Coronary angiography in the presence of peripheral vascular disease: femoral or brachial/radial approach?

Safety and efficacy of brachial approach for coronary angiography and percutaneous coronary intervention

BACKGROUND

There are many percutaneous coronary approaches. The most commonly used one is the radial artery because of its lowest risk of adverse vascular events. However, it could not be an option in some situations as congenital radial artery hypoplasia and spasm. In these cases, the second most common access is the femoral artery. The current literature over the brachial artery access is controversial. Thus, the aim of this study was to verify the brachial artery approach's effectiveness and safety.

RESULTS

We studied 300 patients who underwent elective coronary angiography and angioplasty in our institution with failed radial access between August 2022 and February 2023. They were classified into two groups; 150 patients with brachial access and 150 with femoral access. Access, procedural and fluoroscopy times were recorded. All patients were examined carefully immediately after the procedure and before discharge to assess any complications. Left brachial access was used more frequently than left femoral access (32.7% vs. 22.7%, P = 0.05), but no significant difference noted regarding right sided or bilateral access. Procedure time, fluoroscopy time, and contrast volume did not significantly differ (P = 0.19, 0.06 and 0.1 respectively). However, brachial group had shorter access time (2.6 ± 1.1 vs. 3.4 ± 0.7 min, P = 0.05) and hospital stay (3.5 ± 1.1 vs. 5.9 ± 1.3 days, P < 0.001). Regarding major and minor complications (especially hematomas), they were significantly less in the brachial arm (P = 0.04 and P = 0.05, respectively).

CONCLUSIONS

Brachial access is a safe, efficient and non-inferior to the femoral route for coronary intervention whenever radial access is not an option.

Transradial versus transfemoral approach for coronary angiography and angioplasty - A prospective, randomized comparison

Background

PCI has been done traditionally through transfemoral route. But now transradial and transbrachial routes are also coming up in practice. We compared transradial versus transfemoral routes for ease of operability, time for procedure, complications, and failure rates through a prospective study.

Methods

Four hundred Patients admitted in department of cardiology for percutaneous interventions were enrolled in the study. 200 patients were assigned to each group randomly. A single team did all the procedures. Pre procedure, intra procedure and post procedure data of all the patients was collected, tabulated and analysed properly.

Results

Access time (6.0 ± 1vs 4.2 ± 0.7; P =0.001); Fluoroscopy time and overall procedure time (29 ± 11.3 Vs. 27.3 ± 12.4 min) were more with trans radial than transfemoral route, respectively. The most common post procedure complication, ecchymosis was seen in 20.5% in transfemoral group compared to 12.5% in transradial group (P 0.031). Thrombophelibites (17.5 VS 8%, P0.004); Hematoma (14.5 Vs 0%, P 0.005); post procedure access bleed (7 VS 3%, P 0.039) were seen in transfemoral than transradial group, respectively. Failure rates were almost similar. None of our patients had post procedure myocardial infarction, stroke, acute renal failure and infections.

Conclusion

Transradial approach of PCI is better than transfemoral route with respect to complications like bleeding, haematoma formation, thrombophelebites and ecchymosis is concerned. However access and fluoroscopic time is more with the former. We recommend the transradial route for PCI.

Trial registration

Trial is retrospectively registered in ClinicalTrials.gov with the Identifier: NCT02983721, Date of registration is December 2, 2016.

The use of machine learning for the identification of peripheral artery disease and future mortality risk

OBJECTIVE

A key aspect of the precision medicine effort is the development of informatics tools that can analyze and interpret "big data" sets in an automated and adaptive fashion while providing accurate and actionable clinical information. The aims of this study were to develop machine learning algorithms for the identification of disease and the prognostication of mortality risk and to determine whether such models perform better than classical statistical analyses.

METHODS

Focusing on peripheral artery disease (PAD), patient data were derived from a prospective, observational study of 1755 patients who presented for elective coronary angiography. We employed multiple supervised machine learning algorithms and used diverse clinical, demographic, imaging, and genomic information in a hypothesis-free manner to build models that could identify patients with PAD and predict future mortality. Comparison was made to standard stepwise linear regression models.

RESULTS

Our machine-learned models outperformed stepwise logistic regression models both for the identification of patients with PAD (area under the curve, 0.87 vs 0.76, respectively; P = .03) and for the prediction of future mortality (area under the curve, 0.76 vs 0.65, respectively; P = .10). Both machine-learned models were markedly better calibrated than the stepwise logistic regression models, thus providing more accurate disease and mortality risk estimates.

CONCLUSIONS

Machine learning approaches can produce more accurate disease classification and prediction models. These tools may prove clinically useful for the automated identification of patients with highly morbid diseases for which aggressive risk factor management can improve outcomes.

