Use of Intra-Arterial Papaverine for Severe Arterial Spasm during Radial Cardiac Catheterization

ABSTRACT: Coronary angiography and intervention can be performed safely using the radial artery. However, arterial spasm is often encountered and usually amenable to nitrate/verapamil therapy. Rarely, surgical intervention is required to remove catheters and wires. Intra-arterial papavarine can be used to treat severe radial artery spasm and prevent the need for urgent surgical intervention.

J INVASIVE CARDIOL 2008;20:551–552

Case Report. A 46-year-old female presented with a 2-month history of nonexertional left-sided chest pain radiating to her arms. She had no significant past medical history, but was a smoker of 10 cigarettes per day for several years. She was on no medication and had no family history of note. Her cardiovascular examination was normal and her resting 12-lead electrocardiogram and chest X-ray were unremarkable. She underwent a Bruce protocol exercise tolerance test on which she managed 6 minutes before stopping due to fatigue and chest pain. Her electrocardiograms revealed minor lateral ST changes.

Coronary angiography was performed via her right radial artery. Radial artery puncture was straightforward, and a left 3.5 Judkins catheter was used to attempt left coronary angiography. Unfortunately, the J-tipped guidewire formed a loop at the brachial bifurcation and the distal end went down the ulnar artery as a loop (Figures 1A and B). Despite gentle traction, the wire became stuck in this position due to severe arterial spasm. Intra-arterial nitrates and verapamil were administered, but this failed to release the wire. An attempt was made to snare the tip of the wire at the brachial bifurcation via the right femoral artery (Figure 2); unfortunately, this was also unsuccessful. Coronary angiography via the femoral approach revealed normal coronary arteries.

The patient was prepared for possible vascular surgery to remove the wire. Prior to going to the surgical theater, the patient was given 30 mg of intra-arterial papaverine stat. An MPA-1 multipurpose catheter (Cordis Corp., Miami Lakes, Florida) was then used to push on the wire at the brachial bifurcation. The guidewire suddenly became released from the ulnar artery and was advanced up to the aortic root and straightened (Figure 3). The wire and catheter were then removed. The patient was anticoagulated with intravenous heparin overnight and discharged the following day after remaining well. The patient had no long-term sequelae in her right hand.

Arterial spasm is often encountered during cardiac catheterization via the radial artery. Nitroglycerin and verapamil have been used as spasmolytics for radial artery catheterization; phentolamine has been reported to be an alternative to verapamil and nicorandil used with verapamil as a cocktail has been shown to be effective in preventing radial artery spasm. Papaverine is a benzylisoquinoline with vasodilatory and muscle spasmolytic action, although its use for radial artery spasm has not been reported previously. Although papaverine is unlicensed for use in cardiac catheterization, it can be invaluable when given intra-arterially to relieve severe spasm and represents a novel solution to preventing the need for vascular surgery.