Reduced Radial Artery Occlusion in Transradial Cerebral Angiography: Key Predictive Factors and Preventive Measures from a Single-Center Study of 543 Patients

Introduction

In recent years, there has been increasing clinical use of the transradial approach (TRA) for cerebral angiography and neurointerventional treatment [1]. However, due to the narrow diameter and weak pulsation of the radial artery, the success rate of initial puncture is lower than that of femoral artery puncture. Additionally, repeated punctures can lead to spasm, reducing the chance of successful puncture in the procedures [2,3]. Furthermore, the complications of TRA include radial artery occlusion (RAO); although it is often asymptomatic, it can reduce the likelihood of repeat radial artery intervention and increase the rates of femoral artery puncture [4]. Therefore, this retrospective study from a single center aimed to evaluate the incidence of and factors associated with radial artery occlusion in 543 patients who underwent transradial cerebral angiography.

Material and Methods

ETHICS STATEMENT:

This single-center, retrospective study included 543 patients who underwent TRA for cerebral angiography at our hospital from July 2021 to February 2024. The study was approved by the Institutional Review Board/Ethics Committee Review Board of our hospital (approval No. B2023–119). All patients were informed about the risks of TRA for cerebral angiography and intraoperative medication (eg, use of heparin) and signed the consent form.

STUDY GROUP DESIGN:

We included 543 patients who underwent TRA for cerebral angiography. The subjects were divided into 2 groups – 32 in the RAO group and 511 in the No-RAO group. The male-to-female ratio was 280: 263, with an average age of 54.5±15 years (range: 12–78 years).

Inclusion criteria were: (1) ultrasound evaluation of vessel diameter (radial artery diameter ≥1.5 mm) before puncture; (2) first-time recipients of TRA for cerebral angiography, with no prior history of TRA intervention; and (3) provided informed consent.

Exclusion criteria were: (1) acute ischemic stroke within 2 weeks; (2) surgery contraindications such as liver and renal insufficiency; (3) history of radial artery surgery (such as uremic dialysis endovascular fistula); and (4) failed TRA and changed to transfemoral approach (TFA).

RADIAL ARTERY PUNCTURE AND CATHETERIZATION:

All patients were placed in supine position, with the forearm pronated and the wrist elevated. The radial artery puncture area was sterilized and infiltrated with 0.5 ml 1% lidocaine. To explore the effect of different puncture needles and radial artery sheaths on the incidence of RAO, either a Cordis (Cordis, America) or a Terumo (Terumo, Japan) 20-G puncture needle were randomized and used to puncture the radial artery. Following successful puncture of the radial artery, patients were randomly assigned to receive either an 11-cm or 16-cm radial artery sheath (Terumo, Japan) during the DSA.

WHETHER ADDING HEPARIN OR NO ADDING HEPARIN: In general, the radial artery is prone to spasm (Figures 1, 2), so that after confirming successful sheath placement, an antispasmodic agent’s mixture (commonly composed of 0.2 ml nitroglycerin and 2.5 mg verapamil) was immediately injected into the sheath to prevent radial artery spasm. To explore the effect of heparin on the incidence of RAO, we established 2 groups: a heparin group in which heparin (2500 U) was added to the antispasmodic agents, and a non-heparin group in which heparin was not added to the antispasmodic agents.

POST-PROCEDURE HEMOSTASIS TECHNIQUE:

After TRA for cerebral angiography was completed. TR-Bands were used to establish hemostasis, with routine inflation of 12 ml and gradual deflation of 2 ml every 2 h for 3 consecutive times. The TR-Bands were release after 6 h.

ASSESSMENT OF EARLY RAO BY ULTRASOUND:

Early RAO was defined as the occurrence of radial artery occlusion within 24 h. When releasing the TR-Bands after 24 h, ultrasound was repeated. If radial artery flow could not be examined by Doppler ultrasound, it was considered to be early radial artery occlusion, and attention was paid to whether the patient had forearm pain or hematoma (Figures 3, 4).

