Manual heating of the radial artery (Balbay maneuver) to facilitate radial puncture prior to transradial coronary catheterization | Revista Portuguesa de Cardiologia (English edition)

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"titulo" => "Aquecimento manual da artéria radial (manobra de Balbay) para facilitar a punção radial antes da cateterização coronária" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 674 "Ancho" => 975 "Tamanyo" => 86920 ] ] "descripcion" => array:1 [ "en" => "Manual heating of the radial artery with the palm (Balbay maneuver)." ] ] ] "textoCompleto" => "IntroductionThe transradial access approach is effective for cardiac catheterization and percutaneous coronary intervention.<a class="elsevierStyleCrossRefs" href="#bib0145">1,2</a> It is becoming increasingly popular due to lower vascular complication rates, reduced costs, and earlier mobilization.<a class="elsevierStyleCrossRefs" href="#bib0155">3–6</a> Local complications remain low even in high-risk subgroups such as the elderly or obese, females, after acute myocardial infarction or under anticoagulation.<a class="elsevierStyleCrossRefs" href="#bib0175">7–10</a> The transfemoral approach is associated with greater procedural complications, particularly access-site major bleeding, which is becoming an increasingly important issue in the era of more potent antiplatelet and antithrombotic agents used to prevent cardiac ischemia, and is associated with more adverse clinical events, including mortality.<a class="elsevierStyleCrossRefs" href="#bib0195">11,12</a> Although the transradial approach is a demanding technique, with a steep learning curve due to a high number of procedural failures before gaining experience, at present it is the first-line access in many interventional cardiology centers.<a class="elsevierStyleCrossRefs" href="#bib0205">13–15</a> In a comparison of radial and femoral approaches in patients undergoing coronary angiography or intervention, a lower rate of access-related complications was observed with radial access.<a class="elsevierStyleCrossRef" href="#bib0220">16</a> In the RIVAL study on patients with acute coronary syndrome, radial artery access reduced the composite primary outcome and mortality.<a class="elsevierStyleCrossRef" href="#bib0200">12</a> The RIFLE-STEACS study showed that radial access in patients with ST-segment elevation acute coronary syndrome is associated with significant clinical benefits, in terms of both lower morbidity and cardiac mortality.<a class="elsevierStyleCrossRef" href="#bib0225">17</a> In the MATRIX trial of patients with acute coronary syndrome undergoing invasive management, radial as compared with femoral access reduced net adverse clinical events, through a reduction in major bleeding and all-cause mortality.<a class="elsevierStyleCrossRef" href="#bib0230">18</a> For these reasons, the radial approach is becoming increasingly popular.The main problem is the difficulty of the initial puncture of a small and highly reactive artery. Radial spasm increases after subcutaneous injection of lidocaine during local anesthesia, because lidocaine at room temperature is colder than body temperature.Cold stimulates the sympathetic nervous system and sympathetic stimulation causes vasoconstriction.<a class="elsevierStyleCrossRef" href="#bib0235">19</a> Subcutaneous injections of lidocaine or other medications cause radial artery vasoconstriction, which hampers radial puncture, sheath insertion and coronary angiography. Manual heating inhibits cold-induced vasoconstriction and may decrease the duration of sheath insertion.Topical and subcutaneous use of nitroglycerin before transradial access has been shown to facilitate radial access by increasing the diameter of the artery, improving palpability of the radial pulse and reducing arterial spasticity.<a class="elsevierStyleCrossRefs" href="#bib0240">20,21</a>The present study was a prospective randomized trial comparing manual heating of the radial artery vs. the combination of subcutaneous nitroglycerin plus diltiazem before transradial access in terms of the spasmolytic effect on the radial artery and ease of transradial access.MethodsStudy populationBetween July 2015 and September 2015, a total of 106 consecutive patients who underwent a transradial approach due to suspected stable coronary artery disease were enrolled in the study. Patients with previous transradial coronary revascularization, acute coronary syndrome, abnormal pulse oximetry plethysmography test, hemodynamic impairment, uncontrolled hypertension, vasculopathy, or inability to tolerate nitroglycerin or lidocaine due to allergy or medication interactions were excluded. In total, 16 patients were excluded, and 90 patients were included and randomized.Hypertension was defined as documented systolic blood pressure of ≥140 mmHg and/or diastolic blood pressure of ≥90 mmHg in at least two measurements or active use of any antihypertensive agent. Diabetes was diagnosed as fasting plasma glucose over 126 mg/dl or 2-h glucose over 200 mg/dl in any measurement or active use of an antidiabetic agent. Smoking was defined as current smoking. Patients’ weight and height were recorded and body mass index (BMI) was calculated as weight in kg divided by the square of height in m. Body surface area (BSA) was calculated using the Mosteller formula.Blood samples were obtained from the antecubital vein after a 12-hour fasting period. A Coulter LH series analyzer (Beckman Coulter Inc., Hialeah, FL) was used to obtain a complete blood count. Plasma levels of triglycerides, high-density lipoprotein, low-density lipoprotein, glucose, and creatinine were assessed using an automated chemistry analyzer (Abbott Aeroset, USA) using commercially available kits (Abbott, USA).The study complied with the principles of the Declaration of Helsinki and was approved by the local ethics committee. All patients provided written informed consent before the procedure.Measurement of radial artery diameterAll patients underwent radial artery ultrasound before catheterization. The radial artery was measured using B-mode ultrasound (Mindray M7 system, Mindray Medical International Limited, Shenzhen, PRC), using a 7L4s linear probe (5-10 mHz) before the procedure. The radial artery was located, and radial diameters were measured 3 cm proximal to the styloid process at the R peak of the electrocardiogram. For each image, the mean of five measurements was obtained.ProceduresPatients undergoing transradial cardiac catheterization were randomized to a combination of subcutaneous nitroglycerin plus diltiazem or to manual heating (Balbay maneuver). The operators were blinded to the study. The operator's assistant used one of the two methods, and then cardiac catheterization was performed by the operator. The baseline patency of the palmar arch was assessed with a combination of pulse oximetry and plethysmography as described by Barbeau et al.