Feasibility and Safety of a 5 French Transradial Coronary Angiography with a 90 Minute Hospital Discharge
Shazmeen Shahed1*, Kevin S. Levitt1,2, Anup K. Gupta1, and Mohammad I. Zia1,3
1Michael Garron Hospital, University of Toronto, Canada
2Women’s College Hospital, University of Toronto, Canada
3Sunnybrook Health Sciences Centre, University of Toronto, Canada
Shazmeen Shahed, Michael Garron
Hospital, University of Toronto, Canada. Tel: 1-647-550-7060; Email: firstname.lastname@example.org
Submitted: 29 May, 2019; Accepted: 19 June, 2019; Published: 21 June, 2019
Cite this article:
Shahed S, Levitt KS, Gupta AK, Zia MI (2019) Feasibility and
Safety of a 5 French Transradial Coronary Angiography with a 90 Minute Hospital Discharge. JSM Clin Med 5 1: 4.
Background: Transradial coronary angiographies (TRA) across Canada are performed using varying radial sheath sizes. Some
studies have demonstrated lower complication rates with TRA using 5 French sheaths. Using 5 French sheaths along with optimal
discharge times can result in improved access to this potentially life-saving procedure.
Objective: To retrospectively analyze the feasibility of using 5 French sheath and discharging patients within 90-minutesof a coronary
Methods: Patients undergoing TRA with a 5 French sheath were retrospectively analyzed. Radial artery patency was assessed by
Allen’s test pre-operatively. Patient demographics, risk factors, anti-platelet drugs, heparin, angiogram quality, time to clamp release and
discharge were recorded. Patients were contacted after 24-hours to learn about potential complications after discharge.
Results: Four hundred patients were retrospectively analyzed and the mean age of the sample was 64 ± 10.6 years, of which 65%
were males. Thirty-two percent were smokers, 58% were dyslipidemic, 33% were diabetic, 63% were hypertensive. Fifty-eight percent of
patients were on Aspirin and 6% were on dual anti-platelet therapy. Average heparin dose was 58 ± 9 units/kg. Angiographic quality was
diagnostic in 100% of cases. Median time from sheath pull to clamp release was 80 minutes (interquartile range (IQR) 75 to 85) and from
sheath pull to discharge was 90 minutes (IQR 85 to 95). Complication rate due to post-clamp removal bleeding was 1%.
Conclusion: Based on the study, using a 5 French catheter and optimizing post-procedure discharge time to 90-minutes, results in
improved workflow in the catheterization laboratory and enhances patient satisfaction without compromising patient safety or angiographic quality.
Keywords: Coronary angiography; TRA procedures
Transradial coronary angiographies (TRA) across Canada
are performed using varying radial sheath sizes due to lack
of standardization. Performing this procedure using 5 French
sheaths and optimizing discharge times can result in improved
work flow in cardiac catheterization laboratories. This could
potentially improve access to this lifesaving procedure. We aim
to share our center’s experience of using a 5 Fr catheter with a
Coronary angiography (CA) is the precursor to treating
coronary artery disease (CAD) and is a widely used gold standard
diagnostic procedure. Studies that have been done to reduce
the invasiveness of CA indicate that TRA decreases hemorrhagic
complications while enabling early ambulation [1-4].
Some studies have indicated that while performing
transradial procedures, decreasing the caliber of the catheter
results in fewer complications. Rates of arterial occlusion and
intraprocedural patient discomfort were also found to decrease
[5-9]. While this should also be theoretically applicable to TRA,
the same has not been systematically studied.
Worldwide, TRA procedures are performed using different
sheath sizes with varying post-procedure discharge times.
Performing the procedure using 5 French sheaths, combined
with optimal discharge times can potentially increase patient
turnover in cardiac catheterization laboratories and result in
better access to this life-saving procedure. With this study, we
aim to share our center’s experience of using a 5 French sheath
with a 90-minute discharge time for coronary angiographies.
Research design and setting
This retrospective feasibility study was conducted at Michael
Garron Hospital (MGH), Toronto, Ontario which has one of the 19 catheterization laboratories of Ontario. MGH is a diagnostic
only site and an average of 1450 angiographies are performed annually.
