Maarten van Leeuwen

The Effect of Transradial Coronary Catheterization on Upper Limb Function

OBJECTIVES The aim of this study was to analyze the change of upper limb function when percutaneous coronary procedures were performed through the radial artery. BACKGROUND It is currently unknown if upper limb function is affected by transradial (TR) catheterization. METHODS Between January 2013 and February 2014, upper limb function was assessed in a total of 338 patients undergoing coronary catheterization in an ambulatory setting (85% radial approach, 15% femoral approach). Upper limb function was assessed with the self-reported shortened version of the Disabilities of Arm, Shoulder, and Hand questionnaire. The presence and severity of upper extremity cold intolerance was assessed with the self-reported Cold Intolerance Symptom Severity questionnaire. Both questionnaires were completed before the catheterization and at 30-day follow-up. Higher scores represent worse upper limb functionality or symptoms. The nonparametric Wilcoxon signed-rank test was used to assess the change of upper limb function and symptoms over time. RESULTS Upper limb function did not change significantly over time when catheterization was performed through the radial artery (p=0.06). The number of procedure-related extremity complaints that persisted during 30-day follow-up were not different between both access groups (TR access 10.5%, transfemoral access 11.5%; p=0.82). The upper extremity was not affected by cold intolerance after TR access at 30-day follow-up (p=0.91). CONCLUSIONS Upper limb function was not affected when coronary catheterizations and interventions were performed through the radial artery.

The Rotterdam Radial Access Research: Ultrasound-Based Radial Artery Evaluation for Diagnostic and Therapeutic Coronary Procedures.

Background—Radial artery wall might be damaged after cannulation for cardiac catheterization. We investigated structural changes of the radial artery wall after catheterization to understand whether these might predict radial pulsation loss or occlusion and local pain or functional impairment of the upper extremity. Methods and Results—Ninety patients underwent transradial coronary angiography or intervention and were scanned with a high-resolution 40-MHz ultrasound before cannulation and at 3 hours and 30 days after procedure. Acute injuries of the radial artery occurred in all patients: dissection and intramural hematoma were the most common. However, these phenomena did not predict loss of radial pulsation or occlusion, local pain, or functional impairment at 30 days. Overall, the radial artery lumen was significantly reduced distal to the puncture site. Radial artery intima and total wall thickness increased 3 hours after puncture and persisted at 30 days. Radial occlusion and pulsation loss were observed in 3.9% and 9.2% of patients, respectively, at 30 days. Smaller radial artery lumen at baseline increased the risk of radial pulsation loss at 30 days (odds ratio, 1.23; P=0.049). The number of radial puncture attempts predicted pulsation loss (odds ratio, 2.64; P=0.027), occlusion (odds ratio, 3.49; P=0.022), and symptoms (odds ratio, 2.24; P=0.05) at 30-day follow-up. Conclusions—After catheterization, radial artery puncture site is associated with increased intima and total wall thickness and with modest decrease of inner lumen diameter. Acute injuries of the vessel wall were ubiquitous, but contrary to repeated puncture attempts, did not seem to affect postprocedural radial occlusion or loss of pulsation.

The ACRA Anatomy Study (Assessment of Disability After Coronary Procedures Using Radial Access): A Comprehensive Anatomic and Functional Assessment of the Vasculature of the Hand and Relation to Outcome After Transradial Catheterization

Background— The palmar arches serve as the most important conduits for digital blood supply, and incompleteness may lead to digital ischemia when the radial artery becomes obstructed after cardiac catheterization. The rate of palmar arch incompleteness and the clinical consequences after transradial access are currently unknown. Methods and Results— The vascular anatomy of the hand was documented by angiography in 234 patients undergoing transradial cardiac catheterization. In all patients, a preprocedural modified Allen test and Barbeau test were performed. Upper-extremity function was assessed at baseline and 2-year follow-up by the QuickDASH. Incompleteness of the superficial palmar arch (SPA) was present in 46%, the deep palmar arch was complete in all patients. Modified Allen test and Barbeau test results were associated with incompleteness of the SPA (P=0.001 and P=0.001). The modified Allen test had a 33% sensitivity and 86% specificity for SPA incompleteness with a cutoff value of >10 seconds and a 59% sensitivity and 60% specificity with a cutoff value of >5 seconds. The Barbeau test had a 7% sensitivity and 98% specificity for type D and a 21% sensitivity and 93% specificity for types C and D combined. Upper-extremity dysfunction was not associated with SPA incompleteness (P=0.77). Conclusions— Although incompleteness of the SPA is common, digital blood supply is always preserved by a complete deep palmar arch. Preprocedural patency tests have thus no added benefit to prevent ischemic complications of the hand. Finally, incompleteness of the SPA is not associated with a loss of upper-extremity function after transradial catheterization.

