Atherosclerotic coronary heart disease has an important place among cardiovascular diseases, which are the most common cause of mortality and morbidity all over the world. Although anamnesis, physical examination, laboratory and non-invasive stress tests are usually sufficient for diagnosis, some patients require coronary angiography, which is the gold standard imaging method(1). The main advantage is that it clearly shows the coronary anatomy and allows treatment with percutaneous coronary intervention to be performed in the same session. As coronary angiography laboratories become more widespread and more easily accessible, they are being used more frequently all over the world. Coronary angiography can be accessed from the femoral, radial, brachial, ulnar or axillary arteries. As atherosclerotic coronary artery disease is a progressive and chronic condition, many patients undergo repeated coronary angiography interventions and, therefore, have multiple artery access sites(2–3).
Distensibility and elasticity determined by vascular tone are two important parameters that reflect subclinical damage in arteries. There are many publications in the literature demonstrating that a decrease in distensibility and elasticity is associated with undesirable cardiovascular events and directly linked to subclinical atherosclerosis in the arteries. Although both distensibility and elasticity can be evaluated with many different imaging methods, ultrasonography is the most preferred modality, as it is cheap and easily accessible(4–7).
The effect of these interventions on the femoral artery is not clear in patients undergoing femoral artery catheterization for coronary angiography. The aim of this study was to evaluate this effect through measurements of the distensibility and elasticity of the femoral arteries on the accessed and non-accessed sides in patients who had previously undergone unilateral femoral artery coronary angiography.
This single-center cross-sectional study included patients who were followed up in the Cardiology Outpatient Clinic of Baskent University, Faculty of Medicine, Adana Hospital after undergoing coronary angiography from the femoral artery at least 1 year prior. The patients were divided into 4 groups according to the number of interventions performed on the femoral artery. Those whose femoral artery was accessed once formed Group 1 (
Known peripheral arterial disease, atrial fibrillation, patients who were accessed at both femoral arteries (at different times or at the same time), patients with percutaneous coronary intervention, hypertension, patients with lower or larger femoral sheath implantation than 6 Fr, diabetes mellitus, familial hypercholesterolemia, smoking, presence of collagen tissue disease, presence of autoimmune disease, chronic kidney disease, chronic liver disease, steroid use, presence of hypo- or hyperthyroidism, patients who had their last femoral artery accessed less than 1 year prior to the study, patients with ejection fraction (EF) <40%, patients with severe heart valve disease, presence of active infection, patients undergoing previous cardiac surgery, age <18 years or >65 years, all local complications for femoral access (dissections, hematoma, arteriovenous fistula, pseudoaneurysm), as well as patients whose image quality results were insufficient or patients not wanting to participate in the study were excluded.
All participants were placed in the supine position and then connected to an electrocardiogram and monitored. B-mode duplex ultrasonography revealed a longitudinal visualization of the femoral arteries by visualizing the right and left common femoral arteries. In this image, the lumen diameter (LD) was calculated by measuring the intima-intima distance between the distal and proximal walls. The media-media distance was measured, and the vessel diameter (VD) was recorded. All measurements were taken separately during the systole and diastole, and the maximum and minimum of these values were calculated (VDmax, VDmin, LDmax, LDmin). Figure 1 shows the measurement of LDmax and VDmax in systole (A), and LDmin and VDmin in diastole (B). All measurements were performed in 3 consecutive heartbeats, and the mean values of these 3 measurements were recorded. Systole and diastole separation were performed according to the ECG. The formula [(VDmax –VDmin) / VDmin] × 100 was used for femoral artery distensibility (%)(9). Femoral artery elasticity (% / mmHg) was calculated according to the formula ([(LDmax –LDmin) / LDmin] / ΔP) × 100%(9–10). In this formula, ΔP = the difference between systolic and diastolic blood pressure. All measurements of both distensibility and elasticity were performed automatically using dedicated software.
The study was carried out in accordance with the criteria of the Helsinki Declaration, and approval was obtained from the local ethics committee. After giving detailed information about the study, written consent forms were obtained from all participants.
