Aim RADIAL 2013
Non Occlusive Radial artery
Injury and Long term effects
Dr Sudhir Rathore
MD, MRCP(UK),FACC, FESC
Consultant Interventional Cardiologist
Frimley Park Hospital NHS Foundation Trust, Surrey &
St George’s Hospital, London, UK
Conflict of Interest
conflict of interest in relation to this
Transradial access is rapidly becoming alternative and
preferred vascular access site.
Radial artery is medium sized muscular artery.
Repeated coronary procedures needs patent and healthy
Radial artery is being used increasingly as a conduit for
Creation of arteriovenous fistulae for haemodialysis.
Transradial access potentially results in injury to radial
artery and can range from endothelial dysfunction to RA
All efforts must be made to minimise radial artery injury
Non Occlusive RA injury: Historical
Non-occlusive radial artery injury: Reported in around 50% of the
RA in the form of neo-intimal hyperplasia, radial artery stenosis etc.
Nagai et al (1999): Early- segmental stenosis (22%), no flow ( 9%).
Late : segmental stenosis (1%), diffuse stenosis ( 22%) and no flow
Wakeyama et al (2003): IVUS: LA of 5.05±1.26mm² in the repeatTRI group vs. LA of 5.62±1.35mm² in the first-TRI group, p=0.032
and MLD of 2.37±0.31mm in the repeat-TRI group vs. MLD of
2.51±0.33mm in the first-TRI group, p=0.028), whereas the intimamedia cross sectional area (IMcsa) and intima-media thickness
(IMT) were significantly greater than those in first-TRI patients.
Edmundson and Mann: Repeat procedure group and control group
(6.7±0.8mm2 vs. 5.0±0.7mm2, p<0.01).
Intimal tears: 32%
thickness in patients
Taishi Yonetsu et al. EHJ, April 22, 2010
Vascular function- Impact of Artery to
FMD: Impact of no. of catheters and smoking
Heiss. C et al. JACC Interv. 2:1067-1073, 2009
Hypothesis and Exercise protocol
exercise training may be beneficial for
post-catheterization recovery of radial artery
Patients attended the laboratory twice: before
the catheterization (Pre) and 7 weeks after the
The training consisted of exercise with a
handgrip dynamometer (Stoelting, Wood Dale,
III) with a rhythmic sequence of 30 contractions
per minute timed to a metronome, for 30
minutes in a seated position three times a week.
Effects of Trimetazidine on endothelial
dysfunction after TRI.
group: Pre/10 weeks (10.4 ± 3.4% vs.
6.3±2.9%, P < 0.01).
TMZ group: (10.1 ± 3.6% vs. 9.2 ± 3.6%, P =
Multivariate analysis: repeated RA sheath injury
and TMZ use (OR 7.40, 95% CI 1.42-38.53, P <
0.05, and OR 0.08, 95% CI 0.02-0.30, P < 0.01,
respectively) were independent predictors of the
decrement of FMD.
Park KH et al, Interv Cardiol. 2012 Aug;25(4):411-7
Drug eluting Introducer sheath-Preclinical
sheaths in porcine femoral arteries.
Immediately after PCI: Control/NO-coated,
luminal thrombosis(33% vs, 12%)
At 1 week: less intimal inflammation score, less
luminal thrombosis, and smaller intimal
hyperplasia was noted in NO group.
NO coating prevents local complications and
induces less vascular injury.
Hemelesberger R, et al. JACC Interv, 2011;4:98-106
Predictors for RA injury
size and artery to sheath ratio,
Number of catheters used,
Use of heparin,
Radial artery spasm,
?Hydrophilic coated sheaths,
Take Home Message 1
artery injury is common after TRA.
RA occlusion rates could be significantly reduced
by adopting routine patent haemostasis and use
of Heparin (5000 Units or more).
Compression devices should be removed early
and in timely fashion.
Radial artery spasm should be avoided and
treated promptly using vasodilators and other
measures to reduce radial artery injury and
Predictors of RA injury should be identified and
adequate measures taken.
Take Home Message 2
endothelial function (FMD) and GTN
mediated function are significantly impaired after
Vascular functions recover to baseline in three
RA to sheath ratio (<1), smoking and higher
number of catheter exchanges seems to result in
higher extent of injury.
Less injury with smaller diameter catheters (45Fr vs. 6Fr): Sheath size as per indication.
Secondary prevention of risk factors could
potentially reduce vascular injury.
Role of Prehabilitation: Isometric exercise of
forearm could reduce vascular injury.
studies needed to assess the non
occlusive injury and vascular function.
Novel radial sheaths and catheter (thin
Drug coated sheaths (NO, LNMMA)
Clinical studies involving graft patients.