Rationale and design of the Hunting for the off-target propertIes of Ticagrelor on Endothelial function and other Circulating biomarkers in Humans (HI-TECH) trial

Background Among the 3 approved oral P2Y12 inhibitors for the treatment for patients with acute coronary syndrome (ACS), ticagrelor, but not prasugrel or clopidogrel, has been associated with off‐target properties, such as improved endothelial‐dependent vasomotion and increased adenosine plasma levels. Methods The HI‐TECH study (NCT02587260) is a multinational, randomized, open‐label, crossover study with a Latin squares design, conducted at 5 European sites, in which patients free from recurrent ischemic or bleeding events ≥30 days after a qualifying ACS were allocated to sequentially receive a 30 ± 5‐day treatment with prasugrel, clopidogrel, and ticagrelor in random order. The primary objective was to evaluate whether ticagrelor, at treatment steady state (ie, after 30 ± 5 days of drug administration), as compared with both clopidogrel and prasugrel, is associated with an improved endothelial function, assessed with peripheral arterial tonometry. Thirty‐six patients undergoing evaluable endothelial function assessment for each of the assigned P2Y12 inhibitor were needed to provide 90% power to detect a 10% relative change of the reactive hyperemia index in the ticagrelor group. Conclusion The HI‐TECH study is the first randomized, crossover study aiming to ascertain whether ticagrelor, when administered at approved regimen in post‐ACS patients, improves endothelial function as compared with both clopidogrel and prasugrel.

Effects of Ticagrelor, Prasugrel, or Clopidogrel at Steady State on Endothelial Function

Ticagrelor is a nonthienopyridine direct and reversible P2Y12 platelet receptor antagonist, and unlike prasugrel or clopidogrel inhibits, at least partially, the sodium-independent equilibrative nucleoside transporter 1 [(1)][1]. This ticagrelor-mediated off-target effect has potential to improve

Impact of sheath size and hemostasis time on radial artery patency after transradial coronary angiography and intervention in Japanese and non-Japanese patients: A substudy from RAP and BEAT (Radial Artery Patency and Bleeding, Efficacy, Adverse evenT) ra

During transradial (TR) access, it remains unclear whether differences in baseline patients characteristics and hemostasis care impact the rate of radial artery occlusion (RAO). We sought to compare the rate of RAO after TR access with the 6 French(Fr) Glidesheath Slender (GSS6Fr, Terumo, Japan) or a standard 5 Fr sheath in Japanese and non‐Japanese patients.

Body Mass Index Is Associated With Microvascular Endothelial Dysfunction in Patients With Treated Metabolic Risk Factors and Suspected Coronary Artery Disease

Background Obesity is key feature of the metabolic syndrome and is associated with high cardiovascular morbidity and mortality. Obesity is associated with macrovascular endothelial dysfunction, a determinant of outcome in patients with coronary artery disease. Here, we compared the influence of obesity on microvascular endothelial function to that of established cardiovascular risk factors such as diabetes mellitus, hypertension, hypercholesterolemia, and smoking in patients with suspected coronary artery disease. Methods and Results Endothelial function was assessed during postocclusive reactive hyperemia of the brachial artery and downstream microvascular beds in 108 patients who were scheduled for coronary angiography. In all patients, microvascular vasodilation was assessed using peripheral arterial tonometry; laser Doppler flowmetry and digital thermal monitoring were performed. Body mass index was significantly associated with decreased endothelium‐dependent vasodilatation measured with peripheral arterial tonometry (r=0.23, P=0.02), laser Doppler flowmetry (r=0.30, P<0.01), and digital thermal monitoring (r=0.30, P<0.01). In contrast, hypertension, hypercholesterolemia, and smoking had no influence on microvascular vasodilatation. Especially in diabetic patients, endothelial function was not significantly reduced (control versus diabetes mellitus, mean±SEM or median [interquartile range], peripheral arterial tonometry: 1.90±0.20 versus 1.67±0.20, P=0.19, laser Doppler flowmetry: 728% [interquartile range, 427–1110] versus 589% [interquartile range, 320–1067] P=0.28, and digital thermal monitoring: 6.6±1.0% versus 2.5±1.7%, P=0.08). In multivariate linear regression analysis, body mass index was the only risk factor that significantly attenuated endothelium‐dependent vasodilatation using all 3 microvascular function tests. Conclusions Higher body mass index is associated with reduced endothelial function in patients with suspected coronary artery disease, even after adjustment for treated diabetes mellitus, hypertension, hypercholesterolemia, and smoking.

