Effects of methods used to achieve hemostasis on radial artery occlusion following percutaneous coronary procedures: a systematic review
Authors: Fernandez Ritin S. , Lee Astin 
Published: March 2017

EXECUTIVE SUMMARY

Background
Transradial access to percutaneous coronary procedures is becoming the preferred access route, and it is being increasingly used for emergent and elective procedures. However, radial artery occlusion (RAO) continues to remain an adverse occurrence following sheath removal or in the first 24 hours following sheath removal due to the smaller diameter of the artery.

Objectives
The overall objective of this study was to synthesize the best available research evidence related to the effects of methods used to achieve hemostasis on RAO rates after percutaneous coronary procedures.

Inclusion criteria Types of participants
The current review considered trials that included adult patients (18 years and over) who have had a coronary angiography or coronary re-vascularization intervention via the radial artery.

Types of intervention(s)
The interventions of interest were the use of various hemostatic methods compared to traditional interventions to prevent RAO.

Types of studies
All randomized and quasi-randomized controlled trials evaluating the effect of various hemostatic methods on RAO rates after percutaneous coronary procedures were included in the review.

Outcomes
The primary outcome of interest was the incidence of RAO at the time of discharge and persistent occlusion at the time of follow-up.

Search strategy
The search aimed to find published and unpublished trials through electronic databases, reference lists and key reports. An extensive search was undertaken for the following databases – CINAHL, Embase, PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL). Databases were searched up to May 2016. The search for unpublished trials included Dissertation Abstracts International, World Cat, Clinicaltrials.gov, ProQuest Dissertation and Theses and MedNar.

Methodological quality
Methodological quality was assessed independently by two reviewers using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) checklist. Disagreements that arose between the reviewers were resolved through discussion.

Data extraction
Quantitative data were extracted from papers included in the review by one reviewer using the standardized data extraction tool from JBI-MAStARI. The data extracted were checked by a second reviewer. Disagreements that arose between the reviewers were resolved through discussion. All results were subject to double data entry in Review Manager.

Data synthesis
Statistical pooling of the data was not possible due to the heterogeneity of the trials; therefore, the findings are presented in narrative form. However, figures have been used to illustrate the results.

Results
A total of seven trials were included in the review. One trial demonstrated a significant reduction in RAO rates in patients who had a mean arterial pressure (MAP)-guided TR band to a standard TR band (odds ratio [OR] 0.08; 95% confidence interval [CI] 0.02, 0.37). A statistically significant reduction in the incidence of RAO was observed among patients who received a biopolymer dressing (Chitosen) compared to those who received the TR band (OR 2.20; 95% CI 1.20, 4.02). No statistically significant difference in the incidence of RAO was reported between those who received the TR band and those who received either the elastic bandage (P = 0.08) or T band (P = 0.76). Similarly, no statistically significant difference in rates of RAO among patients was reported among those who had pro-coagulant dressings compared to those who had short or long manual compression. One trial that compared the TR band to a MAP-guided TR band demonstrated no statistically significant difference in the time taken to obtain hemostasis between the two groups (P = 0.61). A statistically significant reduction in the time taken to obtain hemostasis was observed among patients who received the hemostatic biopolymer dressing compared to the TR band. No statistically significant difference in the incidence of hematoma was identified among patients who received pneumatic compression or traditional compression to achieve hemostasis.

Conclusion
There is limited evidence to support the use of any single hemostatic method to prevent RAO rates after percutaneous coronary procedures. Although used extensively, there is evidence of no effect of the pneumatic compression method using the TR band on the incidence of RAO at discharge or follow-up, the time taken to obtain hemostasis and the incidence of hematoma. The MAP-guided compression method and the Biopolymer dressing (Chitosen) were superior to the TR band compression method, and patent hemostasis was superior to hemoband in the prevention of RAO. However, these results are based on single trials and should be interpreted with caution. The evidence obtained from the review does not provide a concrete base for the development of practice guidelines. Until more robust evidence is available, practices will continue to be dictated by local preferences and available resources.