ABC | Volume 113, Nº5, November 2019

Original Article Costa-Mateu et al. Catheterization with one-catheter strategy Arq Bras Cardiol. 2019; 113(5):960-968 Procedural issues Only patients referred for diagnostic coronary angiography by right radial access were recruited, because TIG I catheters are not designed to perform coronary angiography by left radial access or femoral access. 6,9 Patients were assigned to two-catheter or one-catheter strategy at the discretion of the interventional cardiologist. Palpable right radial artery, as well non-pathological Allen’s test, were mandatory to perform right radial access. In order to minimize arterial spasm, sublingual diazepam (10 mg) was given 30 minutes before the administration of local anesthesia subcutaneously. Using the Seldinger technique, a 5 or 6 Fr hydrophilic radial Glidesheath was implanted (RADIFOCUS® INTRODUCER II; Terumo Europe N.V., Leuven, Belgium). Then, an intra-arterial bolus with 2 mg of verapamil and 50 IU/Kg of unfractionated heparin was administered. The radial glide sheath was removed immediately after the diagnostic procedure, and hemostasis was obtained by 4-hour compression with conventional compressive dressings. 12 Standard J-curve 0.035 guide wire (Radifocus M; Terumo Europe N.V., Leuven, Belgium) was used for the insertion and exchange of catheters. In order to obtain optimal quality images by coronary angiography, minimum of 5 views for the left coronary artery and minimum of 3 views for the right coronary arterywere taken. The contrast volumeusedwas 7mL at 3mL/sec for the left coronary artery and 4 mL at 2 mL/sec for the right coronary artery. However, the amount of contrast in each injection and the final number of views for correct assessment of the coronary tree was at the operator’s discretion. Low-osmolar iodinated contrastmedia [Xenetix 350 (Iobitridol; Guerbert Group, Villepinte, France)] in combinationwith robotic contrast injector ACIST CVi® (ACIST Medical Systems, Eden Prairie, MN, USA) was used to make contrast administration uniform. The images were acquired as follows: low-quality fluoroscopy at 7.5 images/sec for coronary cannulation and cinefluoroscopy at 15 images/sec for coronary views. Data related to baseline clinical characteristics, indication for coronary angiography and angiographic characteristics (number of coronary vessels with stenosis >50%), volume of iodinated contrast, radial spasm, access crossover, need for supplemental catheters, procedural duration, direct economic costs and information regarding exposure to ionizing radiations were collected. In the case of failure to engage the coronary artery ostium, crossover to alternative strategy was performed. All data generated were collected prospectively and entered into a specific computerized database. Statistical analysis SPSS Statistics 24.0 software package (SPSS Inc., Chicago, IL, USA) was used for data analysis. All p values ​were evaluated in two tails, with p values < 0.05 considered statistically significant. Categorical variables were expressed as count (percentage) and were compared using the chi-square test. Continuous variables were explored for normal distribution using the Kolmogorov-Smirnov test. Normally distributed variables were expressed as mean (1 standard deviation) and non-normally distributed variables were expressed as median (interquartile range) and were compared using unpaired Student’s t-test or U Mann-Whitney tests as appropriate. Results A total of 1,953 diagnostic coronary procedures, in 1,829 patients, was collected between January 2013 and June 2017. Two-hundred fifty-two procedures (12.9%) were performed by one-catheter strategy and 1,701 procedures (87.1%) by two-catheter strategy. The study flowchart is shown in Figure 2. Baseline clinical characteristics Baseline clinical characteristics are shown inTable1. Therewere no differences between the two comparison groups Procedural indications and angiographic characteristics Data regarding angiographic indications and characteristics are shown in Table 2. No differences were detected between comparison groups in clinical presentation, diseased vessels and coronary artery disease extension. Endpoints Table 3 shows the comparative data regarding endpoints. The one-catheter strategy group received less amount of iodinated contrast than the two-catheter strategy group [77 (60–105) mL vs. 92 (64–120) mL; p < 0.001]. Also, the one-catheter strategy group presented less radial spasm (6.0% vs. 8.9%, p < 0.001) and shorter coronary procedures [Fluoroscopy time: 3.9 (2.2-8.0) min vs. 4.8 (2.9-8.3) min, p = 0.001] than the two-catheter strategy group. No differences between one-catheter and two-catheter strategies were observed in access crossover (3.6% vs. 4.9%, p = 0.360) and need for supplemental catheters to complete coronary angiography (15.9% vs. 12.5%, p=0.132). Also, there were no differences in exposure to ionizing radiations, evaluated as DAP [3488 (2556–5369) mGy.m2 vs. 3711 (2393-5762) mGy.m2; p = 0.831] and air kerma [582 (407–917) mGy vs. 641 (424–974) mGy; p=0.165]. Regarding economic analysis, the one-catheter strategy reduced direct costs attributable to coronary procedures [149 (140–160) € /procedure vs. 171 (160–183) € /procedure; p < 0.001] in comparison with the conventional strategy. Discussion The main findings of our investigation were that one‑catheter strategy, with TIG catheters, is associated with reduction in radial spasm, iodinated contrast consumption, duration of the coronary procedure and economic costs in coronary angiography. Radial spasm is a relatively common complication during transradial coronary catheterization, and its incidence is variable, ranging from 5% to 30%. 12-16 This complication reduces patient comfort and procedural success, 1-13 and when it involves the need for crossover to transfemoral access it is related with an increase in vascular complications. 17 Although the overall rate of radial spasm in our investigation (9.0%) was in the lower range of studies that have evaluated this item in coronary procedures, one-catheter strategy allowed reducing the incidence of radial spasm (one-catheter strategy: 5.2% vs. two-catheter strategy: 9.3%, p = 0.022). 962