From April 2017 to June 2018,700 patients who underwent
coronary angiographies at MGH were sampled. Patients were
not excluded on the basis of clinical presentation, gender, race,
weight or height. Written consent was obtained from all patients
for the procedure, and the study was approved by the Ethics
Review Board of Michael Garron Hospital.
Inclusion Criteria and Exclusion Criteria
The study included patients presenting with stable angina,
unstable angina, atypical angina pain or angina after Coronary
Artery Bypass Graft (CABG) or Percutaneous Coronary
Intervention (PCI) requiring elective angiography. To accurately
assess the applicability of a 90-minute discharge time, the study
excluded in-patients and patients who were admitted postprocedure
requiring immediate CABG or PCI. Patients requiring
conversion from radial to femoral access were also excluded from
the sample. Patients were excluded if their Right Radial Allan’s
test was positive or if the LIMA graft needed to be cannulated.
After applying the inclusion and exclusion criteria, a total of 400
patients were retrospectively analyzed.
Instrumentation and Angiographic Technique
All angiographies were performed using standard procedures
by an experienced physician. Allen test was performed preprocedure
to determine the patency of radial artery. As per
standard protocol, lidocaine was administered as a local
anesthetic and an introducer needle was used to gain access to
radial artery. Vasodilation was done using Nitroglycerine (100-
250mcg). A 5 Frenchhydrophilic coated radifocus introducer
sheath by Terumo that provides pathway to a 5 FrenchJR-4
catheter by Infiniti and 5 French FL-3.5 by Impulse was used
to obtain standard angiographic views. Heparin (4000-5000
units) was administered intravenously to prevent radial artery
Once the introducer sheath was retracted, the radial clamp was
placed for hemostasis while ensuring patency of the radial artery.
The clamp was disengaged after a median time of 80 minutes
and radial artery patency was checked. Further to occurrence of
hemostasis from the catheterization site, patients were allowed
to ambulate under supervision. Subsequent to ambulation, at a
median time of 90 minutes from sheath retraction, patients were
discharged with an accompaniment. After disengagement of the
clamp at 80 minutes, on non-occurrence of hemostasis, patients
were clamped for an additional 60 minutes and discharged only if
no further complications were observed. Discharge instructions
included, a return to emergency in case of chest pain, bleeding at
the site of catheterization or persistent numbness of hand. As per
standard of care at the institution, a follow-up call was arranged
within 24 hours to answer the following questions:
1. Was there bleeding from the catheterization site?
2. Has the swelling of the hand increased abnormally?
3. Was there increased numbness or tingling sensation of the hand?
Statistical analysis and endpoints
The following parameters were recorded: patient age, gender,
risk factors, antiplatelet therapy, angiogram quality, heparin
dosage administered, time to clamp release, time to discharge,
radial patency at discharge and bleeding complications.
Quantitative variables were presented as arithmetic mean ±
standard deviation and qualitative variables were presented as
percentages. For skewed variables, median and inter-quartile
range was reported.
Data pertaining to the following endpoints was recorded and analyzed:
1. Time to clamp removal post TRA
2. Time to discharge post TRA
3. Bleeding post procedure
4. Bleeding at 24 hours
Four hundred patients were retrospectively analyzed for
the study. The mean age of the study sample was 64 ± 10.6
years, of which 65% were males. (Table 1) represents the
demographics of the sample. (Table 1) demonstrates risk factors
of the sample. Based on analyzed data, 32% of patients were
smokers, 58% were dyslipidemic, 33% were diabetic and 63%
were hypertensive. Medical records indicate that 36% of patients
were not on any anti-platelet therapy, 58% were on aspirin
and6% on dual anti-platelet therapy and as shown in (Table 1). Of the 6% on dual therapy, 3% were on aspirin and plavix, and
the remaining 3% on aspirin and ticagrelor. Patients that were
on Vitamin K antagonists or NOACS were not bridged. Vitamin K
antagonists were held for 5 days prior and NOACS were held for
2 days prior. Routine INR check was not performed on the day of
the procedure as per our protocol.