<a class="elsevierStyleCrossRef" href="#bib0250">22</a> in all patients. Patients with a type D response on the Barbeau test were excluded from the study. Routine prior sedation with agents such as midazolam or diazepam was not used in the study. In the first study arm, 200 mg nitroglycerin plus 2 mg diltiazem subcutaneously was used at the time of local anesthesia (1% lidocaine subcutaneously) regardless of the presence of a faint radial pulse. In the other study arm, manual heating (Balbay maneuver) was applied to all patients regardless of the presence of a faint radial pulse. The Balbay maneuver is defined as heating the radial artery site for three minutes with the palm (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) after administration of 1% lidocaine for local anesthesia subcutaneously. An arterial sheath is then inserted into the artery. In the study we used the Seldinger technique with a single anterior wall puncture. The artery was punctured with a sharp hollow needle, the syringe was detached and the guidewire advanced through the lumen of the needle, and the needle was withdrawn. A 10-cm 6F hydrophilic sheath (Radifocus Introducer II, Terumo, Leuven, Belgium) was then passed over the guidewire into the vessel.<a class="elsevierStyleCrossRefs" href="#bib0255">23,24</a> After sheath insertion, a radial cocktail containing 2 mg diltiazem, 200 mg nitroglycerin and heparin 5000 IU diluted in a 10-ml syringe was injected gradually through the sheath side arm into the radial artery. Coronary angiography was performed using 6F catheters (Boston Scientific). All coronary angiograms were performed by two interventional cardiologists experienced in radial access.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Study endpointThe study endpoint was puncture score, defined as score 1: successful puncture at first attempt; score 2: second attempt; score 3: third attempt; score 4: fourth attempt or more; score 5: puncture failed.Statistical analysisSPSS 21.0 for Windows (IBM SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Continuous variables were expressed as means ± standard deviation and categorical variables were expressed as numbers and percentages. The Kolmogorov-Smirnov test was used to test normality of distribution and the Student's t test and the Mann-Whitney U test were used to compare parametric and nonparametric continuous variables, respectively. Differences between treatment groups for categorical variables were analyzed using the chi-square test. A p value <0.05 was considered significant.ResultsA total of 90 patients were enrolled in the study, 45 randomized to subcutaneous nitroglycerin plus diltiazem and 45 to manual heating (Balbay maneuver). The mean age of the participants was 60.2±10.8 years and 68.8% were male. Baseline characteristics and laboratory parameters were similar between groups with the exception of aspirin use (p>0.05). Patients’ weight, height, BMI, and BSA were similar between the groups (p>0.05) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Complications were rare: one hematoma in the drug treatment group and one radial artery occlusion in the heating group. Baseline radial artery diameter was similar between the groups (2.41±0.46 vs. 2.29±0.48 mm; p=0.242). There was also no difference between the groups in blood pressure (p>0.05). Puncture score was lower in patients with manual heating than in those treated with subcutaneous nitroglycerin plus diltiazem (2 [1-3]) vs. 1 [1-2]; p=0.001) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Successful puncture of the radial artery at the first attempt was significantly more common in the manual heating group (p=0.001) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionOur study demonstrated that the Balbay maneuver after local anesthesia in the setting of radial access for coronary angiography or angioplasty was feasible, facilitated radial artery puncture and may decrease the duration of sheath insertion. This result was observed with operators highly experienced in transradial access, and could be generalized for less experienced operators, including those training in the technique. This is the first study to demonstrate the feasibility of preprocedural manual heating of the radial artery.The radial access was first used in 1989. This approach showed real advantages, with fewer bleeding and vascular complications, earlier mobilization and earlier discharge from the hospital. But insertion of a radial sheath in the radial artery may be technically difficult because of small artery caliber, arterial vasospasm and low patient pain threshold. The radial artery has a small diameter (2.3-3.4 mm) and is composed of concentric smooth muscle layers, with dense alpha-1 adrenergic innervation.<a class="elsevierStyleCrossRefs" href="#bib0265">25–27</a> Spasm is the major complication of radial access and occurs mainly in females when there are painful and repeated punctures.Tarhan et al. reported that hypothermia plays an important role in radial artery vasospasm.<a class="elsevierStyleCrossRef" href="#bib0280">28</a> It is important to determine the main factors that cause abnormal vasoconstrictor activation in the vessel, which include trauma from the lidocaine injector, temperature changes, and release of vasoconstrictors and certain hormones. For a transradial approach, lidocaine or other subcutaneous pharmacological agents such as nitrates or calcium channel blockers injected into the radial access site are at room temperature. Room temperature (around 22-24°C) is always colder than body temperature. Exposure to cold stimulates cold receptors in the skin, which causes cold thermal sensations and stimulates the sympathetic nervous system. Sympathetic stimulation causes vasoconstriction in skin, arms and legs.<a class="elsevierStyleCrossRef" href="#bib0235">19</a> This physiological response of the body after lidocaine or other subcutaneous injections causes radial artery vasoconstriction, which hampers radial puncture, sheath insertion and coronary angiography. Manual heating may decrease the duration of sheath insertion.In our study we performed the Balbay maneuver to counteract the vasoconstrictor effects of cold. Manual heating of the radial access site results in vasodilation, a stronger radial pulse and greater likelihood of successful radial artery puncture with the Seldinger needle. Puncture scores were lower in patients with manual heating than in those treated with subcutaneous nitroglycerin plus diltiazem. This result shows that the Balbay maneuver after lidocaine injection facilitates radial puncture and sheath insertion. The technique is cheap, involving no additional cost, and can be performed by anyone. We believe that the Balbay maneuver could be routinely used in transradial coronary catheterization.Our study is limited by being in a single center with a small sample, and so further investigation is needed. It was also not a double-blind study; only the operators were blinded. Furthermore, there was no control group who did not undergo either subcutaneous nitroglycerin plus diltiazem injection or manual heating.ConclusionManual heating of the radial artery site significantly reduced the number of radial puncture attempts. Preprocedural manual heating of the radial artery area by the Balbay maneuver is feasible and facilitates radial