Abstract: Aims. To assess the impact of aging on the incidence and severity of radial spasm during coronary catheterization. Background. One of the main predictors for transradial approach failure during coronary catheterization is the occurrence of radial spasm. Although it has been suggested that radial spasm might be more common in old patients, the role of confounding factors in older populations and the intuitive thinking that younger patients are more prone to spasm render this debate still active. Methods. This was a transversal study, which prospectively included consecutive patients referred to our center for elective coronary catheterization during a 6-month period. Results. A total of 190 patients were included. The mean age was 67.9 ± 3.6 years and 130 (68%) were males. Overall, 32 (16.8%) presented with radial spasm. Patients with radial spasm were younger (64.8 ± 12.1 years vs 69.6 ± 12.6 years; P=.04). In the quartile analysis, the largest difference was observed between patients ≤61 years and those >80 years, who presented with a rate of spasm of 25.6% and 9.1%, respectively (P=.04). Multivariable analysis showed that the age of patients was inversely related to the occurrence of radial spasm, decreasing 3% with every additional year (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.94-0.99), and the number of catheters, increasing around 50% with every additional used catheter (OR, 1.54; 95% CI, 1.07-2.23). Conclusion. The main finding of the present paper is the inverse association between aging and radial spasm. The present study suggests the need to intensify preventive measures in young patients in order to reduce the incidence of radial spasm.
J INVASIVE CARDIOL 2015;27(12):E303-E307
Key words: radial artery spasm, radial intervention, complications
Transradial approach was initially described by Campeau1 in 1989 and represents one of the most common access sites for cardiac catheterization. Although radial approach has been shown to be an effective alternative that reduces vascular complications,2,3 it cannot be used in all patients. One of the main predictors of transradial failure is the occurrence of radial spasm.4,5 Radial spasm is a relatively common complication during transradial catheterization. Its incidence ranges from 5%-30%4-8 depending on the definition and operator’s experience. It is well known that radial spasm impacts patient comfort4-6 and catheterization/intervention success.4,5 In addition, the need for femoral cross-over after transradial failure is associated with a higher risk of vascular complications.9 Several factors, such as repeated radial puncture, small radial diameter, female gender, and the use of large sheaths, have been linked to higher incidence of radial spasm.7,8,10,11 Although it has been suggested that radial spasm might be more common in elderly patients,8 no specific studies exploring both the incidence and severity of radial spasm in relation to patient age have been published to date. Indeed, a better knowledge of this association might allow the establishment of more tailored preventive strategies in specific patient groups. The aim of the present study was to assess the impact of aging on the incidence and severity of radial spasm during coronary catheterization.
This was a transversal study, which prospectively included 190 consecutive patients referred to our center for elective left cardiac catheterization during a 6-month period. Exclusion criteria included: (1) age <18 years or >90 years; (2) ST-elevation myocardial infarction (STEMI); (3) hemodynamic instability; (4) previous coronary artery bypass graft surgery; (5) non-palpable radial pulses; (6) abnormal Allen’s test; and (7) brachial arteriovenous fistula.
The study protocol was approved by the ethics committee of our institution following the ethical guidelines of the 1975 Declaration of Helsinki. All patients gave written informed consent before inclusion.
Cardiac catheterization. Transradial coronary angiography was performed by experienced operators with at least 300 transradial procedures within the previous 12 months. Radial pulse assessment and Allen’s test were performed before the inclusion.
Sublingual diazepam (10 mg) was given 30 minutes before the intervention. One minute after the administration of subcutaneous local anesthesia, transradial access was obtained using a modified Seldinger technique with a luer-lock needle (Vygon) and a 5 or 6 Fr radial glide sheath (Terumo Corporation). After sheath insertion, 5000 units of unfractionated heparin and 2.5 mg of verapamil were injected into the radial artery. In cases of coronary intervention, additional units of heparin were given to achieve a final dose of 70 UI/kg. Ad hoc percutaneous coronary interventions were performed based on operator judgment with or without upsizing to a 6 or 7 Fr system.
