Letter to the Editor

Sub-cutaneous Nitroglycerin:Good Example of the ‘‘KISS’’Rule!

TO THE EDITOR

We read with great interest the report by Pancholyet al. on the use of subcutaneous nitroglycerin toreverse radial artery spasm after initial failed attempt[1]. The authors should be commended for describingan inexpensive, yet highly successful technique toovercome radial artery spasm. Although often cited asan obstacle to transradial catheterization, radial arteryspasm is a rare event in experienced hands (4.7% inPancholy et al.’s report). Yet, the temporary loss of ra-dial pulse can be very frustrating as it renders transra-dial access nearly impossible. In an academic environ-ment, this might sometimes occur when fellows or res-idents get accustomed with the technique! Indeed withthe radial artery, the first attempt is always the bestattempt! When radial artery spasm occurs, the radialistis faced with a few options: turn to contralateral radialartery (cumbersome), use the homolateral ulnar artery[2] (trickier), wait until pulse returns. . ., or revert tofemoral approach. As proposed by Pancholy et al., wehave successfully used subcutaneous nitroglycerin toaccelerate radial artery pulse return after transient col-lapse. We, recently, have further refined the technique

by directly mixing xylocain 2% with nitroglycerin(�50% vol/vol) at the time of local anesthesia. Thisseems to work effectively as we have not faced anydifficulties in canulating radial arteries in several hun-dred consecutive cases. This is also particularly helpfulwhen radial artery pulse is reduced secondary to previ-ous and sometimes numerous repeat transradial cathe-terizations. Since the negative impact of bleeding afterPCI is increasingly recognized, we must further stressthe benefits for patients of using transradial approach.In this regard, the use of subcutaneous nitroglycerinprovides an easy solution to facilitate radial or ulnarartery catheterization.

Olivier F. Bertrand, MD, PhDEric Larose, DVM, MDJosep Rodes-Cabau, MD,Hopital Laval, Institut Universitaire deCardiologie et de PneumologieChemin Ste Foy, Quebec, Canada

REFERENCES

1. Pancholy SB, Coppola J, Patel T. Subcutaneous administration of

nitroglycerin to facilitate radial artery cannulation. Catheter Car-

diovasc Interv 2006;68:389–391.

2. Mangin L, Bertrand OF, De La Rochelliere R, Proulx G, Lemay

R, Barbeau G, Gleeton O, Rodes-Cabau J, Nguyen CM, Roy L.

The transulnar approach for coronary intervention: A safe alterna-

tive to transradial approach in selected patients. J Invasive Car-

diol 2005;17:77–79.

Received 15 November 2006; Revision accepted 18 November 2006

DOI 10.1002/ccd.21040

Published online 9 March 2007 in Wiley InterScience (www.interscience.

wiley.com).

' 2007 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 70:161 (2006)