Feasibility and Safety of Coronary Procedures via an Arteriovenous Graft Approach in Patients on Maintenance Hemodialysis

BACKGROUND

Traditionally, a radial or brachial arterial approach is unadvisable in hemodialysis patients. Consequently, coronary angiography or angioplasty is usually performed via a femoral artery approach in these patients, who carry a higher risk of vascular access complications. In hemodialysis patients, arteriovenous grafts (AVG) are created for repeated punctures; however, the feasibility and safety of a trans-AVG approach for coronary angiography or angioplasty remains unclear.

METHODS

In our institution, cardiac catheterizations were attempted via AV grafts in hemodialysis patients with a U-shaped forearm AVG. We retrospectively identified coronary angiography or angioplasty procedures in hemodialysis patients from a computer-based database in our hospital. The procedure details and outcomes were obtained from review of the clinical, angiographic and hemodialysis records.

RESULTS

From 2008 to 2013, 167 procedures in hemodialysis patients were identified from 2866 diagnostic or interventional coronary procedures in our institution. Out of these, 24 procedures in 17 patients were performed via a trans-AVG approach. In all AVG procedures, a 6F 16-cm or 7F 10-cm sheath was placed from the AVG into the brachial artery. All diagnostic procedures were successfully performed. In 14 procedures, the patients also underwent angioplasty and all of the angioplasty procedures were successful. There was no arterial spasm, arterial dissection, puncture site hematoma, or acute thrombosis of the AVG during or after the procedures.

CONCLUSIONS

A trans-AVG approach appears to be a feasible and safe route for coronary angiography or angioplasty in hemodialysis patients with a U-shaped forearm AVG. However, further studies with a larger patient number are necessary.

KEY WORDS

Arteriovenous graft; Hemodialysis; Percutaneous coronary intervention.

Transradial Peripheral Arterial Procedures

Increased understanding and increased adoption of transradial catheterization across the world have led to further exploring of radial artery access for transradial endovascular interventions in peripheral artery disease (PAD). This article discusses the advantages and limitations of the transradial approach for endovascular medicine by using case examples, illustrations, and videos. The details about how to use a radial approach for PAD intervention, including and tips tricks, are discussed.

Clinical and socioeconomic factors associated with unrecognized peripheral artery disease

Peripheral artery disease (PAD) is a highly prevalent condition that frequently goes undetected and untreated. Socioeconomic factors associated with unrecognized PAD are not known. The ankle-brachial index (ABI) was calculated in 1656 study participants undergoing non-emergent coronary angiography with PAD defined as an ABI <0.9. Subjects were followed for mortality and cardiovascular outcomes. Compared to those without PAD, those with unrecognized PAD at enrollment were older, had higher rates of cardiovascular comorbidities, and had higher major adverse cardiovascular events (MACE) (p<0.03 for all). Among those enrolling without a reported history of PAD, there was a higher prevalence of PAD with decreasing income (p=0.004), education level (p<0.001), social isolation (p=0.027) and depression (p=0.034); 50% of these individuals reported symptoms suggestive of claudication. In conclusion, the prevalence of unrecognized PAD is high amongst a cohort of high-risk individuals referred for coronary angiography. A profile of lower socioeconomic status is associated with unrecognized PAD. These subjects will report symptoms suggestive of claudication and impaired walking ability when directly queried.

Sex differences in the prevalence of peripheral artery disease in patients undergoing coronary catheterization

To determine whether there are sex differences in the prevalence of peripheral artery disease, we performed an observational study of 1014 men and 547 women, aged ≥ 40 years, referred for elective coronary angiography. Women were slightly older, more obese, had higher low-density lipoprotein cholesterol (LDL-C) levels and systolic blood pressure (BP), and were more likely to be African American. Women had higher high-density lipoprotein cholesterol (HDL-C) levels, lower diastolic BP, and were less likely to smoke or to have a history of cardiovascular disease. Women had less prevalent (62% vs 81%) and less severe coronary artery disease (CAD) (p < 0.001 for both) by coronary angiography, but more prevalent peripheral artery disease (PAD) as determined by the ankle-brachial index (ABI) than men (23.6% versus 17.2%). Independent predictors of lower ABI were female sex, black race, older age, tobacco use, CAD, diabetes, and triglyceride level. In a full multivariable logistic regression model, women had a risk-adjusted odds ratio for PAD of 1.78 (95% CI 1.25-2.54) relative to men. Among patients referred for coronary angiography, women have less prevalent and less severe CAD, but more prevalent PAD, a sex difference that is not explained by traditional cardiovascular disease risk factors or CAD severity. Clinical Trial Registration-URL: http://clinicaltrials.gov. Unique identifier: NCT00380185.

Brachial Approach for Coronary Angiography and Intervention: Totally Obsolete, or a Feasible Alternative When Radial Access is Not Possible?

