Acetylcholine Spasm Provocation Test By Trans-Radial Artery And Vein Approach : A Case Report

70-year-old man admitted to our hospital because of chest discomfort on effort. Because we inserted the 6 Fr sheath into the wrong radial vein, we replaced the 5 Fr sheath into the radial vein. We inserted the 6 Fr sheath into the radial artery. We performed the acetylcholine and ergonovine spasm provocation tests under the temporary pace maker insertion. After the procedures, we compressed the radial artery and vein with radial band simultaneously. No bleeding or hematoma was found after the removal of radial band. We could perform the acetylcholine test via the radial artery and vein without any complications.


Introduction
According to the Japanese Circulation Society (JCS) guidelines, the insertion of temporary pace maker is necessary during acetylcholine testing.1) We reported the brachial artery and vein approach spasm provocation tests of acetylcholine.2) We recently performed the radial artery and brachial vein approach spasm provocation test of acetylcholine. Here, we report a case whom we could successfully perform the acetylcholine test via the radial artery and vein approach procedure.

Case report
In 2000, 52-year-old man admitted to another hospital because of chest oppression on exercise. Just mild atherosclerosis on the mid left anterior descending (LAD) artery was found. Intracoronary ergonovine administration of 40 g into the right coronary artery (RCA) caused focal spasm on segment 2-3, while subtotal occlusion at segment 7 was recognized after the administration of 64 g ergonvoine into the left coronary artery (LCA). He was diagnosed as multiple coronary spastic angina. Under the two calcium-channel antagonists (nifedipine R 80 mg and benidipine 8 mg/day) and statin (fluvastatin 15 mg), he was well controlled. In 2018, coronary computed tomography was performed. Coronary atherosclerosis on both left anterior descending artery and circumflex artery was suspected, while myocardial thallium scintigraphy showed the anterior and inferior ischemia.
We tried to perform the coronary angiography including the acetylcholine test. We failed the puncture of brachial vein and punctured the radial artery. We inserted the 6 Fr sheath into the wrong radial vein. We replaced the 5 Fr sheath into the radial vein. We again punctured the radial artery near the radial vein and cannulated with 6 Fr sheath. (Figure 1-A) No significant coronary stenosis was found on control coronary angiography (Figure 2-A, 2-B). We performed the acetylcholine test on both coronary arteries (Figure 1-B). No spasm was provoked after the intracoronary administration of 20/50/80/100 g acetylcholine (Figure 2-C, 2-D). Intracoronary ergonovine test was performed. Typical spasm was not provoked after the administration of 40/64 g ergonovine (Figure 2-E, 2-F). After the administration of nitrate, no significant fixed stenosis was recognized (Figure 2-G, 2-H). We could successfully perform the pharmacological spasm provocation tests via the radial artery and vein approach procedures (Figure 1-C) and compressed the puncture sites with the radial band simultaneously (Figure 1-D). After the 8 hours' compression of radial band, no bleeding or hematoma was found around the puncture sites. He discharged well next morning.

Discussion
We could successfully perform the pharmacological spasm provocation tests including the intracoronary acetylcholine test via the radial artery and vein approach procedure. No bleeding or hematoma was found after the 8 hours' compression of the radial band.
During performing the acetylcholine test, it is necessary to insert the temporary pace maker for safety. We used femoral vein, internal jugular vein, or brachial vein to insert the temporary pace maker. Initially, we performed the acetylcholine tests via the femoral artery and vein.3) Next, we performed the acetylcholine tests by the brachial artery and femoral vein. In 2000, we reported the brachial artery and vein approach acetylcholine tests. 1) Recently, we performed the radial artery and brachial vein approach acetylcholine tests. However, two compression sites were necessary and the exercise disturbance of the upper arm was recognized.
Acetylcholine testing without the temporary pace maker was reported by Ong et al. 4) However, even more than 3 minutes administration of acetylcholine showed the back-up pace maker rhythm set at 40 beats/minute in a quarter of patients with LCA testing. 5) Acetylcholine tests in the RCA were performed in just a third of their study patients. We recommend the temporary pace maker insertion when we performed the intracoronary acetylcholine testing as the JCS guidelines. Although the routine radial vein insertion may be difficult, radial artery and vein approach acetylcholine tests were feasible and safe in this case. The most important issue was the just one compression site and more comfortable for patients.

Conclusions
We could successfully perform the radial artery and vein approach acetylcholine test without any complication in this case. When we failed the insertion of brachial vein sheath, radial vein insertion may be another choice on acetylcholine tests.