nitroglycerine, nitroprusside, or both in preventing ... cocktail study.pdf · nitroglycerine,...

Nitroglycerine, Nitroprusside, or Both in Preventing Nitroglycerine, Nitroprusside, or Both in Preventing Radial Artery Spasm During Transradial ArteryRadial Artery Spasm During Transradial ArteryRadial Artery Spasm During Transradial Artery Radial Artery Spasm During Transradial Artery CatheterizationCatheterization

Kintur SanghviCezar StaniloaeSudhesh SrivastavaJohn Coppola

Journal of Invasive CardiologyApril 2006 ISSN: 1042-3931 -Volume 18 - Issue 4

Disclosure

None4/18/2010 11:14:42 AM

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None

Transradial Intervention

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Advantages. Limitations: Technically difficult: Nearly 0% local site complication. Better quality of life for the patients

and the staff.

Access failure. Radial spasm. Loops and tortuosity of Radial and

Reduce cost. Same day discharge. All coronary and peripheral vascular

interventions are possible except for

Subclavian. Longer learning curve

interventions are possible except for few exceptions.

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Radial Vs Femoral approach for diagnostic and PCI procedures: Systemic overview and meta-analysis

12 randomized trials n = 3234 (J A C ll C di l 2004 44 349 356 )12 randomized trials n = 3234 (J Am Coll Cardiol 2004 44: 349-356 )

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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

t tor treat spasm.

Role of direct Nitric oxide donor is unknown.

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Objective

Primary: To compare the efficacy of three different intra-arterial vasodilating cocktails inreducing the incidence of radial artery spasm in patients undergoing transradial coronaryangiogramangiogram.

Secondary: To assess the predictors of arterial spasm in this large group of patients.

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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 endpointOccurrence of radial artery spasm.

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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 - 100 mcgNitroglycerine 100 mcg - 100 mcg

Nitroprusside - 100 mcg 100 mcg

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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 toremove the sheath at the end of the procedure, or presence of fore-arm painexperienced by the patient.experienced by the patient.

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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<0 05Statistical significance was considered for P<0.05

Data were expressed in mean ± standard deviation.

Quantitative variables: the paired t test.

Qualitative variables: the chi square test.Qualitative variables: the chi square test.

Multigroup ANOVA to compare the 3 different groups.

A backward regression multivariate analysis was performed to establish thepredictors of radial artery spasm.

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Results Clinical and Procedural variables

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Results Occurrence of Spasmp

137140123 119

100

120

P = 0 597

60

80Total PtsSpasm

P = 0.597

15 16 1320

40Spasm

13

0Group A Group B Group C

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Conclusion & Discussion

The addition of a direct NO donor to Nitroglycerine, does not reducesthe risk of radial artery spasm.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, nosignificant improvement in the incidence of the radial artery spasm.(the concept that certain triggers of arterial spasm cannot be(the concept that certain triggers of arterial spasm cannot becounteracted by the mere use of vasodilators ).

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ResultsUnivariate analysis for predictor of spasm y p p

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ResultsMultivariate analysis for predictor of spasm y p p

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Conclusion & Discussion

Morphometric factors play a significant role in predicting theoccurrence of radial artery spasm.occurrence of radial artery spasm.

The age or sex of the patient, presence of diabetes, BSA andsmoking played no role in prediction of radial spasm as wassmoking played no role in prediction of radial spasm as wassuggested by some other studies.

The relationship between the size of the radial artery the body size 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.

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Limitation

Subjective evaluation of Radial artery spasm.Id l ld b Obj i P ll b k S A iIdeal would be Objective: Pull back, Sonogram, Angiogram

Effect of Sedative / hypnotics was not evaluated.yp

Important in predicting arterial spasm, than each individualcomponent separatelycomponent separately.

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Radial Cocktail study II

Multicenter radomization All pateints: Heparine

Radial and Subclavian Angiog

Radial Cocktail (Verapaamil + NTG)

+

Radial Cocktail(Verapaamil + NTG)

N d ti

SedationNo Cocktail

No CocktailNo Sedation.

Sedation No sedation No Cocktail No Sedation.

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Thank YouThank You

nitroglycerine, nitroprusside, or both in preventing ... cocktail study.pdf · nitroglycerine,...

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