artery puncture in patients undergoing transradial cardiac catheterization.Ethical disclosuresProtection of human and animal subjectsThe authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data.Right to privacy and informed consentThe authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres859453" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec853562" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres859454" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec853561" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Measurement of radial artery diameter" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Procedures" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Study endpoint" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Statistical analysis" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Results" ] ] ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0055" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-03-23" "fechaAceptado" => "2016-11-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec853562" "palabras" => array:3 [ 0 => "Cardiac catheterization" 1 => "Manual heating" 2 => "Transradial access" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec853561" "palabras" => array:3 [ 0 => "Cateterização coronária" 1 => "Aquecimento manual" 2 => "Acesso transradial" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTransradial access is widely used for both diagnostic and interventional cardiac procedures. The use of transradial access offers several advantages, including decreased bleeding, fewer vascular complications, and reduced length of hospital stay and cost. However, the small size of the radial artery limits the size of the equipment that can be used via this approach. In this study we sought to investigate whether preprocedural manual heating of the radial artery facilitates radial artery puncture. MethodsPatients undergoing transradial cardiac catheterization were randomized to subcutaneous nitroglycerin plus diltiazem or manual heating. The study endpoint was puncture score (score 1: easiest – puncture at first attempt; score 2: second attempt; score 3: third attempt; score 4: fourth attempt or more; score 5: puncture failed). ResultsNinety consecutive patients were enrolled in the study, 45 allocated to the drug treatment group and 45 to the heating group. Patients underwent radial artery ultrasound before catheterization. Complications were rare: one hematoma (drug treatment group) and one radial artery occlusion (heating group). Baseline demographic and clinical characteristics were similar. Baseline radial artery diameter was similar in both groups (2.41±0.46 mm and 2.29±0.48 mm in the heating and drug treatment groups, respectively). However, the median puncture score was lower in the heating group (1; interquartile range 1-2) compared to the drug treatment group (2; interquartile range 1-3; p=0.001). ConclusionsPreprocedural manual heating of the radial artery facilitates radial artery puncture in patients undergoing transradial cardiac catheterization." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "ObjetivoO acesso transradial (ATR) é usado habitualmente quer para procedimentos diagnósticos quer de intervenção coronária. O uso de ATR oferece várias vantagens: redução das hemorragias, menos complicações vasculares, menor tempo de internamento e representa menos custos associados. Porém, o reduzido calibre da artéria radial limita o tamanho dos dispositivos que podem ser usados por este acesso. Neste estudo, investigamos se o prévio aquecimento da artéria radial facilita, ou não, a punção radial. MétodosDoentes submetidos a cateterismo cardíaco por ATR foram aleatorizados para uma administração subcutânea de uma combinação de nitroglicerina e diltiazem ou, em alternativa, aquecimento manual da artéria radial. O endpoint do estudo foi o score de punção (score 1: punção simples à primeira tentativa; score 2: punção à segunda tentativa; score 3: punção à terceira tentativa; score 4: punção à quarta ou mais tentativa; score 5: punção radial falhada). ResultadosNoventa doentes consecutivos foram incluídos no estudo – 45 no grupo de tratamento farmacológico e 45 no grupo de aquecimento manual. Os doentes fizeram avaliação ecográfica da artéria radial antes do cateterismo. As complicações ocorreram de forma rara: um hematoma (grupo tratamento) e uma oclusão radial (grupo aquecimento). As caraterísticas basais demográficas e clínicas foram semelhantes. O diâmetro basal da artéria radial foi semelhante em ambos os grupos (2,41 ± 0,46 mm e 2,29 ± 0,48 mm nos grupos de aquecimento e de tratamento, respetivamente). No entanto, o score de punção foi mais baixo no grupo aquecimento (1; intervalo interquartil 1-2) comparado com o grupo tratamento (2; intervalo interquartil 1-3; p=0,001). ConclusõesO aquecimento manual da artéria radial facilita a punção radial em doentes submetidos a cateterismo cardíaco por via transradial." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 674 "Ancho" => 975 "Tamanyo" => 86920 ] ] "descripcion" => array:1 [ "en" => "Manual heating of the radial artery with the palm (Balbay maneuver)." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "BMI: body mass index; BSA: body surface area; CAD: coronary artery disease; PCI: percutaneous coronary intervention. Data are given as mean ± SD or n (%)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameters \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug treatment (n=45) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Manual heating (n=45) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58.3±11.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62.2±9.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.097 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (66.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (71.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.649 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight, kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64.3±12.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">67.0±15.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.389 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Height, cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">162±7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">163±8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.761 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24.3±4.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24.9±5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.553 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BSA, m2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.68±0.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.73±0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.330 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smoking, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 (40.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 (48.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.396 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 (51.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (71.