DATA COLLECTION:

We collected data on patient demography (eg, age, sex), clinical data (eg, incidence of radial artery occlusion), whether heparin was added in the antispasmodic agents, number of radial artery punctures attempts, radial sheath length, radial artery diameter, and type of puncture needle used.

STATISTICAL ANALYSIS:

Statistical analysis was performed using IBM SPSS-25.0 for Windows (IBM, USA). Hypotheses about the independence of the 2 attributes were tested using the chi-squared (χ²) test and the t test for quantitative attributes. Univariate and multivariate analyses of complications and crossover were performed using logistic regression. Differences between traits in the treatment groups were considered statistically significant at P<0.05.

Results

REGARDING THE USE OF HEPARIN:

Among the 302 patients who had heparin added to the antispasmodic agents for preventing radial artery spasm, 2 experienced RAO. Among the 241 patients who did not have heparin added to the antispasmodic agents, 30 experienced RAO. The RAO occurrence rate was significantly lower in the heparin group compared to the non-heparin group (χ²=20.031, P<0.0001).

REGARDING THE PUNCTURE ATTEMPTS:

Among the 323 patients with fewer than 3 puncture attempts, 9 experienced RAO. Among the 220 patients with more than 3 puncture attempts, 23 experienced RAO. The RAO occurrence rate was significantly lower in patients with fewer than 3 puncture attempts compared to those with more than 3 puncture attempts (χ²=13.8751, P<0.0002).

REGARDING DIFFERENT LENGTHS OF RADIAL ARTERY SHEATH:

Among the 220 patients in whom a 16-cm sheath was used, 4 experienced RAO. Among the 323 patients using 11 cm sheath, 28 experienced RAO. Patients in whom a 16-cm sheath was used had a significantly lower RAO occurrence rate than in those in whom 11-cm sheaths were used (χ²=11.074, P<0.0009).

REGARDING DIFFERENT DIAMETERS OF RADIAL ARTERY SHEATH:

Among 284 patients for whom a 4F sheath was used, 14 experienced RAO. Among 259 for whom a 5F sheath was used, 18 experienced RAO, but there was not a significant difference in RAO occurrence (χ²=0.9969, P=0.3181 >0.05).

REGARDING DIFFERENT USE OF PUNCTURE NEEDLE:

Among 288 patients treated using a Terumo (Terumo, Japan) 20-G puncture needle, 9 experienced RAO. Among 255 patients treated using a Cordis (Cordis, America) 20-G puncture needle, 23 experienced RAO. The RAO occurrence rate was significantly lower in the Terumo puncture needle group compared to the Cordis puncture needle group (χ²=8.4737, P<0.0036).

MULTIPLE LOGISTIC ANALYSIS:

The independent risk factors of reduce the radial artery occlusion were adding heparin to the antispasmodic agents (OR=0.076, 95% CI: 0.018–0.321, P<0.001), less than 3 radial artery puncture attempts (OR=0.245, 95% CI: 0.111–0.541, P<0.001), using an 16-cm long radial artery sheath (OR=0.195, 95% CI: 0.067–0.564, P=0.003), and using a Terumo puncture needle (OR=0.325, 95% CI: 0.148–0.717, P=0.005) (Table 3).

Discussion

LIMITATIONS:

This was a single-center study with limited sample size, inevitably having selection bias. Further research with larger sample sizes is needed to study the timing and optimal dose of heparin during TRA for cerebral angiography. The same method of hemostasis was used, and the effect of the hemostasis method on the results was not compared.

Conclusions

In summary, this study is the first to explore the reasons for early RAO occurrence in TRA for cerebral angiography. Due to significant differences in procedural techniques between neurointervention and cardiac intervention, the conclusion regarding radial artery occlusion rates from cardiac intervention may not directly apply to neurointervention. Our preliminary research suggests that the lower the incidence of early RAO after TRA for cerebral angiography may be related to adding heparin to the antispasmodic agents for preventing RAS immediately, reduce radial artery punctures attempts, and the use of 16-cm sheaths.