Effects of different puncture approaches on the curative effect and safety of patients with combined cardiovascular and cerebrovascular angiography

doi:10.21203/rs.3.rs-2970092/v1

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Effects of different puncture approaches on the curative effect and safety of patients with combined cardiovascular and cerebrovascular angiography

https://doi.org/10.21203/rs.3.rs-2970092/v1

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published 01 Jan, 2023

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Objective

To compare the curative effect and safety of transradial artery approach and transfemoral artery approach in combined heart-brain angiography.

Methods

120 patients who received combined cardio-cerebral angiography in our hospital were selected and divided into a transradial artery approach group (TRA) and a transfemoral artery approach group (TFA) according to the random number table. The postoperative efficacy and safety of the two groups were compared.

Results

There was no statistically significant difference in puncture time and operation time between the two groups ( P > 0. 05). Postoperative bed rest time, hospitalization time, and X-ray exposure time in the TRA group were shorter than those in the TFA group, and the difference was statistically significant ( P < 0. 05). Before operation and 3 days after operation, there was no significant difference in LVEF between the two groups ( P > 0. 05). The overall incidence of complications in the TFA group was higher than that in the TRA group. The incidence of hematoma and pseudoaneurysm in TFA group was higher, and the difference was statistically significant (P < 0.05).

Conclusions

For simultaneous heart-brain angiography, interventional therapy via radial artery and femoral artery has good curative effect and can improve cardiac function. However, interventional therapy through the radial artery can shorten the postoperative bed rest time and hospitalization time, and reduce the incidence of complications.

simultaneously cerebral coronaryangiography

trans radial access

trans femoral access

atherosclerosis

Simultaneously cerebral coronary angiography (SCCAG) was first reported in 1991 [1], and many studies are currently focusing on this topic [2, 3]. Compared with trans femoral access (TFA) for angiography, trans radial access (TRA) has fewer complications, is easier to compress to stop bleeding, reduces bed rest time, and is more comfortable for patients[4]. Therefore, TRA has been recommended by relevant guidelines [5–7].

With the continuous development and change of the selection of puncture sites, a large number of studies have emerged to compare the advantages and disadvantages of different approaches. The transfemoral approach is easy to operate and has a high success rate, but it is prone to complications such as vagal reflex and pseudoaneurysm, and the lower limb on the puncture side needs to be immobilized after the operation, and the patient will stay in bed for a long time, and may also experience constipation and inconvenient urination., Elderly patients will also cause lower extremity venous thrombosis due to prolonged bed rest, which is unfavorable for the prognosis of patients. After the radial artery intervention, the arterial sheath can be removed immediately without braking, the body position is not high, and the difficulty of hemostasis is relatively low, which can effectively shorten the bed rest time, relieve the pain of the patient, and reduce the occurrence of local complications such as pseudoaneurysm rate [8]. So far, the effect of different puncture points on perioperative complications and length of hospitalization stay (LOS) in SCCAG patients has rarely been reported. The purpose of our study was to compare the efficacy and safety of transradial and transfemoral approaches in combined cardiocerebral angiography.

1. Patient

A total of 120 patients who received combined heart-brain angiography in our hospital were selected and divided into TRA group and TFA group according to the random number table method. Both groups received combined heart-brain angiography. The TRA group was treated via the radial artery, and the TFA group was treated via the femoral artery. Patients signed informed consent for coronary angiography or stent, cerebral angiography and stent. The study was approved by the Medical Ethics Committee.

2. Inclusion and exclusion criteria

Inclusion criteria: patients with intracranial and extracranial vascular stenosis detected by non-invasive imaging methods, and patients with moderate or greater coronary stenosis, who need to undergo both cerebral angiography and coronary angiography at the same time for diagnosis or treatment.Exclusion criteria: a. Select the puncture path according to the following criteria. ①Inclusion criteria for radial artery access: the preoperative modified Allen test was positive and the diameter of the radial artery was > 2 mm by ultrasound evaluation. ② Inclusion criteria of femoral artery route: patients with stenosis or obstructive lesions in peripheral arteries, Raynaud's phenomenon, hand trauma and/or surgery history, known arm anatomical variation, radial artery as a blood vessel for coronary artery bypass grafting or dialysis treatment. bPatients who need second-stage treatment after combined heart-brain angiography, the second-stage treatment includes carotid artery, vertebral artery, subclavian artery stent implantation, coronary artery stent implantation, coronary artery stent surgery, carotid endarterectomy. c Acute myocardial infarction, acute cerebral infarction and other patients requiring emergency surgery. dPatients in cardiogenic shock. ePatients with severe hepatic and renal insufficiency. fPatients with coagulation disorders.