Data collection and definitions. All demographic, clinical, and interventional information was prospectively collected and entered into a dedicated database. In order to minimize both patient and physician subjectivity, radial spasm was defined as the presence of at least two of the following criteria:12 (1) persistent pain in the arm; (2) pain after catheter manipulation; (3) pain after sheath removal; (4) catheter manipulation resistance; or (5) resistance during sheath removal. A Hamilton test was used to assess the anxiety and pain of patients during cardiac catheterization.13
Statistical analysis. The results are expressed as mean ± standard deviation for normally distributed data (as assessed by the Shapiro-Wilks test) or as median and range for non-normally distributed data. Comparisons between groups were performed using unpaired t-test or Mann-Whitney U-test for continuous variables and Chi-square or Fisher’s exact test for categorical variables.
Multivariate linear regression analysis was used to identify the independent predictors of radial spasm. The variables included in the multivariable analysis were the ones with a P<.10 in the univariable analysis and other relevant variables on previous studies.5,10 Our model included age, gender, number of catheters, and catheter diameter. In order to describe the demographic, clinical, and interventional characteristics of the population, patients were divided into quartiles (quartile 1, ≤61 years; quartile 2, 62-72 years; quartile 3, 73-79 years; and quartile 4, ≥80 years). Groups were analyzed using the ANOVA test with Bonferroni correction for multiple comparisons. Results were considered statistically significant at a P-value <.05. Statistical analyses were carried out using SPSS package version 20.0.
A total of 190 patients were included in the study, of whom 130 (68%) were males. The mean age of the population was 67.9 ± 3.6 years and the mean body mass index (BMI) was 26.9 ± 4 kg/m2. Patients were distributed in quartiles according to their age as previously mentioned. Baseline and procedural characteristics are shown in Table 1. A higher percentage of males and smokers were observed in the first quartile (Table 1). No differences in the sheath size, number of catheters, or number of radial punctures were observed among groups. Nonetheless, patients ≥80 years (fourth quartile) had shorter fluoroscopy and procedural times compared with younger patients (Table 2).
Among all patients, 32 (16.8%) presented with radial spasm. The main characteristics of patients according to the presence or absence of radial spasm are described in Table 3. Patients with radial spasm were significantly younger (64.8 ± 12.1 years vs 69.6 ± 12.6 years; P=.04). Indeed, the largest difference was observed between patients in the first (≤61 years) and fourth quartile (≥80 years), who had spasm rates of 25.6% and 9.1%, respectively (P=.04) (Figure 1).
Multivariable analysis showed that the age of patients was inversely related to the occurrence of radial spasm (Figure 2), which decreased 3% with every additional year (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.94-0.99) and the number of catheters, which increased around 50% with every additional used catheter (OR, 1.54; 95% CI, 1.07-2.23). Importantly, the presence of radial spasm was not associated with longer procedural time (63.3 ± 40.1 minutes with spasm vs 44.2 ± 29.7 minutes without spasm; P=.01) and fluoroscopy time (15.7 ± 10.2 minutes with spasm vs 11.6 ± 9.2 minutes without spasm; P=.02).
With regard to spasm severity (ie, the number of items) and comfort, patients ≥80 years had less pain and more comfort compared with other groups (Table 4). However, the tolerance to the procedure was generally high in all groups and most of the patients were willing to have another procedure if necessary.
Access crossover was needed in 5.2% of patients: contralateral radial in 3.1% (2 patients in the 62-72 years group and 4 patients in the 73-79 years group) and femoral in 2.1% (1 patient in the ≤61 years group, 1 patient in the 62-72 years group, and 2 patients in the 73-79 years group).
The main finding of the present study is the inverse association between aging and radial spasm. In addition, the subgroup analysis showed that patients >80 years had the lowest rate of radial spasm and pain prevalence during cardiac catheterization through the radial artery.
