reduce RAS.

Introduction

The radial artery is fast becoming the preferred access site for performing coronary angiography and percutaneous coronary intervention (PCI) [1]. In UK, adoption of the transradial access site (TRA) for PCI has increased from 10% in 2006 to over 60% in 2012 [2]. TRA is associated with reduced mortality and major adverse cardiac events (MACE) in selected cohorts at high risk of bleeding complications [2], [3], [4], thought to be related to a reduction in major access site related bleeding complications [1], [5]. Transradial access is also associated with improved patient comfort and has also shown to be the preferred access site amongst patients undergoing PCI and be more cost effective than transfemoral access [6], [7], [8].

However, TRA approach is not without limitations, it is associated with a longer learning curve and complex procedures requiring large French size guide catheters may not always be possible particularly in patients with small diameter radial arteries. Furthermore operators may encounter radial artery spasm (RAS) [9] during TRA particularly at the beginning of the learning curve, or when encountering radial anomalies. A previous review of 19 papers with 7197 participants found that the incidence of RAS was 14.7% in patients in whom the radial artery was chosen as the access site for coronary angiography or PCI [10].

RAS leads to patient discomfort, increased risk of vascular complications and procedure failure rate. Various drugs such as nitroglycerin, verapamil, isosorbide mononitrate are used to reduced the risk of RAS. However, there is high variability in practice amongst operators for administration of these drugs. Furthermore, there are no guidelines or recommendations for using such drugs in day-to-day practice. Therefore, we conducted a systematic review of the available literature to evaluate the efficacy of agents used for prevention of RAS.

Section snippets

Methods

We searched MEDLINE and EMBASE on October 2014 using the broad search terms: “vasodilator” AND “radial artery occlusion” OR “radial artery spasm” OR “transradial.” The search results were reviewed by two independent judicators (CSK, MR) for studies that met the inclusion criteria and relevant reviews. The bibliographies of included studies and relevant reviewers were screened for additional studies.

We included studies that evaluated any intra-arterial drug administered in the setting of TRA.

Results

Our search yielded 123 relevant articles and after screening and reviewing full manuscripts, 21 articles met the inclusion criteria with 22 clinical studies [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32]. The process of study selection is shown in Fig. 1.

The study design and participant characteristics of the included trials is shown in Table 1. Majority of studies (n = 14) used blinding and these studies took place

Other outcomes

Several studies evaluate outcomes other than RAS. Abe et al. found that ISDN was most potent vasodilator compared to verapamil, lignocaine and placebo [12]. While this study examined multiple doses, it was underpowered across each group. Boyer et al. found that a combination of nitroglycerin and verapamil was associated with greater vasodilation compared to placebo [13]. Byrne et al. found that magnesium is a more potent vasodilator than verapamil [14]. Carrillo et al. found similar

Discussion

In this largest and up-to-date review on intra-arterial vasodilators to reduce RAS, we have found that many agents have been evaluated as potential vasodilators to reduce RAS. We found that the pooled rate of RAS in the placebo arm of several studies was 12% and only 5 mg of verapamil had lower pooled rates of RAS (4%). There were many single studies that evaluated the efficacy of different agents but many of these were underpowered. Nitroglycerin appears to reduce RAS but other less studied

Conclusion

In this largest and up-to-date review on intra-arterial vasodilators use to reduce RAS, we have found that the verapamil at a dose of 5 mg or verapamil in combination with nitroglycerine are the best combinations to reduce RAS. The use of other agents to prevent RAS such as nicardipine, ISMN and magnesium requires more studies. Operators should consider optimal sheath and catheter selection, as well as pharmacological regime to minimize RAS particularly in procedures undertaken in patients at

Funding

None.

Disclosure statement

The authors report no financial relationships or conflicts of interest regarding the content herein.

Acknowledgement

None.

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