Continuous variables were tested for normal distribution by using the Kolmogorov-Smirnov test. The results including normally distributed variables were expressed as mean ± standard deviation, while non-normally distributed variables were expressed as medians and interquartile ranges (IQR). Categorical variables were shown as absolute values and percentages. Continuous variables with a normal distribution were analyzed with one-way analysis of variance (ANOVA) or paired samples t-test, as appropriate (paired samples t-test for dependent variables, one-way ANOVA for independent variables). Continuous variables with a non-normal distribution (for independent variables) were analyzed with the Kruskal-Wallis test. Categorical variables of independent samples were compared with the chi-square test. A
The evaluation included a total of 231 patients; 59 in Group 1, 57 in Group 2, 55 in Group 3, and 60 in Group 4. Baseline demographic, clinical and laboratory values of the groups are shown in Tab. 1. There was no statistically significant difference in femoral distensibility and elasticity between the accessed and non-accessed sides in Group 1 (
Group 1 ( |
Group 2 ( |
Group 3 ( |
Group 4 ( |
|
|
---|---|---|---|---|---|
Age [years] | 59.23 ± 5.62 | 60.7 ± 4.98 | 58.76 ± 5.66 | 59.61 ± 5.61 | 0.282 |
Female sex [n (%)] | 23 (38.98) | 28 (49.12) | 21 (38.18) | 27 (45) | 0.598 |
BMI [kg/m2] | 28.68 ± 3.56 | 28.73 ± 3.49 | 28.49 ± 3.18 | 28.71 ± 3.79 | 0.982 |
Creatinine [mg/dL] | 0.78 ± 0.1 | 0.77 ± 0.11 | 0.79 ± 0.12 | 0.8 ± 0.13 | 0.577 |
Hb [gr/dL] | 13.67 ± 1.29 | 13.76 ± 1.49 | 14.1±1.41 | 13.57 ± 1.41 | 0.2 |
WBC [/mm3] | 7510 ± 1659 | 7212 ± 1923 | 7123 ± 1738 | 7309 ± 1887 | 0.614 |
Platelets [100/mm3] | 280 (172) | 274 (56) | 245 (45) | 238 (81) | 0.075 |
FPG [mg/dL] | 101.73 ± 9.87 | 102.16 ± 8.23 | 102.85 ± 10.26 | 102.53 ± 9.63 | 0.93 |
HDL [mg/dL] | 45.47 ± 7.46 | 47.66 ± 9.05 | 47.36 ± 8.75 | 47.2 ± 6.97 | 0.457 |
LDL [mg/dL] | 130.81 ± 16.35 | 135.1 ± 21.37 | 130.3 ± 16.73 | 132.21 ± 17.36 | 0.491 |
Triglyceride [mg/dL] | 145 (88) | 134 (67) | 128 (79) | 147 (69) | 0.258 |
EF [%] | 58.61 ± 2.91 | 58.78 ± 3.29 | 58.76 ± 2.97 | 59.08 ± 3.16 | 0.866 |
SBP [mmHg] | 122.95 ± 6.8 | 124 ± 6.43 | 123.87 ± 9.12 | 122.82 ± 9.34 | 0.799 |
DBP [mmHg] | 80.97 ± 5.45 | 81.04 ± 5.31 | 80.93 ± 5.83 | 81.60 ± 4.97 | 0.895 |
USG time [month]* | 28 (16) | 29 (13.5) | 28 (14) | 27 (17.75) | 0.918 |
SYNTAX Score | 7 (4) | 11 (6) | 15 (7) | 17 (5.75) | <0.001 |
ASA [ |
33 (55.93) | 47 (82.45) | 48 (87.27) | 55 (91.66) | <0.001 |
Beta blocker [ |
6 (10.16) | 27 (47.36) | 47 (85.45) | 55 (91.66) | <0.001 |
Ca CB |
6 (10.16) | 6 (10.52) | 6 (10.9) | 5 (8.3) | 0.968 |
Trimetazidine |
0 (0) | 0 (0) | 0 (0) | 12 (20) | NA |
Nitrates [ |
0 (0) | 0 (0) | 11 (21.81) | 51 (85) | NA |
Ranolazine |
0 (0) | 0 (0) | 6 (10.9) | 17 (28.33) | NA |
Group 1 ( |
Group 2 ( |
Group 3 ( |
Group 4 ( |
|||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Access side | No access side |
|
Access side | No access side |
|
Access side | No access side |
|
Access side | No access side |
|
|
Distensibility [%] | 9.40 ± 0.84 | 9.48 ± 0.75 | 0.107 | 9.02 ± 0.81 | 9.23 ± 0.75 | <0.001 | 8.49 ± 0.77 | 9.18 ± 0.9 | <0.001 | 8.14 ± 0.74 | 9.03 ± 0.81 | <0.001 |
Elasticity [%/mmHg] | 0.23 ± 0.03 | 0.23 ± 0.03 | 0.433 | 0.21 ± 0.02 | 0.22 ± 0.02 | <0.001 | 0.19 ± 0.02 | 0.21 ± 0.02 | <0.001 | 0.16 ± 0.01 | 0.2 ± 0.02 | <0.001 |
This is the first study reported in the literature which examines the effects of femoral artery access on femoral artery distensibility and elasticity after coronary angiography. According to the results obtained, femoral artery interventions performed for coronary angiography reduce femoral artery distensibility and elasticity.
Decreased distensibility and elasticity of the elastic arterial system are well-known to be associated with atherosclerosis and cardiovascular complications. It has been shown that distensibility and elasticity are significantly associated with the development and progression of atherosclerotic diseases that lead to cardiovascular events. In addition, researchers have also documented that distensibility and elasticity vary among different vascular segments. Evaluating these differences will be helpful for better understanding of the local changes of atherosclerotic plaques in the arterial system(11,12).
Although some studies have examined the impact of percutaneous coronary interventions on endothelial function, there are few studies evaluating the effect of coronary angiography alone(13–15). In addition, the majority of studies found in the literature focus on the radial artery, so the femoral artery has not been studied in this respect. In a study by Tak
This study was performed only on patients where 6 French sheaths were used. It is not known how sheaths of other thicknesses would affect the results. The compression time at the insertion site after coronary angiography was not standard, and it is not known whether this time would affect the findings. The effect of these results on the femoral arteries in the long term, and whether this effect has clinical significance, is also unknown. Since the selection of patients was done retrospectively, and some interventions were performed with outdated machines, we were unable to determine the dose of radiation each subject received, which might affect femoral artery properties. The number of patients in the study was limited, and the findings need to be supported by studies enrolling more patients.
A single 6-French access on the femoral artery during coronary angiography does not affect femoral artery elasticity and distensibility in the long term, whereas multiple accesses may adversely affect femoral artery distensibility and elasticity.