Author + information
- Adel Aminian, MD∗ (, )
- Jacques Lalmand, MD and
- Dariouch Dolatabadi, MD
- ↵∗Centre Hospitalier Universitaire de Charleroi, Bd. Paul Janson 92, 6000 Charleroi, Belgium
We read with interest the report by Deftereos el al. (1) on significant reductions in the incidence of radial artery spasm, access site crossover, and procedure-related patient discomfort induced by the routine administration of low doses of an opioid-benzodiazepine combination during transradial coronary intervention. Although the investigators should be congratulated on their well-designed and adequately powered study, potential limitations of the study must be emphasized. One of these is related to the systematic use of a 6-F sheath for radial access. Indeed, in a large series of ultrasound measurements, Yoo et al. (2) found that the mean radial artery diameter was 2.69 ± 0.40 mm in men and 2.43 ± 0.38 mm in women, with a range of 1.15 to 3.95 mm. In that study, the proportion of patients with mean radial artery diameters < 2.52 mm (the outer diameter of a 6-F sheath) was 44% (32% in men, 60% in women). Of note, the radial sheath used in the study of Deftereos et al. (1) was the 6-F Glidesheath (Terumo Medical Corporation, Somerset, New Jersey), which has an outer diameter of 2.62 mm. Therefore, we can assume that a substantial proportion of patients included in the study had sheath-to-artery ratios > 1 which have been shown not only to increase the incidence of severe radial flow reduction but also to increase the incidence of pain during sheath insertion and removal (3,4). Moreover, the maximal catheter size used to perform coronary angiography and/or intervention in each group is not reported. Importantly, 52.1% of the study population underwent coronary angiography without ad hoc percutaneous coronary intervention. In this subset of patients, one can consider that using 5-F or even 4-F sheaths and catheters could have resulted in a substantial reduction in the rate of radial spasm. In the same way, 5-F sheaths and catheters are suitable for many noncomplex coronary interventions. Along with sedation, downsizing of radial sheaths and catheters, whenever possible, is a major strategy for reducing vascular complications during transradial access, including radial spasm. Deftereos et al. (1) also report a 34% relative reduction in the rate of access-site crossover in the treatment group, which was mainly related to a reduction in the rate of spasm. The presence of anatomical variations at the level of the upper limb arteries is a well-known cause of radial spasm and access-site crossover. However, the overall rate of these anatomical variations and their incidence in each group are not reported. An imbalance in the rate of complex arterial anatomical variations between the 2 groups could be a potential confounder and needs to be ruled out. In these situations, specific options besides sedation are advocated to reduce patient discomfort, such as careful and gentle manipulation of diagnostic and guiding catheters, the use of the smallest catheter size required to complete the procedure, and the use of hydrophilic-coated wires and catheters to cross the anatomical variations (5).
- American College of Cardiology Foundation