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Objectives for this course:
1- Master the essentials of a successful complex PCI by using the radial approach
2- Essential questions on radial approach and the use of the specific radial device(s)
3- Clinical case strategy and radial approach limits
4- Anatomical variations in the Radial artery.
5- Master the essential steps of a successful radial procedure.

In this lecture, we focus on four parts:
1- The incidence of radial artery spasm during transradial cardiac catheterization
2- The predisposing factors for radial artery spasm
3- Discussion on management (prevention and treatment) of radial artery spasm
4- Discussion on sedation and sheathless guiding catheters.

The transradial approach (TRA) to coronary interventions is becoming increasingly popular due to lower vascular complication rates, reduced procedural costs, and earlier patient mobilization.
The TRA has also been used for cerebral angiography and vertebral artery stenting.
One of the most common complications of the TRA is radial artery spasm (RAS), which causes significant discomfort to the patient and can prevent the successful completion of the procedure.

Various vasodilators, alone or in combination as a cocktail, have been advocated to prevent spasm of the radial artery during instrumentation for coronary procedures and during harvesting and implantation of the vessel for use as a bypass conduit.

Until now, it has not been possible to measure RAS objectively. Assessment of the efficacy and comparison of various vasodilators have therefore not been performed.

Radial artery spasm can be defined as a temporary, sudden narrowing of the radial artery. It is usually diagnosed clinically and angiographically during cardiac catheterization. Clinically, it is associated with pain in the forearm which is aggravated by movement of the catheter/sheath, and there is difficulty in manipulating the catheter. There is also loss of radial pulse and damping of radial arterial pressure.

Radial arteriogram is usually obtained to confirm spasm and also to exclude vessel trauma. Angiographic confirmation is important as sometimes pain in the arm may not be caused by spasm but by other factors like tortuosity/loops in radial, brachial, or subclavian arteries which make the catheter movement difficult and cause pain to the patient. Quantification of radial artery spasm is also possible by using an automatic pullback device, although its practical use in the management of spasm remains undefined.

The reported incidence of radial artery spasm during transradial cardiac catheterization ranged from 4% to 20% in the literature. The big range in the rate of incidence could be accounted partly by different types of intra arterial vasodilatory cocktails used in different cardiac catheterization laboratories. There is currently no definitive standard protocol for the optimal vasodilatory cocktail to be administered after successful insertion of the radial sheath.

Most vasodilatory cocktails will incorporate nitroglycerin on top of intra arterial heparin. Others may include verapamil and less commonly used agents like nitroprusside, nicorandil, diltiazem, lidocaine, molsidomine, magnesium sulphate, phentolamine, etc.

The exact mechanism causing radial artery spasm is unclear. Several clinical and anatomical factors have been identified as predisposing an individual to develop radial artery spasm during transradial cardiac catheterization.

This exhaustive list of factors includes smaller radial artery diameter, presence of fixed atherosclerotic lesions, entrance of guidewires into side branches (thus inducing spasm), vessel tortuosity, larger arterial sheath diameters, longer procedure duration, female sex, younger age, lower body mass index, diabetes mellitus, number of catheters used, volume of contrast medium used, and unsuccessful access at first attempt.

Preprocedural radial flow-mediated dilation has also been shown to be a significant predictor of arterial spasm, and its measurement can be performed noninvasively before cardiac catheterization. The measurements obtained by duplex ultrasound can help one decide on the vascular access route, size of the sheaths/catheters, or the type of vasodilatory cocktail to be used.

Radial artery spasm can be prevented by using well-proven intra arterial vasodilatory cocktails. Most vasodilatory cocktails will incorporate nitroglycerin on top of intra arterial heparin, and its effectiveness in reducing the radial artery spasm has been reported by several studies.

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