1. Transradial Interventions
Difficult Anatomic Substrate: Challenges and Solutions
Ramon Quesada, MD, FACP, FACC, FSCAI
Medical Director, Structural Heart ,Complex PCI & Cardiac Research
Miami Cardiac & Vascular Institute, Miami, Florida
Clinical Associate Professor of Medicine,
Florida International University
Herbert Wertheim School of Medicine

2. Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship Company
Grant/Research Support None
Consulting Fees/Honoraria Abbott, Cordis, St. Jude, W.L. Gore, Terumo & Boston Scientific Corporation
Major Stock Shareholder/Equity None
Royalty Income None
Ownership/Founder None
Intellectual Property Rights None
Other Financial Benefit None

3. TRA~ Start to Finish Subclavian & Coronary Cannulation ACCESS
Traversing Subclavian Tortuosity
Anatomical Variations
Rare but possible Complications
ACCESS
Anatomical Variations
Radial Artery Spasm
Perforation
Removal of Sheath/
Catheter
Radial Artery Occlusion
Hematoma / Pseudoaneurysm
Bleeding/Compartment syndrome
Hemostasis

4. But ….Does Difficult Anatomy = Difficult Decisions?

5. Dealing with Difficult Anatomic Substrates using TRA
You may not know “pre-access” that an anatomic challenge exists
If the patient has a radial pulse then the anatomy distal to the wrist can be managed
Getting the “right tool and technique” for the job translates into successful TRA access even with difficult anatomy

6. Forearm Normal Vascular Anatomy
Fujii et al. J Invasive Cardiol 2010;22:536-40

7. Incidence and Implications of Arterial Anomalies
Analysis and incidence of arterial anomalies completed by Fujii et al on 163 consecutive patients.
Classification of all anomalies and then stratification of the “difficulty” of transradial access for that anomaly was completed.
Overall it was concluded that 98.8% of patients were acceptable for TRA.
Fujii et al. J Invasive Cardiol 2010;22:536-40

8. Dealing with Difficult Anatomic Substrates using TRA
You may not know “pre-access” that an anatomic challenge exists
If the patient has a radial pulse then the anatomy distal to the wrist can be managed
Getting the “right tool and technique” for the job translates into successful TRA access even with difficult anatomy

9. Anatomical Variations
Fujii et al. J Invasive Cardiol 2010;22:536-40

10. Anatomical Variations
Fujii et al. J Invasive Cardiol 2010;22:536-40

11. Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064
Causes of Transradial Approach Percutaneous Coronary Intervention Failure
Radial Artery Loop
Guidewire-induced Dissection
Severe Spasm not relieved by inter-arterial nitro & verapamil
Severe Subclavian Tortuosity
Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:

12. Radial Anomalies and Procedural Failure7%
2.3%
2.5%
2.0%
Lo TS, et. Al. Heart, 2009:95:

13. Difficult Anatomic Challenge Scenario #1 “the radial loop”

14. 360o Radial Loop

15. Wire across 360o Radial Loop

16. Use a 2.0 Balloon over Wire followed by 6 Fr Diagnostic Catheter

17. “Possible” Vascular Complications Associated with TRA May Occur with Difficult Anatomy
Spasm
Bleeding
Hematoma
Compartment Syndrome
Perforation, laceration, dissection
Evulsion of artery
Pseudo-aneurysm
Subcutaneous granulomatous reaction to hydrophilic coating
Cutaneous infection
Subacute and delayed occlusion
Digital ischemia
Accelerated atherosclerosis
Transient vocal cord paralysis
Mediastinal hematoma
Delayed reflex sympathetic dystrophy

18. Dealing with Difficult Anatomic Substrates using TRA
You may not know “pre-access” that an anatomic challenge exists
If the patient has a radial pulse then the anatomy distal to the wrist can be managed
Getting the “right tool and technique” for the job translates into successful TRA access even with difficult anatomy

19. With difficult anatomy choose the right tool to avoid complications

20. Adjunctive Tools for TRA
For tortuosity at the radial brachial level, and anatomical variations, coronary floppy wires are sufficient.