Introduction: This study aims to assess the safety and feasibility of brachial arterial puncture for coronary procedures when radial access is not possible. Radial arterial approach is the usual option for coronary procedures in our hospital. Whenever radial access is not possible, the brachial approach is preferred instead of the femoral approach. As many clinicians considered percutaneous brachial coronary angiography as an obsolete and hazardous procedure, we carried out this study to compare the outcomes of the brachial approach to the femoral approach in our centre. Materials and Methods: We retrospectively evaluated all cases of brachial artery puncture and femoral artery puncture in our centre from 1 January 2007 to 31 March 2009 through a prospectively collected database and looked for all complications which occurred in both groups. Results: The femoral group had a slightly higher incidence of major complications – 3 out of 121 cases (2.5%) in the femoral group and 1 out of 180 cases (0.6%) in the brachial group, even though this was not statistically significant (P = 0.15). There was also no difference between these 2 groups for minor complications: 8 patients (4.4%) in the brachial group and 6 patients (5%) in the femoral group developed haematoma that did not require any blood transfusion or surgery. There was no incidence of brachial artery thrombosis and no puncture-related neurological deficit documented in the brachial group. Conclusion: Brachial artery puncture and catheterisation may be a viable, safe and efficient alternative to the transfemoral approach in a centre that is experienced with the arm approach, when radial access is not possible. Key words: Angiography, Complications, Diagnostic cardiac catheterisation, Percutaneous coronary intervention

[Transradial approach and kidney disease]

Patients with chronic kidney disease have a high cardiovascular risk and mortality. This problem is growing because of the aging of the population and prevalence of diabetes. Transradial approach is traditionally prohibited due to the injury that catheterization induces on this artery that could possibly influence its suitability as an arteriovenous fistula. Paradoxically, the increased risk of major vascular complications with femoral access leads to transgress this rule. Indeed, transradial approach by reducing dramatically the rate of vascular bleeding complications leads to a significant reduction of adverse events and mortality, especially in the high cardiovascular risk sub-group. In patients with chronic kidney disease, choice of vascular access site should compare the potentially fatal risk of vascular complications with the one of traumatizing the artery needed to create a distal hemodialysis access site. Thus, chronic renal insufficiency even on hemodialysis should not be an absolute contraindication to radial approach, which could be used individually by a skilled team and in a mini-invasive spirit. A large randomised study comparing radial and femoral access in this population is needed.

Diagnostic coronary angiography in patients with peripheral arterial disease: a sub-study of the Coronary Artery Revascularization Prophylaxis Trial

BACKGROUND

Although patients in need of elective vascular surgery are often considered candidates for diagnostic coronary angiography, the safety of this invasive study has not been systematically studied in a large cohort of patients scheduled for an elective vascular operation. The goal of this sub-study of the Coronary Artery Revascularization Prophylaxis (CARP) trial was to assess the safety of coronary angiography in patients with peripheral vascular disease.

METHODS

The CARP trial tested the long-term benefit of coronary artery revascularization prior to elective vascular operations. Among those patients who underwent diagnostic coronary angiography during screening for the trial, the associated complications were determined at 24 hours following the diagnostic procedure.

RESULTS

Over 5,000 patients were screened during a 4-year recruitment period at 18 major VA medical centers and the present cohort consists of 1,298 patients who underwent preoperative coronary angiography. Surgical indications for vascular surgery included an expanding aortic aneurysm (AAA) (n = 446; 34.4%) or arterial occlusive disease with either claudication (n = 457; 35.2%) or rest pain (n = 395; 30.4%). A total of 39 patients had a confirmed complication with a major complication identified in 17 patients (1.3%). Complication rates were higher in patients with arterial occlusive symptoms compared with expanding aneurysms (1.8% vs. 0.5%; P = 0.07) and were not dissimilar with femoral (2.8%) versus nonfemoral (4.7%) access sites (P = 0.42).

CONCLUSIONS

Coronary angiography is safe in patients with peripheral arterial disease undergoing preoperative coronary angiography. The complication rate is higher in patients with symptoms of arterial occlusive disease.

Transbrachial Stent-Assisted Coil Embolization of Right Posterior Inferior Cerebellar Artery Aneurysm: Technical Case Report

OBJECTIVE AND IMPORTANCE

We describe a case of stent-assisted coil embolization of a wide neck right posterior inferior cerebellar artery (PICA) aneurysm via a transbrachial artery approach.

CLINICAL PRESENTATION

A 73-year-old woman with a past medical history of hypertension, hyperlipidemia, colon cancer, and osteoporosis presented with a throbbing occipital area headache. Magnetic resonance angiography revealed a wide neck right PICA aneurysm. She presented for a planned endovascular stent-assisted coil embolization.