3. Operation

According to the patient's department, if unstable angina is the first symptom, coronary angiography should be performed first. If ischemic stroke is the first symptom, cerebral angiography should be performed first; after local anesthesia at the puncture point, a radial artery puncture needle should be used to puncture through the wall. Puncture the femoral artery with "non-transmural method". After successful puncture, the loach guide wire was sent to guide the corresponding catheter for operation. For whole cerebral angiography via the radial artery route, a 260cm loach guidewire, pigtail catheter and SIM-2 catheter were selected for vessel selection. After the long loach guide wire guides the pigtail catheter into the ascending aortic arch, ascending aortic angiography is performed to clarify the blood vessels on the aortic arch. Then, with the help of the pigtail catheter, a 260cm loach guide wire is introduced into the distal end of the descending aorta, and the loach guide wire is retained After withdrawing the pigtail catheter, the SIM-2 catheter was inserted. Superselective cerebral angiography was performed after the descending aorta was used. Coronary angiography and surgery were performed by the Department of Cardiology, and cerebral angiography was performed by interventional neurologists. Intervention operations were performed by senior attending physicians with intervention qualifications. (Figure1).

4. Indicators

Surgical related indicators: puncture time, operation time, postoperative bed rest time, hospitalization time and X-ray exposure time; cardiac function indicators: left ventricular ejection fraction; complication rate: urinary retention, vagal reflex, vasospasm, hematoma, false aneurysm.

5. Statistical Methods

SPSS 25.0 statistical software was used for analysis. Measurement data were expressed as mean ± standard value, and t-test and rank-sum test were used respectively. Categorical variables were described by frequency (rate), and χ2 test or Fisher's exact probability method was used. A statistically significant difference was considered to be P < 0.05.

1. General Information of the Patient

There were 120 patients, aged 39–81 years, with an average age of 60.31 ± 8.32 years. Among them, 66 were male (55.0%), 59 were smoking (49.2%), 53 were drinking (44.2%), 58 were hypertension (48.3%), 49 were diabetes (40.8%), and 35 were hyperlipidemia (29.2%). %), and 2 cases (1.7%) of peripheral vascular disease. See Table 1.

Table 1

Patient Characteristics
	TRA(n = 60)	TFA(n = 60)	P
Age	58.32 ± 8.37	62.29 ± 9.26	0.132
Male	31(51.7%)	35(58.3%)	0.073
Smoking	28(46.7%)	31(51.7%)	0.062
Alcoholism	25(41.7%)	28(46.7%)	0.093
Diabetes	25(41.7%)	24(40.0%)	0.723
Hypertension	27(45.0%)	31(51.7%)	0.092
Hyperlipidemia	17(28.3%)	18(30.0%)	0.682
PAD	1(1.7%)	1(1.7%)
PAD : peripheral vascular disease;

2. Surgical related indicators

There was no statistically significant difference in puncture time and operation time between the two groups ( P > 0.05); postoperative bed rest time, hospitalization time and X-ray exposure time in the TRA group were shorter than those in the TFA group, and the difference was statistically significant ( P < 0.05). See Table 2.

Table 2

Surgical-related indicators
Group	n	puncture time	operation time	bed rest time	hospitalization time	X-ray exposure time
TRA	60	5.32 ± 1.17	62.21 ± 9.26	12.63 ± 1.13	3.63 ± 1.21	12.63 ± 1.94
TFA	60	5.01 ± 1.26	59.51 ± 10.37	22.16 ± 0.91	5.11 ± 1.01	13.73 ± 2.23
t value		0.848	0.924	14.276	9.223	3.272
P value		0.421	0.043	< 0.01	< 0.01	0.032

Table 3

Indexes of Cardiac Function
Group	n	LEVF (%)
		Preoperative	postoperative
TRA	60	43.42 ± 7.22	49.23 ± 6.83
TFA	60	41.91 ± 6.73	48.96 ± 7.71
t value		0.183	0.228
P value		0.611	0.834

3. Cardiac function indicators

We compared preoperative and postoperative left ventricular ejection fraction in the two groups of patients. Before operation, there was no difference in LVEF between the two groups, and 3 days after operation, there was still no significant difference in LVEF between the two groups ( P > 0.05).

4. Complications

We observed the incidence of postoperative complications in the two groups of patients. It can be seen that the overall incidence of complications in the TFA group was higher than that in the TRA group. The incidence of hematoma and pseudoaneurysm in the TFA group was higher, and the difference was statistically significant (P < 0.05), which was the main contribution to the increase in overall complications. See Table 4 for details.

Table 4

Incidence of Complications
Group	urinary retention	vagal reflex	Vasospasm	hematoma	pseudoaneurysm	total incidence
TRA	2(3.3%)	1(1.7%)	1(1.7%)	1(1.7%)	0(0%)	5(8.3%)
TFA	2(5.0%)	2(3.3%)	2(3.3%)	3(5.0%)	2(3.3%)	11(18.3%)
t value	5.372	1.232	1.232	0.921	0.322	0.121
P value	0.421	0.129	0.129	0.031	0.003	0.014

Atherosclerosis mainly occurs in the large and medium arteries in the body, especially the cerebral arteries and coronary arteries. The two often occur at the same time, and have the common characteristics of thickening, hardening, loss of elasticity and contraction of the arterial wall. Clinically, when coronary artery stenosis and carotid artery stenosis coexist, the current treatment options mainly include: simultaneous treatment and staged treatment. When cerebral arteries are also severely stenotic, whichever procedure is performed first carries high perioperative risks. Therefore, in this case, both lesions should be treated simultaneously. Since the treatment regimens and medication strategies of the two diseases are similar, it is relatively easy to achieve combined treatment. From our research results, no matter whether the patients are treated via radial artery or femoral artery, the LVEF of the two groups can be effectively improved, and there is no difference between the two methods, which shows that the radial artery and femoral artery intervention Both can guarantee the therapeutic effect of patients and improve vascular function. But we found that TRA had a shorter operation time, and patients' bed rest and hospital stay were shorter.

