| BackgroundCoronary angiography has been regarded as the gold standard for the diagnosis of coronary atherosclerotic heart disease.Since Campeau introduced transradial coronary angiography and technology in 1989 and Kiemeneij introduced transradial coronary intervention technology in 1993,the radial artery approach has gradually been considered as the main approach of cardiac catheterization technology and coronary intervention technology.A large number of clinical studies have shown that transradial coronary angiography is superior to transfemoral coronary angiography.The main manifestations are as following:fewer complications,better surgical tolerance,shorter hospitalization time,and lower hospitalization costs.Therefore,transradial coronary angiography is more popular among cardiologists and patients.However,the transradial approach still has adverse complications.The most important of which is radial artery occlusion.Radial artery occlusion is mostly asymptomatic and difficult to detect because the palm receives double blood supply.However,once the radial artery is occluded,it will limit the future re-operation of transradial coronary angiography and the formation of catheter fistula in patients undergoing coronary artery bypass grafting and hemodialysis.Therefore,it is important to identify and avoid the risk factors of radial artery occlusion,increase the beneficial factors and prevent or suppress the occurrence of radial artery occlusion.There are two main pathogenesis of radial artery occlusion after transradial coronary angiography:thrombosis and intimal hyperplasia.The endothelium of artery was damaged because of coronary angiography technology.The endothelial smooth muscle cells of the radial artery were dysfunctional and the blood flow-mediated vasodilation function was reduced resulted from coronary angiography technology.Endometrial injury may play a major role in thrombosis and intimal hyperplasia.Radial artery CT scan,intravascular ultrasound and studies of radial artery tissue and function showed that the structure and function of radial artery changed significantly after radial artery intubation.If the sheath diameter of the radial artery exceeds the inner diameter of the radial artery,the endothelium of the radial artery may be severely damaged.This endothelial damage reduces blood flow-mediated vasodilation and is also a key factor in endothelial proliferation and radial artery occlusion.At present,there are many studies on ischemic preconditioning.The earliest protective effect of remote ischemic preconditioning was on the heart,and studies about the protective effect of ischemic preconditioning had referred to liver,lung,brain,kidney and other tissues and organs.Subsequently,there are more and more studies on the protection mechanism of ischemic preconditioning.Although it is still not fully clear,it mainly includes nerve-body fluid conduction,including anti-inflammatory,anti-platelet aggregation,protection of vascular endothelial function and so on.Therefore,we assumed that ischemic preconditioning has a protective effect on the artery,which is closest to the site of the protocol.We observe the effect of ischemic preconditioning on radial artery occlusion after percutaneous coronary angiography,at the same time,to study the risk factors of radial artery occlusion.Objective:To study the effect of ischemic preconditioning on radial artery occlusion.To identify the risk and protective factors,and independent predictors of radial artery occlusion.Methods:We selected patients diagnosed acute coronary syndrome in our hospital who would accept transradial selective coronary angiography for the first time from September 2017 to April 2018.According to the previous research results and our own experimental data,we carried out the pre experiment and determined that the sample size of the single group of this experiment was 290.We enrolled 755 consecutive patients who would undergo selective coronary angiography and interventional therapy.Finally,322 patients had received the protocol of ischemic preconditioning(IC)before coronary angiography and 318 patients were enrolled in the group without the protocol of ischemic preconditioning(non-IC).At the same time,115 patients were excluded from the group because they were not in inclusion criteria but in exclusion criteria.The patients who were rolled in the study were randomly divided into ischemic preconditioning group and non-ischemic preconditioning group according to the odd or even number of their hospitalization numbers.All the rolled patients were signed the informed consent for transradial coronary angiography and consent for the clinical research.Radial artery diameter was measured before operation in all patients.According to the order of operation,the patients in the protocol of ischemic preconditioning group were given the protocol of remote ischemic preconditioning before the operation.The cuff of mercury sphygmomanometer was tied to the right upper arm.The cuff was pressurized up to 200mmHg for about 5minutes,then released for about 5 minutes.The total process was four cycles.Transradial coronary angiography:double antiplatelets therapy(aspirin 300mg,clopidogrel 600mg or tegrilol 180mg)were given to patients before the operation.According to the