Frequency of radial artery occlusion with transradial pneumatic compression band after cardiac catheterization

Objectives Radial artery occlusion is a silent complication of a transradial approach to cardiac catheterization that may complicate subsequent transradial procedures in patients undergoing cardiac catheterization. A transradial band reduces vascular complications and provides brisk, powerful and effective haemostasis. The purpose of this study was to assess the frequency of radial artery occlusion in 180 patients undergoing transradial coronary catheterization. Results The mean age of the study cohort was 54.19 ± 12.30 years. Radial artery occlusion was found in 14 (7.8%) patients. When stratifying by age group and sex, there was no signicant difference in radial artery occlusion between age groups and sex. It was likewise found that comorbidities such as diabetes mellitus, hypertension and smoking, increased the risk of radial artery occlusion however this was observed to be signicant only for diabetes mellitus. We therefore conclude that a transradial pneumatic pressure band is an extremely helpful and safe strategy to prevent radial artery occlusion. Stratication was conducted and the chi square test was applied. The results show a signicant association of radial artery occlusion with diabetes mellitus (p = 0.048) and an insignicant association with gender (p = 0.735), age group (p = 0.447), hypertension (p = 0.608) and smoking (p = 0.085). The results are presented in Table-2.


Introduction
Coronary angiography is viewed as the most effective technique for the diagnosis and management of ischemic heart disease (IHD) 1 . The two most common routes for cardiac catheterization are femoral and radial. Current literature demonstrates that radial access is more secure than femoral access. In any case, the most widely recognized bene t of utilizing a transradial approach is the lower rate of vascular complications 2 . Complications of a radial approach include radial artery spasm, radial artery occlusion, and rarely hematoma or perforation 3 .
Radial artery occlusion (RAO) is typically a silent complication of the transradial approach to cardiac catheterization and it may increase complication rates in future transradial catheterizations.
Plethysmography and duplex ultrasound are required for the diagnosis of RAO as palpation of the pulse at the site of cannulation is not always dependable 4 . An investigation that compared the reliability and viability of a transradial band versus radistop hemostatic pressure gadgets after transradial coronary mediation, demonstrated that RAO was present in 9.2% of patients at the time of discharge and 6.8% of patients at the time of follow-up 5 . Radical access is valuable to patients as it permits early ambulation. Although it is more practical than the femoral approach; it is associated with a higher rate (5-10%) of asymptomatic radial artery occlusion 8 .
Transradial (TR) band utilization is a reliable technique that produces quick hemostasis. A TR band is composed of a plate alongside two in atable balloons. It reduces the risk of RAO. Maintaining radial artery patency through pressure application also prevents future RAOs 9 .
Ch. Pervaiz Elahi Institute of Cardiology Multan is a postgraduate cardiology teaching institution where cardiovascular catheterization is occasionally performed for symptomatic and remedial purposes 16,17 .
The objective of this study was to assess the effectiveness of using a TR band in reducing the risk of RAO when used after a coronary angiogram. The effectiveness of TR band utilization has been recognized internationally 9-11 but data is still lacking in our region.

Methods
Methods: between January 2016 and December 2017. The age range of the study group was 18-70 years. Patients who had undergone previous coronary angiograms through transradial access were excluded from the study. After approval from the hospital ethics committee, all patients satisfying the inclusion criteria were incorporated into the study. Informed consent was taken from patients for utilizing Mean and standard deviation was recorded for quantitative variables while frequency and percentage were determined for qualitative factors. Strati cation was conducted to assess the impact of modi ers on study groups by utilizing the chi square test. A P value ≤ 0.05 was considered signi cant.

Results
Out of 180 patients, 123(68.3%) were male and 57(31.6%) were female. The average patient age was 54.19 ± 12.30 years. Among 180 patients, 82(46.1%) patients were found to have diabetes mellitus and 91(50.5%) had hypertension. 102 (56.7%) patients were smokers (as presented in Table-1). In our study, 14 (7.8%) patients were found to have radial artery occlusion as presented in Figure-1.  The incidence of RAO has been reduced in recent years because of the more utilization of radial approach. In a study by catheter laboratory, the incidence of RAO was 15% in a randomly selected group of 352 patients 12 .
Zankl AR et al 13 detected RAO by Doppler in 10.5% patients undergoing coronary angioplasty. The number of symptomatic patients in this cohort presenting with lower arm pain was 58.5% however none of these patients had symptomatic hand ischemia. Treatment with low molecular weight heparin (LMWH) for a duration of 1 month caused arterial recanalization in 86.7% of these patients and also alleviated side effects. In another examination, 42.5% of patients with RAO reported pain in the forearm within 24hrs following the transradial coronary procedure, with another 7% of patients presenting with similar symptoms a few days later. There was no indication of acute limb ischemia in any patient. Fifty-nine percent of patients with RAO were treated with LMWH. Arterial recanalization, evaluated following 14 days, was signi cantly higher in the LMWH treated group compared to the group without anticoagulative treatment (55.6% versus 13.5%, p < 0.001) 14 .
The Prevention of Radial Artery Occlusion-Patent Hemostasis Evaluation Trial (PROPHET) investigated the effectiveness of patent hemostasis using the Hemoband (HemoBand Corporation, Portland, OR) 15 . Patients were randomly allocated to either a conventional pressure application for haemostasis group (occulusive haemostasis technique) or a pressure application guided by heartbeat oximetry to con rm patent haemostasis group (the ulnar artery was blocked and the HemoBand was released until a pulsatile plethysmography sign was observed). The patent haemostasis group had altogether less RAO than the control group, both at 24 hours (5% versus 12%, P < 0.05) and at 1month (1.8% versus 7.0%, P < 0.05) 22 . Consequently, it was suggested that the TR pneumatic pressure band is an extremely helpful and safe technique in diminishing the risk of radial artery occlusion after transradial cardiovascular catheterization.

Limitations
The key limitation of this investigation was that data collection was only conducted at a single institution. A multicenter study would be useful in determining whether the radial artery occlusion rate of 7.8% is consistent with other medical centers in the region. Based on our results, the use of a TR pneumatic pressure band is a valuable and safe technique in decreasing the recurrence of radial artery occlusion after transradial cardiac catheterization. We therefore suggest that the TR pneumatic pressure band should be utilized routinely after transradial cardiac catheterization to decrease the risk of radial artery occlusion (RAO).

Abbreviations
Radial artery occlusion =RAO Ischemic heart disease =IHD

Declarations
Ethics approval and consent to participate Ethics committee of Chaudhry Pervaiz Elahi Institute of Cardiology, Multan, Pakistan approved the study. Written informed consent was obtained from the patients for participation.

Figure 1
Radial artery occlusion among study population