CASE20210817_002

Dealing with Multiple Radial Artery Spasms

By Alvin Tonang, Sodiqur Rifqi
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Presenter

Alvin Tonang

Authors

Alvin Tonang1, Sodiqur Rifqi1

Affiliation

Dr. Kariadi General Hospital Medical Center, Indonesia1
Vascular Access (transradial) - Vascular Access

Dealing with Multiple Radial Artery Spasms

Alvin Tonang1, Sodiqur Rifqi1

Dr. Kariadi General Hospital Medical Center, Indonesia1

Clinical Information

Patient initials or Identifier Number

S

Relevant Clinical History and Physical Exam

We presented a 65 years old male with stable angina pectoris CCS II andhypertension referred to our hospital. He had a history of NSTE-ACS about 2months ago. Physical examination was unremarkable, except for high bloodpressure, 160/100 mmHg. Resting ECG showed sinus rhythm, with heart rate 65 bpmwithout ST-T changes. Echocardiography showed good LV function with ejectionfraction of 62% and anterior regional wall motion abnormality

Relevant Test Results Prior to Catheterization

Relevant Catheterization Findings

Interventional Management

Procedural Step

We did angiography using rightradial approach, with 6 F sheath. Cocktail consists of heparin andnitroglycerin was used after insertion of the sheath. Angiography was doneusing 5 F Tiger catheter. RCA and LCX was normal, and we could see significant stenosis in the mid LAD with TIMI II flow (Vid 1-3). We did PCI using EBU 3,5 / 6 F guidecatheter. Successfully wiring the LAD using Runthrough Floppy wire, andpredilated using semi-compliant balloon Sapphire II 2,5 x 10 mmuntil 10 atm. We stented using DES Promus P 3,5 x 24 mm until14 atm (Vid 4-6). Final result showed no residual stenosis with TIMI IIIflow (Vid 7-8). The PCI was uneventful, thus we removed the guiding catheterusing 0,038 inch J-wire. After it was removed, suddenly patientfelt severe pain in his right arm. We could not remove the sheath in his rightarm. Contrast injection through radial sheath showed spasm in the radial artery(Vid 9). We gave 200 mcg nitroglycerin intraarterial through radial sheath,but the sheath still entrapped (Vid 10). Then, we tried to give200 mcg diltiazem through radial sheath. After couple of minutes we couldpartially removed the sheath before another restrain felt, then anothercontrast injection showed there were multiple spasms in radial artery (Vid 11). We gave another 200 mcg diltiazemthrough radial sheath, and another contrast injection we saw relieved some ofthe spasms (Vid 12-Image). After another couple of minutes, we finally could removed the sheath (Vid 13-14).

Case Summary

Radial artery spasm(RAS), defined as the temporary, sudden narrowing of the radial artery , is one of the mostfrequent trans-radial access (TRA) challenges. Intra arterial spasmolytic therapy commonly used to relieve RAS wasnitroglycerin and verapamil. Since verapamil was not available, we useddiltiazem and showed it has a potent vasodilatory effect to relieve multipleRAS. We also showed, that not only gentle rotation or manipulation, but removalof the catheter could also triggered RAS. Carefully remove and ensure yourJ-wire inside the catheter position coupled with gentle traction should alwaysbe done in TRA.