order of operation,the patients were sent to the catheter room for coronary artery interventional therapy.The right radial artery was selected as the first access for percutaneous coronary intervention.The radial artery puncture point was 2-3cm away from the styloid process of radius.The strongest pulsation point was selected.2%lidocaine was used to make local anesthesia and 20G puncture needle was used to puncture radial artery by Seldinger technique.After puncture,the blood was returned.Guide wire was inserted along the puncture needle.Artery sheath tube was inserted along the guide wire.According to the patient' s condition and kilogram weight,heparin was given through the lateral foramen of sheath tube during the surgeon in terms of 100iU/kg and at least 3000IU.6F-guided catheter was used in the operation.The sheath of radial artery was removed immediately after operation,and the puncture site of radial artery was compressed with a compressor to prevent bleeding.5.The standard compression tourniquet was used to prevent bleeding after operation.The standard was to touch the radial artery pulsation.The compression tourniquet was decompressed once every 2 hours or so until it was completely decompressed.6.The patency of radial artery was checked by B-mode ultrasonography at the next day after operation.7.Record the time between the end time of the protocol of ischemia preconditioning and coronary angiography;Record the diameter of radial artery before the protocol;Record the medication during perioperative period,and patients' age,sexes,historical diseases,blood lipids and other factors.8.Follow up9.Statistical analyzes were performed using SPSS 23.0(SPSS Inc,IL,USA).Continuous variables were expressed as mean±standard deviation,whereas categorical variables were expressed as numbers(percentages).A multiple logistic regression analysis was performed to identify the influencing factors for RAO.Continuous variables were compared using T test(Independent sample T test and Paired Samples Test).Differences between categorical variables were examined using the Chi-square or Fisher's exact test.A Pvalue<0.05 was considered statistically significant.Results:1.Patients were divided into two groups according to the protocol of IC:IC and non-IC.The rate of RAO was significantly lower in the IC than in the non-IC group(RIC 0.93%vs non-RIC 4.4%,P=0.006<0.05)after TRA 24h.2.Patients were divided into two groups according to the patency of radial artery:radial artery patency(non-RAO)and RAO after TRA 24h.The radial artery diameter was significantly narrower in the RAO group(2.31±0.53)than in the non-RAO group(2.59±0.47).The rate of applying ?-blocker was significantly higher in the non-RAO group(69%)than in the RAO group(41%).The rate of applying trimetazidine was significantly higher in the non-RAO group(49.1%)than in the RAO group(17.6%).3.Multiple logistic regression analysis:The multiple logistic regression analysis using radial artery diameter,IC,?-blocker,and trimetazidine treatments revealed that small radial artery diameter,lack of ?-blockers,and IC were independent predictors of RAO after TRA 24h.4.When we followed up patients after TRA at about the 650day,radial artery diameters were significant smaller in both IC group and Non-IC group(P=0.024 in IC group,P=0.047 in Non-ICgroup).When we followed up at about 890day,radial artery diameters were not significant varies.ConclusionIC might help improving the rate of RAO.The multiple logistic regression analysis showed that small radial artery diameter was independent predictors ofRAO after TRA 24h,and ?-blockers and IC were protective factors of RAO.Radial artery diameter might be smaller in the future after TRA and might stop smaller in some day.BackgroundTransradial coronary intervention has been accepted by majority of surgeons and patients because of its more advantages and less postoperative complications,less hospitalization time,lower hospitalization expenses,and postoperative comfort increased.However,transradial coronary intervention can cause radial artery injury,mainly involving the following four aspects:First.The relationship between radial artery diameter and sheath size,which plays an important role in the acute injury of radial artery.Second.Radial artery intimal tear caused by radial artery puncture;Third.Stretching effect of sheath tube and passage of sheath tube itself;Forth.Radial artery spasm during insertion and withdrawal of radial artery.The injury of radial artery during operation may cause corresponding complications,such as hemorrhage at puncture site,ischemia,hematoma,pseudoaneurysm,arteriovenous fistula,etc,among which radial artery occlusion is the most important.The main causes of radial artery occlusion are thrombosis in situ and intima-media hyperplasia after radial artery injury.Limb ischemic preconditioning is the distal ischemic preconditioning mentioned in most literatures.Its implementation process is to block the arterial blood flow of the limbs by inflating the blood pressure cuff for several minutes,and then to make the blood flow of the limbs recanalize for several minutes by deflating the blood pressure cuff,and repeat several cycles.The process of its action makes neuroendocrine activation,promotes the body to release protective