Asian Cardiovasc Thorac Ann 2001;9:308-311
© 2001 Asia Publishing EXchange Pte Ltd
Routine Transradial Coronary Angiography in the Malaysian Population
Devan Pillay, MRCP,
Lam Kai Huat, MRCP,
Sanjiv Joshi, MRCP,
Mohd Nasir Muda, MRCP,
Zainal Abidin Abdul Hamid, MRCP
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Department of Cardiology National Heart Institute Kuala Lumpur, Malaysia
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For reprint information contact: Devan Pillay, MRCP Tel: 60 3 2698 1333Fax: 60 3 2698 2824 email: devan{at}ijn.com.my Department of Cardiology, National Heart Institute, 145 Jalan Tun Razak, Kuala Lumpur 50400, Malaysia.
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ABSTRACT
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The feasibility and safety of routine transradial coronary angiography was assessed prospectively in 394 patients between March 1998 and July 1999. All patients had a normal Allen's test. The right radial approach was used in 84% of cases and the left in 16%. Radial artery catheterization was successful in 91% of patients; the left coronary artery was selectively catheterized in 92%, and the right coronary artery in 91%. Procedure time was 28 ± 20 minutes, screening time was 8 ± 5 minutes, and 62% of patients were discharged on the same day. The optimal catheter selection was a single Castillo catheter for both coronary arteries. Left ventriculography was performed with the same catheter in 25% of patients. One patient had a left Judkins catheter that kinked and became entrapped in the right subclavian artery, requiring vascular surgery. No coronary or neurological complications were observed. Asymptomatic radial occlusion occurred in 3.5% of patients. The transradial approach was considered to give a high degree of success and an acceptable complication rate in this patient population.
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INTRODUCTION
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Since Lucien Campeau1 first introduced transradial coronary angiography in 1989, it has gained a widespread following. The work of Kiemeneij and colleagues2–5 in transradial coronary angioplasty and stenting has taken interventional cardiology into the realm of minimally invasive angioplasty. In spite of the potential benefits of this approach, coronary angiography continues to be performed via the femoral artery in 85% to 90% of cases. Although there have been significant improvements in catheter dimensions, vascular complications are still frequent with the femoral route, particularly in obese patients, aortoiliac disease, or where potent anticoagulants or thrombolytics are used. Such complications result in prolonged hospital stay and increased need for transfusion; they also prevent early ambulation. This study was designed to determine whether the radial approach could be used routinely for coronary angiography in Malaysian patients. The primary objectives were to assess the feasibility of transradial angiography for selective catheterization of the coronary arteries, and to determine the complication rate and procedure duration. The study also sought to analyze the learning curve and the technical difficulties associated with this approach. Data were collected for future comparison with the femoral route in terms of radiation exposure, procedure duration, and complications.
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PATIENTS AND METHODS
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This prospective study was carried out over a 16-month period in a major tertiary referral center in Malaysia. Transradial angiography was attempted in 394 patients between March 1998 and July 1999. In the early phase of the learning curve, male patients with large radial arteries by palpation were selected. With improved operator experience, females and patients with unstable angina were included. All patients had a functional palmar arch as assessed by an Allen's test.6 Contraindications included a negative Allen's test, chronic renal failure requiring regular hemodialysis, cases where simultaneous right heart catheterization was anticipated, and patients requiring left internal mammary artery angiography.
Informed consent was obtained in all cases. Patients were premedicated with oral midazolam 7.5 mg and intra-muscular diphenhydramine 25 mg. With the arm abducted 30 degrees to the body in the supine position, the hand was hyperextended and held in place with adhesive tape. The right radial approach was used in 84% of patients. Local anesthesia consisted of topical lidocaine-prilocaine cream (EMLA; Astra Zeneca, Uppsala, Sweden) applied 1–2 hours before the procedure, and 1 to 2 mL of 2% lignocaine injected subcutaneously, just enough to produce a wheal over the skin.7 A puncture was made with a short 21G Cook needle. A 6F sheath was used in most patients (Cordis Avanti transradial sheath; Cordis, Miami, FL, USA). Longer sheaths (23 cm) were preferred as these have been claimed to reduce radial artery spasm during catheter manipulation.1 After introduction of the sheath, 5,000 units of heparin and a spasmolytic cocktail consisting of nitroglycerin 200 µg and verapamil 2 mg (mixed in a single syringe and given as a bolus) were injected intraarterially. In the early phase of the study, left and right Judkins diagnostic catheters were used for the left and right coronary arteries, and a pigtail catheter was used for left ventriculography. Later, the Castillo catheter (Cordis, Miami, FL, USA) was used for both left and right coronary cannulation and whenever possible, the left ventriculogram was performed with the same catheter. After completion of the procedure, the sheath was removed immediately, allowing a brisk backflow of blood to expel any clots. Hemostasis was achieved by applying a Strepty P hemostatic device (Nichiban Corporation, Tokyo, Japan) consisting of a central collagen seal and adhesive tape over which a tourniquet was affixed.8 The tourniquet was removed after 1 hour and the Strepty P after 3 hours. Patients were ambulated immediately, and discharged the same day whenever possible.