Non-invasive assessment of the collateral circulation in the hand: validation of the Nexfin system and relation to clinical outcome after transradial catheterisation

AIMS This study aims primarily to assess the extent of the collateral circulation of the hand in a combined population of healthy individuals and patients who underwent transradial catheterisation, using both the Nexfin system and laser Doppler perfusion imaging. METHODS AND RESULTS In total, 85 adults were included in the study (18 healthy volunteers; 67 patients who underwent transradial catheterisation). The perfusion of the thumb was assessed prior to and during complete radial artery compression using laser Doppler perfusion imaging (LDPI) and the Nexfin system. The palmar collateral flow index (PCFI) was compared between both devices and PCFINEXFIN was related to hand angiography and the upper limb function, using the QuickDASH questionnaire. Mean PCFILDPI was 0.77±0.15 and mean PCFINEXFIN was 0.88±0.08. Both were significantly related (Pearson correlation=0.49, 95% CI: 0.31-0.64, p<0.001, agreement -0.11±0.13). PCFINEXFIN correlated with the maximal diameter of the superficial palmar arch (R=0.49, p=0.04) and total minimal arch diameter (R=0.51, p<0.02). High PCFINEXFIN, measured at baseline, was correlated with a lower QuickDASH score for pain, activity and total at one month post transradial catheterisation (p=0.02, p<0.01, p<0.01), but not with discomfort or disability. CONCLUSIONS The Nexfin monitoring system is comparable with laser Doppler perfusion imaging in the quantification of the collateral perfusion in the hand. In patients, the Nexfin-derived collateral flow index measured at baseline is associated with clinical outcome at 30 days post transradial catheterisation.

The long-term effect of transradial coronary catheterisation on upper limb function

AIMS Anatomic and physiologic changes that are induced by radial access may lead to a decrease of upper limb function at long-term follow-up; however, this has never been studied. We aimed to study the long-term effect of transradial catheterisation on upper limb function. METHODS AND RESULTS Between January 2013 and April 2014, upper limb function was assessed in a total of 348 patients with complete one-year follow-up after coronary catheterisation. Upper limb function was assessed with the self-reported shortened version of the DASH questionnaire. The presence and severity of upper extremity cold intolerance was assessed with the self-reported CISS questionnaire. Both questionnaires were completed before the catheterisation and at one-year follow-up. Higher scores represent worse upper limb functionality or symptoms. The non-parametric Wilcoxon signed-rank test was used to assess the change of upper limb function and symptoms over time. Extremity complaints were reported at one-month and one-year follow-up. At one-year follow-up, upper limb function did not change over time when catheterisation was performed through the radial artery (p-value 0.20). Upper extremity was also not affected by cold intolerance at one-year follow-up (p-value 0.09). Extremity complaints were reported equally in both access groups and diminished significantly over time (p-value <0.001). CONCLUSIONS Upper limb function was not affected at long-term follow-up after transradial procedures.

Chronic radial artery occlusion does not cause exercise induced hand ischemia

OBJECTIVES The aim of the study was to evaluate the occurrence of hand ischemia in patients with radial artery occlusion (RAO), using the contralateral hand as control. BACKGROUND Radial artery occlusion is a common complication (6%) after transradial access (TRA) but rarely leads to major ischemic events due to the collateral perfusion of the hand. However, it has been reported that RAO can become symptomatic, possibly as a consequence of hand ischemia. To evaluate the existence of exercise induced hand ischemia in patients with RAO, we initiated the present study. METHODS After a transradial coronary procedure, patients with suspicion of RAO were asked for study participation. After informed consent, radial ultrasound was performed. In patients with confirmed RAO, rest perfusion of the digits was analyzed by laser Doppler digital imaging. Occurrence of ischemia during exercise was assessed with transcutaneous oxygen pressure (TcPO2) and thumb capillary lactate. All analyses were performed in both the RAO side as well as the contralateral side as control. RESULTS RAO occlusion was confirmed in 18 patients. After 5 min of exercise there were no significant differences in TcPO2 (51.4 mmHg [±17.2] vs 43.9 mmHg [±15.5], P = 0.18) or lactate (2.0 mmol/L [±0.7] vs 2.1 mmol/L [±0.7], P = 0.80) between RAO side and control side. Differences in mean TcPO2 were found to be stable during exercise and not different from baseline differences. CONCLUSIONS Chronic radial artery occlusion does not lead to exercise induced hand ischemia.