TRA diagnosis and treatment of coronary artery is very mature, but the time of neurointerventional diagnosis and treatment is still short. Cerebral angiography by TRA began to be reported around 2000 [9–10]. Cerebral angiography via the femoral artery is a traditional clinical approach with long application experience, because the internal diameter of the femoral artery is large, it has a high success rate in puncture, and the difficulty of clinical operation is low, so it has been widely used clinically. With the development of clinical application, the problems of this approach are constantly exposed. For example, postoperative immobilization time of patients should be more than 24 hours, and postoperative patients are prone to pseudoaneurysm and large hematoma at the puncture site[11]. Obese patients will increase the difficulty of puncture and hemostasis, and patients are more prone to pseudoaneurysm. Furthermore, the transfemoral approach is not indicated for patients with spinal deformities [12]. In recent years, with the continuous improvement of interventional diagnosis and treatment technology, more and more medical centers have begun to use TRA as an optional path for nerve interventional diagnosis and treatment, and even use TRA as the preferred puncture method [13–14]. Common complications of TRA puncture include radial artery bleeding, hematoma, compartment syndrome, radial artery spasm, and radial artery occlusion. Compared with the complications of TFA, it is lighter and easier to handle.

We believe that the therapeutic effect is related to the proficiency of the operation and the severity of the disease. It has been suggested that the risk of complications is higher when treating both cerebral and coronary artery disease than when treating a single lesion. However, the results of this study showed that postoperative complications did not increase, indicating that combined heart-brain angiography has good safety. The RIVAL study is a multicenter randomized double-blind controlled study that compared the complication rates of TRA and TFA in patients undergoing coronary artery diagnosis and treatment. The study showed that TRA-related complications were lower than those of TFA [15]. In our study, the overall complication rate of TFA was 18.3%, with hematoma and pseudoaneurysm as the main causes. The patient with hematoma at the puncture point improved after hemostasis by recompression, bandaging and bed rest, without special treatment. The complication rate of TRA group was 8.3%, which was significantly better than that of TFA. In 2021, the results of a Chinese study were consistent with ours, showing that the total complications of vascular puncture in SCCAG patients in the TRA group were less than those in the TFA group [2].

The length of stay is an important indicator for evaluating the utilization efficiency of medical centers, and many studies have focused on the influencing factors of LOS [16–17]. Previous studies have shown that TFA patients need to stay in bed after surgery, while TRA patients have good hemostatic effect and do not need to stay in bed, which will inevitably lead to a significant reduction in LOS, and even meet the requirement of being discharged on the same day [18]. This study also suggested that, in terms of SCCAG patients, LOS was less in the TRA group. This not only helps to increase the comfort of patients, but also can effectively save medical resources under the premise of the current shortage of medical resources, and create a more convenient medical environment for more patients with urgent needs at the same time.

There are some limitations in this study. First, this study is a single-center study, which only reflects the initial experience of using TRA to perform SCCAG in this center. Second, the amount of data included is small. In the next step, we will continue to include data on the basis of this study for further discussion. In conclusion, according to the data of this study, TRA puncture for SCCAG is clinically feasible, relatively safe, and can reduce the hospitalization time of patients.

Ethical Approval

Patients signed informed consent for coronary angiography or stent, cerebral angiography and stent. The study was approved by the Medical Ethics Committee of Peking University International Hospital.

Competing interests

None

Authors' contributions

Yuan-Li Zhao, Wen-Chao Zhang contributed to the conception of the study.Chang-Yu Lu and KL performed and visualized the experiment in silico. Yang Zhao contributed significantly to analysis and manuscript preparation. Hui Xi ，Yang Wang performed the data analyses and wrote the manuscript. All authors contributed to the article and approved the submitted version.

Funding

None

Availability of data and materials

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.

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No competing interests reported.

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Journal Publication

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Effects of different puncture approaches on the curative effect and safety of patients with combined cardiovascular and cerebrovascular angiography

Status:

Journal Publication

Version 1

Abstract

Figures

1. Introduction

2. Materials and Methods

1. Patient

2. Inclusion and exclusion criteria

3. Operation

4. Indicators

5. Statistical Methods

3. Results

1. General Information of the Patient

2. Surgical related indicators

3. Cardiac function indicators

4. Complications

4. Discussion

5. Conclusions

Declarations

References

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1