21. Conventional coronary wire negotiating radial tortuosity

22. Radial Artery Tortuosity: How to Navigate
Feldman 1

23. Radial Artery Tortuosity: To overcome tortuosity, use conventional
Radial Artery Tortuosity: To overcome tortuosity, use conventional .014" standard coronary wire.
Feldman 3

24. Radial Artery Stenosis:
To overcome stenosis, use conventional .014" standard coronary wire
Poveda

25. How would you approach this radial?

26. Use gentle catheter navigation over a universal 0.14” coronary wire
6 Fr radial catheter

27. Proceed with the case…

28. How do you deal with tortuousity?
How to Optimize TRA ~ Subclavian & Coronary
How do you deal with tortuousity?
Use a Benson or Wholey wire into the ascending aorta. If there is significant tortuousity in the subclavian artery, switch to a stiff exchange or Cook or Amplatz wire.
Pull the wire into the shaft of the catheter in order to facilitate torquing for coronary cannulation.
Quesada et al, “Transradial Coronary Interventions”, Interventional Cardiology Secrets, 2003, pp

29. Subclavian tortuosity/coronary cannulation with wire support

30. Commonly Used Guiding Catheter Shapes
Left Arm Approach
Right Arm Approach
For Lesions in LCA
- XB 3.5
- XB 3.0
- JL 4
- JL 3.5
- Kimny
For Lesions in RCA
- JR 4
- AL I or AL II
- AL I
- Castillo 1 & 2
- Barbeau

31. New Diagnostic Radial Catheters
TIG-MOD 4.0
Ikari Right
Ikari Left 31

32. Right transradial access in very anterior arch (bovine)
Diagnostic
Right transradial access in very anterior arch (bovine)
Note: catheter is pointing up resulting in dye induced dissection of left main LAD
Castro dissection lad

33. Special Featured Catheters TIGER and JACKY
Two specific curves that are utilized for right radial approach. Either may be used to facilitate easy cannulation of both the RCA and LCA. The LV can also be entered, pressures measured and hand injection performed.
Show each catheter and how the tips are different. Be sure to point out that each is used independently of the other. PERSONAL PREFERENCE 33

34. Scenario #2 “The Aberrant Artery”

35. Subclavian Anatomic Challenge
The Aberrant Right Subclavian Artery (Arteria Lusoria)

36. Right Subclavian Angiography
This is an Arteria Lusoria
A 6-French radial guiding catheter was advanced into the right subclavian artery and appeared to go directly into the descending aorta, despite repeated attempts to access the ascending aorta

38. How can this be overcome?
In an elective case switching to the left radial or femoral can be considered
In this case – the patient was a STEMI and DBT was a factor
Are there any technical maneuvers that would permit negotiation of this 70° angle?

39. No….
Attempting to negotiate the angle using the Kimny catheter and stiff wire could cause a dissection and a real MESS!
My solution to this challenge was not to switch access but to
Switch catheters…
I chose an angulated pigtail catheter with a soft Benson wire.

40. Pre-intervention coronary angiography: note catheter angulation at the entrance of the ascending aorta

41. Pre-intervention coronary angiography: total occlusion distal RCA (infarct related vessel) TIMI flow = 0 GR4 guiding catheter

42. Post aspiration thrombectomy
Post PCI & BMS

43. Avoid dissection as a result of cannulating via arteria lusoria
Forms an acute angle (70°) with the proximal aortic arch
aberrant right subclavian artery
the false lumen with retained contrast medium
Huang, I, J Chin Med Assoc • July 2009 • Vol 72 • No 7

44. Conclusions
Radial artery anatomical variations and the inherent challenges to interventional technique can be handled with careful selection and use of wires and guide catheters.
Awareness of possible complications to be avoided is the most useful risk reduction technique.
Slow down and be Sure

45. Thank You!