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.052 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hyperlipidemia, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (44.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.280 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (22.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 (40.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.069 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Known CAD, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 (40.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 (51.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.290 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postprocedural PCI, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (6.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (20.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.063 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Creatinine, mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.95±0.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.02±0.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.148 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Preprocedural medical therapy</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beta-blockers, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 (62.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 (48.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.099 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calcium channel blockers, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (20.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (22.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.796 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nitrates, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (8.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (15.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.238 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aspirin, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 (64.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38 (84.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.030 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clopidogrel, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (11.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (17.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.368 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1452701.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics and laboratory parameters of the study population." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "BP: blood pressure; RAD: radial artery diameter. Data are given as mean ± SD, n (%) or median (interquartile range)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameters \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug treatment (n=45) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Manual heating (n=45) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Puncture score, n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (1-3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1-2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preprocedural RAD, mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.41±0.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.29±0.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.242 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Left arm approach, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (20.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.153 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Systolic BP, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">134.4±9.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">135.0±8.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.768 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diastolic BP, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">78.0±6.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79.1±6.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.397 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1452702.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Preprocedural radial artery parameters of the study population." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Data are given as n (%)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Puncture score \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug treatment (n=45) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Manual heating (n=45) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (35.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (71.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.153 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (11.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.091 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (13.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.138 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (6.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.306 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1452703.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Distribution of puncture score." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0145" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outpatient coronary stent implantation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "F. 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Original Article

Manual heating of the radial artery (Balbay maneuver) to facilitate radial puncture prior to transradial coronary catheterization

Aquecimento manual da artéria radial (manobra de Balbay) para facilitar a punção radial antes da cateterização coronária

Sefa Ünala, Burak Açara, Çağrı Yaylaa,

Corresponding author

cagriyayla@gmail.com

Corresponding author.

, Mustafa Mücahit Balcia, Ahmet Göktuğ Ertema, Meryem Karaa, Orhan Madena, Ahmet Temizhana, Muharrem Tolab, Yücel Balbaya

a Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey

b Türkiye Yüksek Ihtisas Training and Research Hospital, Radiology Clinic, Ankara, Turkey

