Randomized Clinical Trial on Short-Time Compression with Kaolin-Filled Pad: A New Strategy to Avoid Early Bleeding and Subacute Radial Artery Occlusion after Percutaneous Coronary Intervention

Politi, Luigi; Aprile, Alessandro; Paganelli, Catia; Amato, A.; Zoccai, Giuseppe Biondi; Sgura, Fabio; Monopoli, Daniel; Rossi, Rosario; Modena, Maria Grazia; Sangiorgi, Giuseppe

doi:10.1111/j.1540-8183.2010.00584.x

Cited by 41 publications

(46 citation statements)

References 12 publications

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“…The QuikClot Interventional Bandage (Z-Medica Corporation, Wallingford, CT) is a new kaolin-filled pad, applied for 15 minutes with a compressive dressing, that in a small, randomized trial has been shown to reduce rates of RAO. 56 More research is needed into the treatment of this condition. Early anticoagulation appears to decrease the risk of persistent occlusion; however, the optimal anticoagulant regimen remains to be determined.…”

Section: Future Directionsmentioning

confidence: 99%

Radial Artery Patency After Transradial Catheterization

Kotowycz

Džavík

2012

Circ: Cardiovascular Interventions

180

133

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T he transradial approach to cardiac catheterization has many advantages over the transfemoral approach and is increasingly being used for both diagnostic coronary angiography and percutaneous coronary intervention (PCI). The technique is associated with fewer vascular access complications [1][2][3] and has been shown to reduce major bleeding when compared with the femoral approach. 4 Patients prefer the radial approach and score higher on quality-of-life questionnaires after transradial catheterization. 3,5 Radial access allows for earlier patient ambulation and same-day hospital discharge in PCI patients 4 -6 and is associated with decreased cost. 5,7,8 Radial artery occlusion (RAO) is a complication of transradial catheterization that can lead to permanent occlusion of the radial artery. Estimated to occur in 1-10% of cases, 9 -14 it has been described as the "Achilles' heel" of the transradial technique. 15 RAO is usually clinically silent because of the dual blood supply to the hand, and for this reason it is often overlooked. In fact, more than 50% of transradial operators do not routinely assess radial artery patency before hospital discharge. 16 However, the complication is not benign, as hand ischemia resulting from RAO has been reported. [17][18][19] Furthermore, once the artery is occluded, it cannot be used as an access site for future catheterization or as an arterial conduit for bypass surgery. RAO renders the ipsilateral ulnar artery unusable as well, because instrumenting and cannulating the ulnar would put the patient's hand at risk of ischemia. In this report, we review the pathophysiology, clinical presentation, and risk factors for RAO, discuss prevention and treatment options, and suggest directions for future research aimed at minimizing this complication. PathophysiologyAcute loss of radial artery patency after cardiac catheterization is thought to be due to a thrombotic process. Sheath insertion leads to local endothelial injury and cessation of blood flow in the radial artery, creating an environment conducive to thrombosis. Many observations about RAO provide indirect evidence to support this hypothesis. RAO tends to occur early after transradial catheterization, and roughly 50% of patients have spontaneous recanalization of the artery within 1-3 months. 10,12 Furthermore, rates of RAO are higher with prolonged cannulation times, 20 -22 whereas RAO is reduced with anticoagulation 23 and nonocclusive hemostasis. 11,24,25 Direct support for the thrombotic hypothesis has come from recent studies that have confirmed the presence of radial artery thrombus on vascular ultrasound, 26 angiography, 27 and pathology. 28 Transradial catheterization can also negatively affect radial artery structure and function. A study using optical coherence tomography found that 67% of radial arteries had intimal tears and 36% had medial dissections immediately after transradial PCI. 29 Other studies have found that minimal lumen diameter and minimal lumen area are smaller in repeat transradial patients than i...

