JACC: CARDIOVASCULAR INTERVENTIONS
22, 2018
ª 2018 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER
EDITORIAL COMMENT
Preventing Acute Radial Artery Occlusion
A Battle on Multiple Fronts*
Jennifer A. Rymer, MD, MBA, Sunil V. Rao, MD
R adial artery occlusion (RAO) is one of the few,
but most common, complications of transra-
dial procedures (1). RAO likely starts with
damage to the radial artery from arterial access, lead-
ing to thrombus formation and intimal-medial thick-
ening similar to the vessel wall injury seen after
balloon dilatation with percutaneous transluminal
coronary angioplasty (2,3). This cascade can be com-
pounded with repeated access attempts. In an anal-
ysis of more than 500 patients undergoing >2
consecutive transradial procedures, the success rate
for using the ipsilateral radial artery for the repeat
procedure was 93% for the second attempt and 81%
for the third, with failures resulting mainly from
chronic RAO, with a 5% risk for failure with each sub-
sequent attempt (R2 ¼ 0.87; p ¼ 0.007) (4). Contem-
porary data estimates are that RAO may complicate
between 1% and 10% of patients undergoing the
transradial approach (3,5). Although the majority of
these occlusions are clinically silent, there are
compelling reasons to prevent RAO. Loss of radial ar-
tery patency limits its use for future access and as a
conduit for bypass grafting. In addition, it can be
symptomatic on rare occasions (6). Anatomically,
the elevated risk for occlusion is likely driven by the
small caliber of the radial artery (the same property
that accounts for the superior safety of radial
compared with femoral access), which is an unmodifi-
able factor; however, other procedural and post-
procedural strategies are important in reducing the
risk for RAO. These include using low-profile cathe-
ters whenever possible to reduce the risk for radial
*Editorials published in JACC: Cardiovascular Interventions reflect the
views of the authors and do not necessarily represent the views of JACC:
Cardiovascular Interventions or the American College of Cardiology.
From the Duke Clinical Research Institute, Durham, North Carolina. Both
authors have reported that they have no relationships relevant to the
contents of this paper to disclose.
ISSN 1936-8798/$36.00
VOL. 11, NO.
artery injury, minimizing radial artery spasm, nonoc-
clusive hemostasis, ulnar compression, and adequate
anticoagulation during the procedure (7). What con-
stitutes “adequate” anticoagulation has been the sub-
ject of some debate and discussion because of the lack
of randomized trial data to guide practice.
SEE PAGE 2241
In this issue of JACC: Cardiovascular Interventions,
Hahalis et al. (8) describe the results of the multi-
center, randomized SPIRIT OF ARTEMIS (Studying
the Priority of Anticoagulation to Prevent Arterial
Occlusion After Forearm Angiographies) study, in
which patients undergoing coronary angiography
were randomized to receive either a high or a standard
heparin dose to determine if anticoagulation intensi-
fication could be used as a strategy to prevent RAO.
Patients treated with high-dose heparin (100 IU/kg)
had significantly lower rates of early RAO compared
with those treated with a standard heparin dose
(50 IU/kg), without any significant increase in risk
for local hematomas or bleeding and without a
significant increase in hemostasis time. Additionally,
the investigators demonstrated an 80% risk reduction
for RAO using a heparin dose >75 IU/kg, compared
with a heparin dose >50 IU/kg, using data from a
pooled analysis.
There were several important limitations of the
study that should be noted. There was significant
variation in the rates of observed RAO at the various
sites (from 0.4% to 10%), which may result from
widely varying practices, including patent hemosta-
sis, ipsilateral ulnar compression, and the use of large
bore sheaths. The investigators comment that the
absence of a shared rigid protocol for post-procedural
hemostasis reflects a more real-world, pragmatic
approach; yet in the setting of a randomized
controlled trial, standardization of these protocols
https://doi.org/10.1016/j.jcin.2018.09.018
2252 Rymer and Rao JACC: CARDIOVASCULAR INTERVENTIONS VOL. 11, NO. 22, 2018

RAO and Patency Strategies NOVEMBER 26, 2018:2251–3

F I G U R E 1 Processes Involved in the Pathophysiology of Radial Artery Occlusion, Strategies Associated With Reducing the Risk for
Radial Artery Occlusion, and 2 Areas Needing Further Research

Specifically, more data are needed to determine whether distal radial access reduces proximal radial artery occlusion (RAO) and to define the
optimal dosing of unfractionated heparin to reduce RAO in patients receiving oral anticoagulant agents.

would serve to better assess the effect of the ran-
domized treatment on the outcome. Additionally,
more than 50% of the patients initially randomized
were later excluded because of crossover or needing
ad hoc percutaneous coronary intervention. Although
these exclusions were relatively well balanced be-
tween the randomization groups, it limits the gener-
alizability of the study to the vast majority of patients
who undergo PCI immediately after
angiography.
The results of the SPIRIT OF ARTEMIS study add to
the body of research on strategies that reduce rates of
RAO and allow repeat use of the ipsilateral radial ar-
tery. It presents compelling evidence to adopt a
strategy of high-dose heparin to reduce the risk for
RAO, but interventional cardiologists should consider
the results in the context of a multifaceted approach to
maintaining radial artery patency (Figure 1). As
mentioned earlier, the Society for Cardiovascular
Angiography and Interventions has provided general
recommendations and best practices to reduce the
incidence of RAO (7). The rates of RAO are significantly
lower when the ratio of the radial artery inner diam-
eter to the sheath outer diameter is >1.0 (RAO rate of
4.0% when this ratio is >1.0 and 13.0% when it is <1.0)
(9). Whether “slender” sheaths or sheathless ap-
proaches can reduce RAO risk remains to be seen
(10,11). Additionally, there is considerable evidence
that patent hemostasis is crucial for reducing rates of
coronary RAO (12,13). Furthermore, the recent PROPHET-II
(Prevention of Radial Artery Occlusion After Trans-
radial Catheterization) randomized trial demonstrated
significant reduction in 30-day rates of RAO with
ipsilateral ulnar compression in addition to patent
hemostasis (14). Moreover, Seto et al. (15) recently
presented data on the use of the Statseal hemostatic
patch (BioLife, Sarasota, Florida) to reduce time to
deflation of the TR band with no significant increase in
RAO or forearm hematomas. Newer approaches such
as distal radial access (i.e., “snuffbox”) may maintain
proximal radial artery patency by avoiding arterial
trauma at the proximal site (16), although larger scale
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 11, NO. 22, 2018 Rymer and Rao 2253
NOVEMBER 26, 2018:2251–3 RAO and Patency Strategies

studies are needed to confirm the long-term safety of
this approach. Additionally,
excluded patients who were on oral anticoagulation;
thus, the data for adequate anticoagulation for pre-
venting RAO in patients taking direct-acting oral
anticoagulant agents or with a therapeutic interna-
tional normalized ratio is unclear and needs to be
studied in a randomized fashion.
Importantly, cardiac catheterization laboratories
using radial access should periodically assess RAO
rates and adopt a preventive strategy to minimize
RAO. As the population of patients undergoing
coronary angiography continues to age and an inva-
the present study sive approach is pursued in an increasingly complex
population, the importance of maintaining radial ar-
tery patency for future transradial angiographic pro-
cedures and potentially for use as bypass graft will be
increasingly critical.
ADDRESS FOR CORRESPONDENCE: Dr. Sunil V. Rao,
The Duke Clinical Research Institute, 508 Fulton
Street (111A), Durham, North Carolina 27705. E-mail:
sunil.rao@duke.edu.

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KEY WORDS quality improvement, transradial
PCI, vascular access