Mean heparin dose administered to patients after sheath
removal was 58 ± 9 units/kg. Angiographic quality observed
during the procedure was diagnostic in 100% of cases. The
median time to clamp release was 80 minutes (IQR 75-85
minutes) and to discharge was 90 minutes (IQR 85-95 minutes)
as demonstrated in (Figure 1). There was no hematoma formation
at catheterization site on clamp removal. Complication rate of
the procedure was 1% as bleeding at catheterization site was
observed in 4 patients after the scheduled clamp removal of 80
minutes. In this case, the patients were clamped for an added 60
minutes as per standard of care at our institution and thereafter
discharged with an accompaniment.
Figure 2 demonstrates the minimum, maximum and average
time from sheath pull to clamp release and discharge along
with the clinical characteristic pertaining to each. The recorded
minimum time to clamp release was 60 minutes and time to
discharge was 75 minutes after sheath pull. The maximum time
taken to release the clamp was 165 minutes and the patient was
discharged at 180 minutes. The delay was due to non-hemostasis
at scheduled clamp removal and patient was clamped further for
85 minutes until hemostasis.
Patients were contacted within 24 hours of discharge to
collect data on complications. They responded in the negative
to post-discharge bleeding at the catheterization site and to
increased swelling or tingling of the hand. As per standard of care, the cardiologist is informed if patients have an emergency room
visit in relation to the procedure. Patients were also educated to
call the clinic if any complications arise. However, there were no
reported visits by the patients to the emergency room or calls to
the clinic regarding complications.
The results of this study indicate that a 5 French catheter
for coronary angiography along with 90-minute post-procedure
discharge time is a feasible methodology as the resulting
complication rate is only 1%.
Based on the sample population, mean age of patients is 64
± 10.6 years. Senior population of Canada was 14% in 2009 and
is projected to increase to 25% by 203 . This will result in
an increased demand for angiographies which can be addressed
by either increasing the number of cardiac catheterization
laboratories across the country or increasing the efficiency of the
procedure. The former poses a significant logistical challenge.
Hence, it is imperative to identify bottlenecks in the diagnostic
process to address the current and future needs of cardiac care.
During this study, we identified the long compression time
of the radial artery post-angiography as one of the bottlenecks.
To address this, we used a 5 French catheter and clamped the
patient for 80 minutes. The patient was discharged at 90 minutes
post-angiography. These results in reduced use of logistical
resources reduced workload and increased patient turnover.
The complication rate with this catheter size and discharge
time combination is only 1%.As a smaller caliber sheath
requires lesser clamp time to achieve hemostasis and prolonged
compression time correlates to increased chances of radial artery
occlusion , it is advisable to use the smallest caliber sheath
necessary for catheterization. This also minimizes trauma to the
inner lumen of the artery during sheath insertion and removal.
The use of 5-French catheter optimizes overall procedure
time, leading to improved patient satisfaction. It also has the
benefit of reducing wait times for the procedure and potentially
has significant prognostic implications. Typically, patients
waiting to undergo angiographies are susceptible to acute
coronary syndrome and hence more prone to ER visits. By
performing angiographies using a 5French catheter, a 90-minute
discharge and reducing procedure wait times, ER resources could
also be more efficiently utilized.
Study limitations and future direction
First, this study is a retrospective feasibility study of a 5
French catheter; hence, data cannot be directly compared to
that obtained with varying catheter sizes. Future studies should
involve randomized controlled trials to enable direct comparison.
Second, to better quantify the impact of reduced discharge time on
wait times for angiography using 5 French catheter, future studies
could be done by multiple operators across centers to capture the
effect on wait times. This would also help reduce any inherent
bias associated with a single center. Future studies should also
compare the use of hemostatic patches as an alternative to using radial clamps to help accelerate patient turnover. Learnings from using 5Frenchcatheter should be documented and disseminated
across operators to familiarize them of technical differences
and specifics associated with it, to help operators from multiple
centers conduct the study.
We believe that our data contributes important findings
to the current limited literature on angiographies with 5 Fr.
This study with its low complication rate supports the use of a
5 French catheter for TRA with a discharge time of 90 minutes
without compromising patient safety. Furthermore, workflow
in the catheterization laboratory is improved which leads to
reduced use of logistical resources, reduced workload and
increased patient turnover. Thus, at our institution, 5 Fr catheters
for angiographies have been adapted as a standard diagnostic