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The transradial access approach is effective for cardiac catheterization and percutaneous coronary intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#44;2</span></a> It is becoming increasingly popular due to lower vascular complication rates&#44; reduced costs&#44; and earlier mobilization&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3&#8211;6</span></a> Local complications remain low even in high-risk subgroups such as the elderly or obese&#44; females&#44; after acute myocardial infarction or under anticoagulation&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">7&#8211;10</span></a> The transfemoral approach is associated with greater procedural complications&#44; particularly access-site major bleeding&#44; which is becoming an increasingly important issue in the era of more potent antiplatelet and antithrombotic agents used to prevent cardiac ischemia&#44; and is associated with more adverse clinical events&#44; including mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">11&#44;12</span></a> Although the transradial approach is a demanding technique&#44; with a steep learning curve due to a high number of procedural failures before gaining experience&#44; at present it is the first-line access in many interventional cardiology centers&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">13&#8211;15</span></a> In a comparison of radial and femoral approaches in patients undergoing coronary angiography or intervention&#44; a lower rate of access-related complications was observed with radial access&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a> In the RIVAL study on patients with acute coronary syndrome&#44; radial artery access reduced the composite primary outcome and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">12</span></a> The RIFLE-STEACS study showed that radial access in patients with ST-segment elevation acute coronary syndrome is associated with significant clinical benefits&#44; in terms of both lower morbidity and cardiac mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">17</span></a> In the MATRIX trial of patients with acute coronary syndrome undergoing invasive management&#44; radial as compared with femoral access reduced net adverse clinical events&#44; through a reduction in major bleeding and all-cause mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">18</span></a> For these reasons&#44; the radial approach is becoming increasingly popular&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The main problem is the difficulty of the initial puncture of a small and highly reactive artery&#46; Radial spasm increases after subcutaneous injection of lidocaine during local anesthesia&#44; because lidocaine at room temperature is colder than body temperature&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Cold stimulates the sympathetic nervous system and sympathetic stimulation causes vasoconstriction&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">19</span></a> Subcutaneous injections of lidocaine or other medications cause radial artery vasoconstriction&#44; which hampers radial puncture&#44; sheath insertion and coronary angiography&#46; Manual heating inhibits cold-induced vasoconstriction and may decrease the duration of sheath insertion&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Topical and subcutaneous use of nitroglycerin before transradial access has been shown to facilitate radial access by increasing the diameter of the artery&#44; improving palpability of the radial pulse and reducing arterial spasticity&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The present study was a prospective randomized trial comparing manual heating of the radial artery vs&#46; the combination of subcutaneous nitroglycerin plus diltiazem before transradial access in terms of the spasmolytic effect on the radial artery and ease of transradial access&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study population</span><p id="par0030" class="elsevierStylePara elsevierViewall">Between July 2015 and September 2015&#44; a total of 106 consecutive patients who underwent a transradial approach due to suspected stable coronary artery disease were enrolled in the study&#46; Patients with previous transradial coronary revascularization&#44; acute coronary syndrome&#44; abnormal pulse oximetry plethysmography test&#44; hemodynamic impairment&#44; uncontrolled hypertension&#44; vasculopathy&#44; or inability to tolerate nitroglycerin or lidocaine due to allergy or medication interactions were excluded&#46; In total&#44; 16 patients were excluded&#44; and 90 patients were included and randomized&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Hypertension was defined as documented systolic blood pressure of &#8805;140 mmHg and&#47;or diastolic blood pressure of &#8805;90 mmHg in at least two measurements or active use of any antihypertensive agent&#46; Diabetes was diagnosed as fasting plasma glucose over 126 mg&#47;dl or 2-h glucose over 200 mg&#47;dl in any measurement or active use of an antidiabetic agent&#46; Smoking was defined as current smoking&#46; Patients&#8217; weight and height were recorded and body mass index &#40;BMI&#41; was calculated as weight in kg divided by the square of height in m&#46; Body surface area &#40;BSA&#41; was calculated using the Mosteller formula&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Blood samples were obtained from the antecubital vein after a 12-hour fasting period&#46; A Coulter LH series analyzer &#40;Beckman Coulter Inc&#46;&#44; Hialeah&#44; FL&#41; was used to obtain a complete blood count&#46; Plasma levels of triglycerides&#44; high-density lipoprotein&#44; low-density lipoprotein&#44; glucose&#44; and creatinine were assessed using an automated chemistry analyzer &#40;Abbott Aeroset&#44; USA&#41; using commercially available kits &#40;Abbott&#44; USA&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The study complied with the principles of the Declaration of Helsinki and was approved by the local ethics committee&#46; All patients provided written informed consent before the procedure&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Measurement of radial artery diameter</span><p id="par0050" class="elsevierStylePara elsevierViewall">All patients underwent radial artery ultrasound before catheterization&#46; The radial artery was measured using B-mode ultrasound &#40;Mindray M7 system&#44; Mindray Medical International Limited&#44; Shenzhen&#44; PRC&#41;&#44; using a 7L4s linear probe &#40;5-10 mHz&#41; before the procedure&#46; The radial artery was located&#44; and radial diameters were measured 3 cm proximal to the styloid process at the R peak of the electrocardiogram&#46; For each image&#44; the mean of five measurements was obtained&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Procedures</span><p id="par0055" class="elsevierStylePara elsevierViewall">Patients undergoing transradial cardiac catheterization were randomized to a combination of subcutaneous nitroglycerin plus diltiazem or to manual heating &#40;Balbay maneuver&#41;&#46; The operators were blinded to the study&#46; The operator&#39;s assistant used one of the two methods&#44; and then cardiac catheterization was performed by the operator&#46; The baseline patency of the palmar arch was assessed with a combination of pulse oximetry and plethysmography as described by Barbeau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a> in all patients&#46; Patients with a type D response on the Barbeau test were excluded from the study&#46; Routine prior sedation with agents such as midazolam or diazepam was not used in the study&#46; In the first study arm&#44; 200 mg nitroglycerin plus 2 mg diltiazem subcutaneously was used at the time of local anesthesia &#40;1&#37; lidocaine subcutaneously&#41; regardless of the presence of a faint radial pulse&#46; In the other study arm&#44; manual heating &#40;Balbay maneuver&#41; was applied to all patients regardless of the presence of a faint radial pulse&#46; The Balbay maneuver is defined as heating the radial artery site for three minutes with the