Impact of Preprocedural Stress Ball Use on Radial Artery Outcomes in Elective Coronary Angiography

Radial artery access has become the preferred approach for coronary angiography and percutaneous coronary intervention (PCI) due to its superior safety profile, reduced bleeding complications, earlier patient mobilization, and improved overall comfort compared to the traditional femoral approach. Despite these advantages, transradial procedures are not entirely free of complications. Radial artery spasm (RAS) remains a significant concern, with reported incidence rates ranging from 4% to 20%, depending on operator experience and patient-related factors. Additionally, vascular complications such as hematoma, arterial dissection, pseudoaneurysm, bleeding at the access site, and post-procedural radial artery occlusion (RAO) can affect procedural success and may limit future access via the same route.

Handgrip exercise has been proposed as a simple, non-invasive, and cost-effective strategy to improve arterial compliance, increase vessel diameter, and potentially reduce vasospasm by enhancing endothelial function and promoting local vasodilation. Despite promising physiologic rationale and preliminary findings in other settings (such as arterial diameter augmentation prior to AV fistula creation), the role of preprocedural hand exercise in preventing radial artery complications during coronary procedures has not been systematically studied in a randomized controlled trial.

This single-center, randomized, double-blind, controlled clinical trial aims to assess whether regular preprocedural hand exercise using a soft stress ball can reduce the incidence of RAS and vascular complications in patients undergoing elective coronary angiography via the transradial approach.

A total of 400 adult patients (aged 18 to 85 years), scheduled for elective diagnostic or interventional coronary procedures via the radial artery, will be enrolled. Patients with contraindications to radial access, prior significant upper limb vascular disease, or inability to perform the hand exercise regimen will be excluded.

Participants will be randomly assigned in a 1:1 ratio to either the intervention group or the control group using a computer-generated randomization sequence. Both the interventional cardiologist performing the procedure and the clinical staff responsible for outcome assessment will remain blinded to group allocation.

Intervention Group: Patients will be instructed to perform handgrip exercises using a soft stress ball for 5 minutes per session, three times per day, for three consecutive days prior to the procedure. Adherence will be monitored through a patient-completed exercise log and direct interview at the time of hospital admission.

Control Group: Patients will receive standard preprocedural care without any specific hand exercise recommendations.

The primary outcomes of the study include:

Incidence of radial artery spasm, defined clinically by resistance to catheter advancement, patient-reported discomfort, or the need for pharmacologic spasmolytics during the procedure.

Overall rate of vascular complications, including access site hematoma, arterial dissection, pseudoaneurysm, and access-related bleeding.

The secondary outcomes include:

Patient-reported pain during radial access, measured using the Visual Analog Scale (VAS).

Incidence of radial artery occlusion (RAO), evaluated at 7 days post-procedure via Doppler ultrasonography.

This study seeks to determine whether a brief period of structured, low-intensity hand exercise can serve as an effective adjunct to routine preprocedural care in patients undergoing transradial coronary angiography. If proven effective, this strategy could be incorporated into standard practice, offering a low-risk and widely applicable method to enhance procedural outcomes, minimize patient discomfort, and preserve radial artery integrity for future access.

Additionally, this trial will contribute valuable data to the growing field of procedural preparation optimization, focusing on patient-involved, non-pharmacological interventions that promote vascular health and procedural success.

Inclusion criteria

• Age between 18 and 85 years
• Elective radial coronary angiography planned
• Written informed consent provided
• Ability to understand and comply with the stress ball exercise protocol (3×5 minutes/day for 3 days prior to procedure)
• Palpable radial pulse on the planned access site

Exclusion criteria

• Emergent or urgent coronary procedures
• Known radial artery occlusion or non-palpable radial pulse on the intended access side
• Prior arteriovenous fistula or vascular surgery in the ipsilateral arm
• History of Raynaud's disease, severe peripheral artery disease, or Buerger's disease
• Neurological or musculoskeletal disorders affecting hand grip (e.g., stroke, advanced arthritis, peripheral neuropathy)
• Cognitive impairment or psychiatric condition preventing protocol adherence
• Inability to use hand muscles effectively (e.g., recent hand trauma, paralysis)
• Unwillingness or inability to perform the stress ball exercises as instructed
• Pregnancy or breastfeeding