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Editor,—We were interested in Mann's editorial on radial coronary angiography and stenting, but disagree with one aspect.1 Mann states that “the discomfort of catheter removal is less than for the femoral approach”. This is the opposite of our own and others' experience using the same equipment.2 3 He adds that “the morbidity of the procedure is less, and patients prefer the radial approach”. In support of this claim, he quotes Kiemeneij's ACCESS study,4 (which merely alludes to unpublished data on procedural comfort) and Cooper et al who used mechanical compression for femoral haemostasis.5He fails, however, to draw attention to similar studies which have shown the opposite—that in addition to being a more technically challenging procedure (with lower success rate and longer procedure duration), the radial approach is more painful.3 6
In addition to this, the limitations of the radial approach are not adequately discussed. Access failure, radial artery spasm, hypotension or bradycardia are seen in up to 20% of cases, and may be serious.2 We believe (certainly for coronary angiography) that the radial approach should be reserved for patients in whom the femoral approach is relatively contraindicated.
This letter was shown to the author, who replies as follows:
The use of verapamil to prevent radial artery spasm has been one of the most important advances in the development of the transradial technique. Earlier studies, including those cited by Dr Hildick-Smith et al, used only nitrates, or sublingual nifedipine, or both to prevent such spasm, and verapamil is a substantially more effective agent.1-1 The intra-arterial administration of 3–5 mg has an immediate onset of action without systemic side effects and should be given before sheath advancement.
The radial artery is extremely sensitive to circulating catecholamines.1-2 Thus, spasm may be provoked or accentuated by anxiety and pain in addition to mechanical manipulation. In this regard, the importance of adequate sedation and analgesia cannot be overemphasised. Other tips regarding management of radial artery spasm can be found on Dr Kiemeneij's website (www.radialforce.org).
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