palm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41; after administration of 1&#37; lidocaine for local anesthesia subcutaneously&#46; An arterial sheath is then inserted into the artery&#46; In the study we used the Seldinger technique with a single anterior wall puncture&#46; The artery was punctured with a sharp hollow needle&#44; the syringe was detached and the guidewire advanced through the lumen of the needle&#44; and the needle was withdrawn&#46; A 10-cm 6F hydrophilic sheath &#40;Radifocus Introducer II&#44; Terumo&#44; Leuven&#44; Belgium&#41; was then passed over the guidewire into the vessel&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">23&#44;24</span></a> After sheath insertion&#44; a radial cocktail containing 2 mg diltiazem&#44; 200 mg nitroglycerin and heparin 5000 IU diluted in a 10-ml syringe was injected gradually through the sheath side arm into the radial artery&#46; Coronary angiography was performed using 6F catheters &#40;Boston Scientific&#41;&#46; All coronary angiograms were performed by two interventional cardiologists experienced in radial access&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Study endpoint</span><p id="par0060" class="elsevierStylePara elsevierViewall">The study endpoint was puncture score&#44; defined as score 1&#58; successful puncture at first attempt&#59; score 2&#58; second attempt&#59; score 3&#58; third attempt&#59; score 4&#58; fourth attempt or more&#59; score 5&#58; puncture failed&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">SPSS 21&#46;0 for Windows &#40;IBM SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41; was used for statistical analysis&#46; Continuous variables were expressed as means &#177; standard deviation and categorical variables were expressed as numbers and percentages&#46; The Kolmogorov-Smirnov test was used to test normality of distribution and the Student&#39;s t test and the Mann-Whitney U test were used to compare parametric and nonparametric continuous variables&#44; respectively&#46; Differences between treatment groups for categorical variables were analyzed using the chi-square test&#46; A p value &#60;0&#46;05 was considered significant&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">A total of 90 patients were enrolled in the study&#44; 45 randomized to subcutaneous nitroglycerin plus diltiazem and 45 to manual heating &#40;Balbay maneuver&#41;&#46; The mean age of the participants was 60&#46;2&#177;10&#46;8 years and 68&#46;8&#37; were male&#46; Baseline characteristics and laboratory parameters were similar between groups with the exception of aspirin use &#40;p&#62;0&#46;05&#41;&#46; Patients&#8217; weight&#44; height&#44; BMI&#44; and BSA were similar between the groups &#40;p&#62;0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Complications were rare&#58; one hematoma in the drug treatment group and one radial artery occlusion in the heating group&#46; Baseline radial artery diameter was similar between the groups &#40;2&#46;41&#177;0&#46;46 vs&#46; 2&#46;29&#177;0&#46;48 mm&#59; p&#61;0&#46;242&#41;&#46; There was also no difference between the groups in blood pressure &#40;p&#62;0&#46;05&#41;&#46; Puncture score was lower in patients with manual heating than in those treated with subcutaneous nitroglycerin plus diltiazem &#40;2 &#91;1-3&#93;&#41; vs&#46; 1 &#91;1-2&#93;&#59; p&#61;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Successful puncture of the radial artery at the first attempt was significantly more common in the manual heating group &#40;p&#61;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Our study demonstrated that the Balbay maneuver after local anesthesia in the setting of radial access for coronary angiography or angioplasty was feasible&#44; facilitated radial artery puncture and may decrease the duration of sheath insertion&#46; This result was observed with operators highly experienced in transradial access&#44; and could be generalized for less experienced operators&#44; including those training in the technique&#46; This is the first study to demonstrate the feasibility of preprocedural manual heating of the radial artery&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The radial access was first used in 1989&#46; This approach showed real advantages&#44; with fewer bleeding and vascular complications&#44; earlier mobilization and earlier discharge from the hospital&#46; But insertion of a radial sheath in the radial artery may be technically difficult because of small artery caliber&#44; arterial vasospasm and low patient pain threshold&#46; The radial artery has a small diameter &#40;2&#46;3-3&#46;4 mm&#41; and is composed of concentric smooth muscle layers&#44; with dense alpha-1 adrenergic innervation&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">25&#8211;27</span></a> Spasm is the major complication of radial access and occurs mainly in females when there are painful and repeated punctures&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Tarhan et al&#46; reported that hypothermia plays an important role in radial artery vasospasm&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a> It is important to determine the main factors that cause abnormal vasoconstrictor activation in the vessel&#44; which include trauma from the lidocaine injector&#44; temperature changes&#44; and release of vasoconstrictors and certain hormones&#46; For a transradial approach&#44; lidocaine or other subcutaneous pharmacological agents such as nitrates or calcium channel blockers injected into the radial access site are at room temperature&#46; Room temperature &#40;around 22-24<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; is always colder than body temperature&#46; Exposure to cold stimulates cold receptors in the skin&#44; which causes cold thermal sensations and stimulates the sympathetic nervous system&#46; Sympathetic stimulation causes vasoconstriction in skin&#44; arms and legs&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">19</span></a> This physiological response of the body after lidocaine or other subcutaneous injections causes radial artery vasoconstriction&#44; which hampers radial puncture&#44; sheath insertion and coronary angiography&#46; Manual heating may decrease the duration of sheath insertion&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In our study we performed the Balbay maneuver to counteract the vasoconstrictor effects of cold&#46; Manual heating of the radial access site results in vasodilation&#44; a stronger radial pulse and greater likelihood of successful radial artery puncture with the Seldinger needle&#46; Puncture scores were lower in patients with manual heating than in those treated with subcutaneous nitroglycerin plus diltiazem&#46; This result shows that the Balbay maneuver after lidocaine injection facilitates radial puncture and sheath insertion&#46; The technique is cheap&#44; involving no additional cost&#44; and can be performed by anyone&#46; We believe that the Balbay maneuver could be routinely used in transradial coronary catheterization&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Our study is limited by being in a single