Our study revealed an incidence of radial spasm of 16.8%. This percentage is in agreement with other published series of experienced hospitals with large transradial experience, as it ranges from 5%-30%.4-8 However, and in contrast with other reports suggesting a higher incidence of radial spasm in older patients,8 our study revealed an inverse relationship, as younger patients were more prone to develop spasm and discomfort during transradial catheterization. Importantly, this association persisted after multivariable analysis including other well-known predictors of radial spasm, namely gender, number of catheters used, and size of catheters used.7,8,10,11
A plausible physiological explanation for the observed higher incidence of radial spasm in older patients might be the progressive process of muscular denervation and endothelial dysfunction with aging.14,15 Old patients have a progressive muscular denervation characterized by the reduction of motor units and muscular fibers.14 Indeed, after the sixth decade of life, the number of motor units starts to decrease.14 These units promote a brief contraction of the muscular cells within the vessel wall, inducing a vasoconstriction process, which translates into arterial spasm and flow impairment. In addition, old patients are more prone to have endothelial dysfunction, which might also be associated with a lower capacity to develop radial spasm.15
As expected, other than aging, the number of utilized catheters was also independently associated with the rate of radial spasm. The recurrent radial stimulation after the repeated catheter exchange is the most probable explanation for this finding. In previous reports, female gender was found to be an independent predictor of spasm as a result of the smaller radial diameter and lower BMI in women.7,8,11 In our series, however, although there was a trend toward a higher incidence of spasm in females, the study did not show a significant difference, which was probably due to the limited number of patients. Of note, the rate of radial spasm was lower in older patients despite the higher percentage of women in this group compared with younger patients.
The present study was performed in stable patients. Although stable patients are more sensitive to develop radial spasm compared with STEMI or other symptomatic patients,16 it is important to highlight that the clinical stability allowed the performance of a systematic and uniform protocol in all patients and a careful evaluation of the symptomatology. In fact, this might explain the low rates of contralateral radial (3.1%) and femoral (2.1%) crossover.
Patient comfort is a pivotal factor when performing transradial interventions.11,13 Although the prevalence of pain during cardiac catheterization did not significantly differ among groups, considering the high rate of radial spasm in patients ≤60 years (25.6%), the authors believe that more intense preventive measures should be recommended in younger patients. As previously published, these measures would be better tolerated in younger patients and would consist of deeper sedation and additional vasodilator drugs.6,11,13
Study limitations. The main limitation of this study was the relatively small sample size and the demographic differences among groups. Although these differences might limit the value of the results after comparing groups, in many cases they are inevitable, as they define the intrinsic characteristics of every segment of age – for instance, a higher frequency of smokers in patients ≤60 years or a higher prevalence of women in the group of patients ≥80 years. In any case, we performed a multivariable analysis in order to correct these differences. Another limitation is the systematic assessment of the size of the radial artery by angiography or echography before catheterization. Finally, the shorter procedural and fluoroscopy times in the oldest group might have reflected different baseline characteristics and less invasive approaches more than the lower percentage of radial spasm.
The main finding of the present paper is the inverse association between aging and radial spasm. In addition, the subgroup analysis showed that patients ≥80 years are the ones who present a lesser rate of spasm and refer less pain during cardiac catheterization. The results of the present study suggest the need to intensify preventive measures in younger patients in order to reduce the risk of radial spasm.
Acknowledgments. We are grateful to Teresa Canales, Rosa Domínguez, Sol Gabaldà, Jorge Gil, Montserrat Gutiérrez, Mireia Niebla, Montserrat Pardo, Moisés Tejedor, and Neus Puig.
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From the Sección de Cardiología Intervencionista del Hospital Clínic de Barcelona. Universitat de Barcelona. Institut d´Investigacions Biomédiques August Pi i Sunyer, Barcelona, Spain.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Freixa is a consultant and proctor for St. Jude Medical. The remaining authors report no conflicts regarding the content herein.
Manuscript submitted November 24, 2014, provisional acceptance given March 6, 2015, final version accepted April 6, 2015.
Address for correspondence: Xavier Freixa, Sección de Hemodinámica Cardiaca, Escalera 3 Planta 4, c/ Villarroel 170, 80136, Barcelona, España. Email: Freixa@clinic.ub.es