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Section: Future Directionsmentioning

confidence: 99%

Radial Artery Patency After Transradial Catheterization

Kotowycz

Džavík

2012

Circ: Cardiovascular Interventions

180

133

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“…Noteworthy, kaolin-filled pads allow for short compression, but evidence on their efficacy is still limited, and these pads were not available in our institution at the time of the trial. 5 The Rotterdam Radial Access Research (R-RADAR) study introduced novel noninvasive ultrasound imaging technology in the space of transradial access. Its relatively small sample size precludes any firm conclusions, yet we believe the findings in terms of arterial injury and healing after transradial access are original, refine current understanding and should spur further research to optimize planning, execution, and postprocedural management of transradial procedures.…”

Section: In Responsementioning

confidence: 99%

Response by Costa et al to Letter Regarding Article, “The Rotterdam Radial Access Research: Ultrasound-Based Radial Artery Evaluation for Diagnostic and Therapeutic Coronary Procedures”

Costa

Daemen

Diletti

et al. 2016

Circ: Cardiovascular Interventions

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In Response:In response to the comments of Chugh et al on our study, 1 we would like to point out that the rate of radial artery occlusion (RAO) ranged from <1% to 30% in recent studies (mean 7.89%), whereas in the Rotterdam Radial Access Research study, this was <4% at all time points. 1 The incidence of RAO varies and seems multifactorial, including anatomic substrate (ie, vessel size), access technique, and access management before, during, and after the procedure. Our study underscores the clinical importance of number of radial punctures to obtain arterial access and its association with RAO, radial pulse loss, and pain and discomfort. In contrast, radial artery size at baseline, which was handled as a continuous variable in our model, had no impact on RAO. We agree with Chugh et al that smaller radial artery size may result in serial puncture attempts. In fact, the median radial inner lumen at baseline in our study was 2.25 mm in patients receiving 1 puncture and 2.01 mm in those receiving >1 puncture. However, a lumen of <2.00 mm did not predict RAO at any time point in our study, confirming our hypothesis that the number of punctures could independently predict RAO.The use of low-dose heparin for short-lasting transradial diagnostic studies resembles standard practice in many institutions throughout the world. Systematic use of a higher heparin dose in a diagnostic setting may result in less RAO, especially when patent hemostasis could not be achieved.2 Still, full anticoagulation is associated with a significant increase in access site bleeding with no further benefit on RAO in a recent, large, double-blind randomized trial.3 Similarly, Pancholy et al 4 demonstrated that shorter compression times (2 versus 6 hours) also reduced RAO. Shorter compression time (15 minutes) with newer compression devices was associated with a higher bleeding rate. Noteworthy, kaolin-filled pads allow for short compression, but evidence on their efficacy is still limited, and these pads were not available in our institution at the time of the trial. 5The Rotterdam Radial Access Research (R-RADAR) study introduced novel noninvasive ultrasound imaging technology in the space of transradial access. Its relatively small sample size precludes any firm conclusions, yet we believe the findings in terms of arterial injury and healing after transradial access are original, refine current understanding and should spur further research to optimize planning, execution, and postprocedural management of transradial procedures. DisclosuresNone. Francesco

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“…time the need of prolonged occlusive compression, as recently demonstrated by our group [5]. Fifth, in the case by Rhyne et al pletismography showed a non pathologic result, suggesting that this test is poorly predictive of ulnar or radial patency.…”

Section: To the Editormentioning

confidence: 71%

Transradial access without preliminary allen test—letter of comment on Rhyne et al.

Biondi‐Zoccai

Moretti

Zuffi³

et al. 2011

Cathet Cardio Intervent

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Randomized Clinical Trial on Short-Time Compression with Kaolin-Filled Pad: A New Strategy to Avoid Early Bleeding and Subacute Radial Artery Occlusion after Percutaneous Coronary Intervention

Abstract: Early sheet removal and short-time compression with QuikClot® Interventional™ can reduce the rate of RAO after diagnostic or interventional procedures especially in patients not on double antiplatelet therapy.

Cited by 41 publications

References 12 publications

Radial Artery Patency After Transradial Catheterization

Radial Artery Patency After Transradial Catheterization

Response by Costa et al to Letter Regarding Article, “The Rotterdam Radial Access Research: Ultrasound-Based Radial Artery Evaluation for Diagnostic and Therapeutic Coronary Procedures”

Transradial access without preliminary allen test—letter of comment on Rhyne et al.

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