center with a small sample&#44; and so further investigation is needed&#46; It was also not a double-blind study&#59; only the operators were blinded&#46; Furthermore&#44; there was no control group who did not undergo either subcutaneous nitroglycerin plus diltiazem injection or manual heating&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Manual heating of the radial artery site significantly reduced the number of radial puncture attempts&#46; Preprocedural manual heating of the radial artery area by the Balbay maneuver is feasible and facilitates radial artery puncture in patients undergoing transradial cardiac catheterization&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical disclosures</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Protection of human and animal subjects</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Confidentiality of data</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Right to privacy and informed consent</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            0 => "Cateteriza&#231;&#227;o coron&#225;ria"
            1 => "Aquecimento manual"
            2 => "Acesso transradial"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transradial access is widely used for both diagnostic and interventional cardiac procedures&#46; The use of transradial access offers several advantages&#44; including decreased bleeding&#44; fewer vascular complications&#44; and reduced length of hospital stay and cost&#46; However&#44; the small size of the radial artery limits the size of the equipment that can be used via this approach&#46; In this study we sought to investigate whether preprocedural manual heating of the radial artery facilitates radial artery puncture&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients undergoing transradial cardiac catheterization were randomized to subcutaneous nitroglycerin plus diltiazem or manual heating&#46; The study endpoint was puncture score &#40;score 1&#58; easiest &#8211; puncture at first attempt&#59; score 2&#58; second attempt&#59; score 3&#58; third attempt&#59; score 4&#58; fourth attempt or more&#59; score 5&#58; puncture failed&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ninety consecutive patients were enrolled in the study&#44; 45 allocated to the drug treatment group and 45 to the heating group&#46; Patients underwent radial artery ultrasound before catheterization&#46; Complications were rare&#58; one hematoma &#40;drug treatment group&#41; and one radial artery occlusion &#40;heating group&#41;&#46; Baseline demographic and clinical characteristics were similar&#46; Baseline radial artery diameter was similar in both groups &#40;2&#46;41&#177;0&#46;46 mm and 2&#46;29&#177;0&#46;48 mm in the heating and drug treatment groups&#44; respectively&#41;&#46; However&#44; the median puncture score was lower in the heating group &#40;1&#59; interquartile range 1-2&#41; compared to the drug treatment group &#40;2&#59; interquartile range 1-3&#59; p&#61;0&#46;001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Preprocedural manual heating of the radial artery facilitates radial artery puncture in patients undergoing transradial cardiac catheterization&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O acesso transradial &#40;ATR&#41; &#233; usado habitualmente quer para procedimentos diagn&#243;sticos quer de interven&#231;&#227;o coron&#225;ria&#46; O uso de ATR oferece v&#225;rias vantagens&#58; redu&#231;&#227;o das hemorragias&#44; menos complica&#231;&#245;es vasculares&#44; menor tempo de internamento e representa menos custos associados&#46; Por&#233;m&#44; o reduzido calibre da art&#233;ria radial limita o tamanho dos dispositivos que podem ser usados por este acesso&#46; Neste estudo&#44; investigamos se o pr&#233;vio aquecimento da art&#233;ria radial facilita&#44; ou n&#227;o&#44; a pun&#231;&#227;o radial&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Doentes submetidos a cateterismo card&#237;aco por ATR foram aleatorizados para uma administra&#231;&#227;o subcut&#226;nea de uma combina&#231;&#227;o de nitroglicerina e diltiazem ou&#44; em alternativa&#44; aquecimento manual da art&#233;ria radial&#46; O <span class="elsevierStyleItalic">endpoint</span> do estudo foi o <span class="elsevierStyleItalic">score</span> de pun&#231;&#227;o &#40;<span class="elsevierStyleItalic">score</span> 1&#58; pun&#231;&#227;o simples &#224; primeira tentativa&#59; <span class="elsevierStyleItalic">score</span> 2&#58; pun&#231;&#227;o &#224; segunda tentativa&#59; <span class="elsevierStyleItalic">score</span> 3&#58; pun&#231;&#227;o &#224; terceira tentativa&#59; <span class="elsevierStyleItalic">score</span> 4&#58; pun&#231;&#227;o &#224; quarta ou mais tentativa&#59; <span class="elsevierStyleItalic">score</span> 5&#58; pun&#231;&#227;o radial falhada&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Noventa doentes consecutivos foram inclu&#237;dos no estudo &#8211; 45 no grupo de tratamento farmacol&#243;gico e 45 no grupo de aquecimento manual&#46; Os doentes fizeram avalia&#231;&#227;o ecogr&#225;fica da art&#233;ria radial antes do cateterismo&#46; As complica&#231;&#245;es ocorreram de forma rara&#58; um hematoma &#40;grupo tratamento&#41; e uma oclus&#227;o radial &#40;grupo aquecimento&#41;&#46; As carater&#237;sticas basais demogr&#225;ficas e cl&#237;nicas foram semelhantes&#46; O di&#226;metro basal da art&#233;ria radial foi semelhante em ambos os grupos &#40;2&#44;41 &#177; 0&#44;46 mm e 2&#44;29 &#177; 0&#44;48 mm nos grupos de aquecimento e de tratamento&#44; respetivamente&#41;&#46; No entanto&#44; o <span class="elsevierStyleItalic">score</span> de pun&#231;&#227;o foi mais baixo no grupo aquecimento &#40;1&#59; intervalo interquartil 1-2&#41; comparado com o grupo tratamento &#40;2&#59; intervalo interquartil 1-3&#59; p&#61;0&#44;001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O aquecimento manual da art&#233;ria radial facilita a pun&#231;&#227;o radial em doentes submetidos a cateterismo card&#237;aco por via transradial&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#245;es"
          ]
        ]
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Manual heating of the radial artery with the palm &#40;Balbay maneuver&#41;&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
