Need for Prophylactic Application of Verapamil in Transradial Coronary Procedures: A Randomized Trial

Abstract

BackgroundVerapamil is traditionally applied prophylactically in transradial procedures to prevent radial artery spasm. However, verapamil may have side effects and is contraindicated in some clinical settings.Methods and ResultsDuring an investigator‐initiated, randomized, double‐blind trial, we evaluated the need for preventive verapamil administration. After vascular access was established, patients received either 5 mg verapamil (n=297) or placebo (n=294). We compared the rate of access site conversions as primary end point using a superiority margin of 5%. Occurrence of code breaks (composite of conversions and unplanned use of verapamil), overall verapamil use, procedural and fluoroscopic times, contrast volume, and subjective pain were investigated as secondary end points. The rate of access site conversions was not different in the 2 arms (placebo 1.7% versus verapamil 0.7%, P=0.28, difference 1.0%, 95% CI for the difference −1.1% to 3.3%). Proportion of code breaks was similar in the 2 groups (3.4% versus 1.3%, P=0.11), whereas overall verapamil use was markedly lower in the placebo arm (2.0% versus 100%, P<0.0001). Procedural time (median [IQR] 16.0 minutes [9.0 to 30.0 minutes] versus 17.0 minutes [10.0 to 31.0 minutes], P=0.37), fluoroscopic time (4.4 minutes [2.1 to 9.6 minutes] versus 4.8 minutes [2.4 to 10.7 minutes], P=0.28), contrast volume (72.5 mL [48.0 to 146.0 mL] versus 75.5 mL [47.0 to 156.5 mL], P=0.74), and pain score (P for trend=0.12) were comparable in the 2 groups.ConclusionsThe preventive use of verapamil may be unnecessary for transradial procedures. The omission of prophylactic verapamil may not only reduce the rate of potential complications related to the drug but also allow the safe extension of the transradial method to those with contraindications to verapamil.Clinical Trial RegistrationURL: http://www.clinicaltrials.gov. Unique identifier: NCT01402427.

Administration of ViperSlide™ for treating severe radial artery spasm: case report and systematic review of the literature

“…Moreover, the "is Verapamil In TransRadial Interventions OmittabLe?" (VITRIOL) trial showed similar access site conversion rates and/or spasmolytic administration rates between the prophylaxis and placebo groups, suggesting that preventive use of verapamil may not be necessary [14]. Applying warmth to the forearm may be helpful in relieving the spasm.…”

Catheter entrapment due to severe radial artery spasm during transradial approach

“…Nitroglycerin is also contraindicated in patients with significant aortic stenosis, hypotension, and cardiogenic shock. Furthermore, a recent study indicated that beyond the learning curve preventive administration of intra-arterial verapamil offers no advantage over ad hoc application in terms of access site conversion rates [20]. In our center, in appropriate cases, a bolus of intra-arterial nitroglycerin and/or intra-arterial verapamil is given prophylactically.…”

Can radial artery pulse grading predict radial artery spasm during transradial approach?

“…In a head-to-head comparison study between nitroglycerin and verapamil there was no statistically significant difference in the ACEI -angiotensin converting enzyme inhibitor; BP -blood pressure; HDL-C -high-density lipoprotein-cholesterol; LDL-C -low-density lipoprotein-cholesterol; RAS -radial artery spasm incidence of RAS [22]. Furthermore, a recent study indicated that beyond the learning curve preventive administration of intra-arterial verapamil offers no advantage over ad hoc application in terms of access site conversion rates [23]. It was also reported that 72.2% of Japanese operators do not use any medication for spasm prophylaxis [23].…”

“…Furthermore, a recent study indicated that beyond the learning curve preventive administration of intra-arterial verapamil offers no advantage over ad hoc application in terms of access site conversion rates [23]. It was also reported that 72.2% of Japanese operators do not use any medication for spasm prophylaxis [23]. In keeping with these recent reports, the preventive use of vasodilators may not be mandatory, especially in centres with high-volume transradial catheterisation.…”