factors,and finally improves the vascular endothelial function,anti-inflammatory,antiplatelet aggregation,anti-oxidation stress,and even anti-apoptosis effects,so as to play its role in protecting ischemia-reperfusion tissues and organs.Our clinical observation found that limb ischemic preconditioning may help to reduce the rate of radial.However,the mechanism is unclear.ObjectiveThe test aimed to investigate the possible mechanism of limb ischemic preconditioning in reducing radial artery occlusion after percutaneous coronary intervention.We established model of rabbits femoral artery injury by imitating the process of coronary intervention,and studied the effects of ischemic preconditioning on the injured artery and some indexs in rabbits Plasma.MethodsTwenty four New Zealand white rabbits were divided into four groups:normal control group(control group):without ischemic preconditioning and femoral artery puncture,5ml blood was collected on the first day and 5ml on the second day,and then the right femoral artery was dissected.Limb ischemic preconditioning group(RIC):ischemic preconditioning was performed on the right lower limb of rabbits,and without femoral artery puncture.The right femoral artery of rabbits was dissected on the second day.5ml blood was collected respectively before ischemia preconditioning and before dissection;Femoral artery puncture group(P):the right femoral artery was punctured and sheathed.Right femoral artery was dissected on the second day,and 5ml blood was respectively collected before femoral artery puncture and dissected;Ischemic preconditioning+femoral artery puncture group(RICP):Ischemic preconditioning was conducted on rabbits right lower limb,and after that the right femoral artery was punctured and sheathed on first day.The femoral artery punctured was dissected on the second day.5ml blood was collected before ischemic preconditioning and before femoral artery dissected.Blood samples were centrifuged and packed separately.Plasma levels of von Willebrand factor(VWF),E-select in,P-selectin,tissue type plasminogen activator(tPA),plasminogen activator inhibitor(PAI-1),tumor necrosis factor-A(TNF-a),interleukin-6(IL-6),interleukin-10(IL-10),nitric oxide(no),endothelin-1(ET-1)were detected before rabbits femoral artery punctured and dissected.We observed the pathological changes of injured vessels and tested the expression of PI3K/Akt/eNOS pathway protein on the vascular endothelial cell.Results:1.Comparison of the right femoral artery diameter and basic plasma parameters in each groupOne way ANOVA was used to compare the diameter of the right femoral artery among the four groups before femoral artery punched.There was no significant difference among the four groups(P>0.05).There was no significant difference in the basic levels of vWF,P-selection,E-selectin,tPA,PAI-1,NO,ET-1,TNF-?,IL-6 a.nd IL-10 among the groups.2.Comparison of plasma indexes before and after femoral artery punched.There was no significant difference in plasma vWF,P-selectin,ET-1,tPA,PAI-1,IL-6,IL-10 and TNF-? between Control and RIC groups,but the plasma NO level was significantly increased in RIC group.Plasma vWF,P?selectin,E-select in,PAI-1,IL-10 and ET-1 levels were significantly increased in P group and RICP group.The increasing degree of vWF and PAI-1 were no significant difference between the two group.The increasing degree of P-selectin and ET-1 in RICP group were significantly lower than those in P group.The plasma levels of IL-6 and TNF-? in the P group were significantly higher than those before operation.The plasma levels of IL-6 and TNF-? in the RICP group were no significant difference compared with those before operation.and the increased values of the two indexes in RICP group were significantly lower than those in P group.The level of plasma tPA was significantly decreased in the P group and RICP group.The decreasing degree level was no significant difference between the two groups.plasma NO level was significantly decreased in P group after operation.It was no significant difference in RICP group after operation compared before operation.And the degree of decreased NO was significantly lower in RICP group than that in P group.3.Pathological results1)HE stainingIn Control group and RIC group,HE staining showed that intima of rabbit femoral artery was intact,the elastic membrane was continuous,and endothelial cells were clearly visible;In P group and RICP group,endothelial cells were partially lost,the continuity of intima was interrupted,the elastic membrane rupture was obvious,and some of the medial membrane degeneration existed.2)The expression of PI3K,Akt and eNOS in vascular endotheliumCompared with Control group,the express ion of P13K,Akt and eNOS in RIC group was significantly higher;the expression of P13K,Akt and eNOS in RICP group was significantly higher than that in P group.ConclusionLimb ischemic preconditioning has function of anti-inflammatory,improving endothelial function and regulating the release of adhesion molecules,which may be the mechanism that limb ischemic preconditioning affected radial artery occlusion rate.Ischemic preconditioning may regulate the release of NO from vascular endothelium through PI3K/Akt/eNOS protein pathway. |
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