Studying the Priority of Anticoagulation to Prevent Arterial Occlusion After Forearm Angiographies - SPIRIT OF ARTEMIS

Dec 03, 2018
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Author/Summarized by Author:
Anthony A. Bavry, MD,MPH,FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Date Published:
10/31/2018
Date Updated:
12/03/2018
Original Posted Date:
12/02/2018
References

Contribution To Literature:

The SPIRIT OF ARTEMIS study showed that high-dose unfractionated heparin was superior to low-dose at preventing radial artery occlusion. 

Description:

The goal of the trial was to evaluate high-dose unfractionated heparin compared with low-dose unfractionated heparin among patients undergoing coronary angiography.


Study Design

  • Randomized
  • Parallel

Patients undergoing radial artery catheterization were randomized to unfractionated heparin 100 IU/kg (n = 908) versus 50 IU/kg (n = 928). Patients in the high-dose group, received half the dose after sheath insertion and the remainder just prior to sheath removal. In either group, heparin could be administered intravenously or intra-arterially. Hemostasis was performed according to operator discretion.

  • Total number of enrollees: 1,836
  • Duration of follow-up: 10 days
  • Mean patient age: 64 years
  • Percentage female: 28%
  • Percentage with diabetes: 25%

Inclusion criteria:

  • Patients ≥18 years of age undergoing coronary angiogram via radial artery access

Exclusion criteria:

  • Crossover to femoral access
  • Ad hoc percutaneous coronary intervention (PCI)
  • Chronic hemodialysis
  • Chronic oral anticoagulation therapy
  • Hemodynamic instability
  • Severe dermo-myoskeletal forearm deformities
  • History of coronary artery bypass grafting and bilateral use of either the internal mammary or radial artery, or ipsilateral use of both the internal mammary and radial arteries
  • Admission for elective PCI

Other salient features/characteristics:

  • Patent hemostasis was not performed in approximately 50%

Principal Findings:

The primary outcome, radial artery occlusion within 10 days, occurred in 3.0% of the high-dose group compared with 8.1% of the low-dose group (p < 0.001). There was no treatment interaction among numerous tested subgroups.

Secondary outcomes:

  • Local hematoma: 23.6% with high-dose vs. 23.0% with low-dose (p = not significant [NS]) heparin
  • Bleeding Academic Research Consortium (BARC) type 3 bleeding: none with high-dose vs. none with low-dose (p = NS) heparin

Interpretation:

Among patients with undergoing radial artery catheterization, high-dose heparin (100 IU/kg) was superior to low-dose heparin (50 IU/kg) at preventing radial artery occlusion. Local hematomas were similar between the groups. There were no major bleeding events. In the high-dose group, half of the dose of unfractionated heparin was given at the conclusion of the case, just before sheath removal, in case crossover to femoral access was needed.

References:

Hahalis GN, Leopoulou M, Tsigkas G, et al. Multicenter Randomized Evaluation of High Versus Standard Heparin Dose on Incident Radial Arterial Occlusion After Transradial Coronary Angiography: The SPIRIT OF ARTEMIS Study. JACC Cardiovasc Interv 2018;11:2241-50.

Editorial Comment: Rymer JA, Rao SV. Preventing Acute Radial Artery Occlusion: A Battle on Multiple Fronts. JACC Cardiovasc Interv 2018;11:2251-3.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Vascular Medicine, Anticoagulation Management and ACS, Interventions and ACS, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Anticoagulants, Arterial Occlusive Diseases, Catheterization, Coronary Angiography, Coronary Occlusion, Hematoma, Hemorrhage, Hemostasis, Heparin, Ischemia, Percutaneous Coronary Intervention, Radial Artery, Secondary Prevention


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