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            "rol" => "short"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; BSA&#58; body surface area&#59; CAD&#58; coronary artery disease&#59; PCI&#58; percutaneous coronary intervention&#46; Data are given as mean &#177; SD or n &#40;&#37;&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug treatment &#40;n&#61;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Manual heating &#40;n&#61;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age&#44; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&#46;3&#177;11&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#46;2&#177;9&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;097&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Male&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;66&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;71&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;649&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Weight&#44; kg</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&#46;3&#177;12&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#46;0&#177;15&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;389&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Height&#44; cm</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">162&#177;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">163&#177;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;761&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">BMI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;3&#177;4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;9&#177;5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;553&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">BSA&#44; m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;68&#177;0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;73&#177;0&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;330&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Smoking&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;48&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;396&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hypertension&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;51&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;71&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;052&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hyperlipidemia&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 &#40;44&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;280&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Diabetes&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;22&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;069&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Known CAD&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;51&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;290&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Postprocedural PCI&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;6&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;063&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Creatinine&#44; mg&#47;dl</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;95&#177;0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;02&#177;0&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;148&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Preprocedural medical therapy</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Beta-blockers&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28 &#40;62&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;48&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;099&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Calcium channel blockers&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;22&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;796&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nitrates&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;8&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;15&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;238&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aspirin&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29 &#40;64&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38 &#40;84&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;030&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Clopidogrel&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;11&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;368&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics and laboratory parameters of the study population&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">BP&#58; blood pressure&#59; RAD&#58; radial artery diameter&#46; Data are given as mean &#177; SD&#44; n &#40;&#37;&#41; or median &#40;interquartile range&#41;&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug treatment &#40;n&#61;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Manual heating &#40;n&#61;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Puncture score&#44; n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;242&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;153&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;397&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Puncture score&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;35&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;71&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;091&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;13&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;138&nbsp;\t\t\t\t\t\t\n
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
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                            1 => "H&#46; Benamer"
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                        "volumen" => "9"
                        "paginaInicial" => "E765"
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2016.11.011

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Year/Month	Html	Pdf	Total

2024 November	8	5	13
2024 October	41	20	61
2024 September	42	36	78
2024 August	26	21	47
2024 July	36	30	66
2024 June	45	39	84
2024 May	32	29	61
2024 April	36	21	57
2024 March	39	18	57
2024 February	36	22	58
2024 January	28	26	54
2023 December	25	24	49
2023 November	28	23	51
2023 October	25	17	42
2023 September	27	19	46
2023 August	23	25	48
2023 July	40	9	49
2023 June	31	15	46
2023 May	42	25	67
2023 April	22	6	28
2023 March	59	30	89
2023 February	38	21	59
2023 January	21	15	36
2022 December	42	19	61
2022 November	35	31	66
2022 October	31	17	48
2022 September	29	26	55
2022 August	19	34	53
2022 July	51	33	84
2022 June	34	20	54
2022 May	24	31	55
2022 April	35	25	60
2022 March	31	47	78
2022 February	33	30	63
2022 January	33	19	52
2021 December	21	31	52
2021 November	34	39	73
2021 October	35	29	64
2021 September	20	26	46
2021 August	40	25	65
2021 July	24	16	40
2021 June	32	19	51
2021 May	57	41	98
2021 April	78	30	108
2021 March	71	21	92
2021 February	69	16	85
2021 January	47	15	62
2020 December	56	5	61
2020 November	53	15	68
2020 October	64	22	86
2020 September	66	11	77
2020 August	31	15	46
2020 July	70	8	78
2020 June	47	10	57
2020 May	71	12	83
2020 April	61	8	69
2020 March	80	17	97
2020 February	141	20	161
2020 January	45	5	50
2019 December	30	8	38
2019 November	48	5	53
2019 October	19	7	26
2019 September	27	15	42
2019 August	29	9	38
2019 July	36	8	44
2019 June	27	5	32
2019 May	37	4	41
2019 April	24	16	40
2019 March	52	14	66
2019 February	27	9	36
2019 January	78	5	83
2018 December	85	10	95
2018 November	87	11	98
2018 October	226	15	241
2018 September	52	14	66
2018 August	40	15	55
2018 July	55	9	64
2018 June	53	12	65
2018 May	70	24	94
2018 April	46	22	68
2018 March	44	14	58
2018 February	17	12	29
2018 January	25	12	37
2017 December	29	16	45
2017 November	26	18	44
2017 October	32	16	48
2017 September	32	32	64
2017 August	46	15	61
2017 July	73	45	118

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