The following data were collected in a database throughout the study period: successful radial puncture and cannulation, selective catheterization of each vessel and type of catheter used (as well as success or failure), procedure duration, screening time, complications, and patient comfort (comfortable/painful). Discrete variables were expressed as percentage frequencies, and continuous variables as mean ± standard deviation.
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RESULTS
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Table 1
shows the demographic and clinical characteristics of the population studied. Table 2 shows the angiographic findings. The overall success rate was 91% (359/394) and there was a trend towards increasing success with time and operator experience. The causes of failure were spasm in 20 patients and anatomical variation in 15. All failed procedures were repeated successfully via the right femoral route. The learning curve in the early phase of the experience is illustrated in Figure 1. The left coronary artery was successfully catheterized in 92% of cases (361/394) and the right coronary artery in 91% (360/394). A Castillo catheter (most commonly, Castillo II) was used in 288 patients with successful intubation of both coronary arteries in 72%. Left ventriculograms were performed successfully in 91 patients (25%) using the same catheter, with good opacification of the left ventricle. The mean procedure time from initial puncture to withdrawal of the last catheter was 28 ± 20 minutes, and the screening time was 8 ± 5 minutes.
Puncture site complications are summarized in Table 3. In one patient with triple-vessel disease, a left Judkins catheter kinked and became entrapped in the right subclavian artery. He subsequently underwent successful coronary artery bypass grafting and surgical repair of the right subclavian artery. One patient developed loss of radial pulse and transient right hand paresthesia due to inadvertent delay in removing the tourniquet. His symptoms improved within 24 hours on heparin infusion, and he had no evidence of hand ischemia on follow-up. Asymptomatic radial artery occlusion was observed in 3.5% of patients by digital palpation; no Doppler evaluation of the radial artery was performed post-procedure. There was no cerebrovascular accident, myocardial infarction, or iatrogenic left main stem dissection. The most common reason for failure was radial artery spasm (6%). The majority of patients (80%) found this procedure acceptable with minimal discomfort, and those who had undergone a previous femoral procedure (8%) preferred the radial approach. Five patients (1.3%) had a repeat procedure performed via the same route without any vascular complications. The majority of patients (62%) were discharged on the same day.
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DISCUSSION
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Male patients predominated in this study because of the initial selection criteria. Very anxious patients should be adequately sedated to reduce the likelihood of radial artery spasm. The successful use of a single catheter for both left and right coronary artery cannulation and subsequent left ventricle opacification was cost-effective and also prevented radial artery spasm and arm pain, which may occur when changing catheters. A "hand-shot" was routinely used when performing left ventriculography, and 15 to 20 mL of contrast medium was sufficient for good opacification of the left ventricle. When using the Castillo catheter for left ventriculography, it is essential to ensure that the catheter tip moves freely within the ventricular cavity, which can be confirmed by fluoroscopy. The transradial approach tends to require longer catheters than the femoral approach, especially with the Castillo catheter which was designed as a brachial catheter. Some difficulty might be encountered in tall patients or those with tortuous arteries, due to insufficient catheter length.
Only one serious complication occurred in the early phase of this study when a left Judkins catheter was trapped in the right subclavian artery. This was probably due to excessive catheter manipulation and torque while trying to engage the left coronary artery without a guidewire in situ. The radial artery occlusion rate of 3.5% compares favorably with the incidence in other large-volume centers.9–12 Routine use of heparin is advocated to reduce the incidence of radial artery occlusion.9,12 Although there were no clinical consequences of radial artery occlusion, the importance of appropriate screening is emphasized to ensure dual blood supply to the hand, with an intact palmar arch. Although many vasodilators have been used to prevent radial artery spasm, He13 showed that a combination of verapamil and nitroglycerin maximally preserved endothelial function of the radial artery, and was also a potent arteriolar vasodilator. Potential damage to the radial artery during cannulation has raised a debate between interventionists and surgeons, especially in view of the increasing use of the radial artery as a free graft for coronary artery bypass surgery. From a practical standpoint, this is not a major issue at our institute as most surgeons tend to use the left radial artery, and interventionists use the right radial artery. Moreover, smaller diagnostic catheters and vascular closure devices have reduced femoral complications and the need for prolonged bed rest. In fact, outpatient femoral angiography is now a somewhat routine procedure. However, the cost of these new vascular closure devices can be prohibitive, especially in a developing country like Malaysia. Radial catheterization allows an outpatient procedure, as found in this study, and it could potentially be used for stenting.14
It was concluded that the transradial route for coronary angiography is safe and associated with a high degree of success. Minimal access-site bleeding complications, early patient ambulation, reduced post-procedure staff requirements, and cost-effectiveness are the important advantages of this technique.15 Although a significant learning curve was noted for proficiency in this procedure, it is strongly recommended that interventional cardiologists should consider using the transradial approach routinely.
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Acknowledgments
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The authors would like to thank Encik Faizal Ramli for the statistical analysis of the data and Puan Azliza Abdullah for typing the manuscript.
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REFERENCES
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ABSTRACT
INTRODUCTION