TECHNIQUE

The initial transfemoral approach was complicated by persistent guide catheter instability due to marked tortuosity of the right vertebral artery (VA). The left VA could not be accessed due to left subclavian occlusion with steal syndrome. Neuroform-2 (Boston Scientific; Natick, MA) stent-assisted Matrix (Boston Scientific; Natick, MA) coil embolization was successfully performed through a 6-French guide catheter using a transbrachial approach.

CONCLUSION

Current advances in technology produce neuroendovascular devices that are smaller with increased flexibility, allowing nonfemoral vascular access to the cerebral circulation via alternate arterial routes. This patient case demonstrates transbrachial access is a viable approach for endovascular aneurysm coil embolization, with or without stent assistance, in cases with an unstable guide catheter due to tortuous vessels or abnormal anatomy when femoral access is complicated or contraindicated.

Transradial cardiac catheterization in patients with coronary bypass grafts: Feasibility analysis and comparison with transfemoral approach

The objective of this study was to analyze the feasibility and safety of transradial catheterization in patients with remote surgical cardiac revascularization. Selective catheterization of coronary bypass grafts might be more difficult and time-consuming from the radial artery as compared to the femoral route. This special patient subset has been either excluded or underrepresented in previous studies. Retrospective review was made of 304 cardiac diagnostic procedures performed from January 2001 through December 2004 in patients with coronary artery bypass grafts in a single center. Patients had to be considered eligible for both transradial and transfemoral approach to be included. Cases with double internal mammary or gastroepiploic grafts were excluded. Selection of the arterial access was individualized according to operator preferences. Among diagnostic cases, transradial access was attempted as first choice in 151 cases (left radial in 133) and transfemoral in 154. Total procedural time (41 +/- 22 vs. 40 +/- 23 min), fluoroscopy time (15 +/- 10 vs. 18 +/- 13 min), and dye volume (180 +/- 64 vs. 192 +/- 73 ml) were similar. Crossover rates were 4.0% in the transradial group and 1.3% in transfemoral (P = 0.28). Only two patients in transradial group needed transfemoral access because of failure to catheterize a bypass graft. Transradial angiography of coronary bypass grafts can be performed with similar success rates as compared with transfemoral procedures and without a significant time delay.

Peripheral arterial disease, acute coronary syndromes, and early invasive management: the TACTICS TIMI 18 trial

BACKGROUND

Patients with peripheral arterial disease (PAD) represent a high-risk patient subset in the setting of non-ST-segment elevation acute coronary syndromes (NSTE ACS). The efficacy and safety of early invasive management for such patients remains unclear.

HYPOTHESIS

Early invasive management would be well tolerated and effective among patients with NSTE ACS and PAD.

METHODS

Patients from the Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction (TACTICS-TIMI) 18 trial were stratified by the presence or absence of PAD and assessed with respect to baseline clinical factors. The outcomes of patients with PAD and NSTE ACS were examined with respect to treatment assignment to either early invasive therapy or conservative treatment of NSTE ACS. Finally, the bleeding and stroke rates of patients with PAD managed invasively were compared with patients with PAD managed conservatively.

RESULTS

Of 2219 patients with NSTE ACS overall, 166 (7.5%) had concomitant PAD. Compared with those patients without PAD, those with PAD were older (75 vs. 62 years, p < 0.001) and were more likely to have high-risk clinical features, including prior histories of bypass surgery (39 vs. 20%, p < 0.001) or diabetes mellitus (38 vs. 27%, p = 0.002), and more ST-segment depression on their 12-lead electrocardiogram (43 vs. 29%, p < 0.001). Among such patients, early invasive management was associated with significant reductions in the risk of myocardial infarction (MI) at 30 days (11.4 vs. 2.3%, p = 0.03). At 180 days, compared with early conservative management, early invasive treatment for patients with PAD and NSTE ACS was associated with similar reductions in MI (12.7 vs. 3.5%, p = 0.04), and was also accompanied by significant reductions in risk of death (10.1 vs. 2.3%, p = 0.05). No excess in bleeding or stroke rates was noted among patients with PAD managed invasively.

CONCLUSIONS

Among patients with NSTE ACS and a history of PAD, early invasive management is well tolerated and accompanied by significant reductions in morbidity and mortality when compared with a more conservative, ischemia-driven approach.

Procedural complications following diagnostic coronary angiography are related to the operator's experience and the catheter size

Cardiac catheterization is performed routinely in hospitals all around the world. Extensive analysis of complications has been performed in the 1980s and early 1990s. However, because of the new therapeutic innovations based on advanced catheter technologies, these data may not apply to the present situation. Still, there are few data about procedural complications of diagnostic cardiac catheterization over the last 10 years. A total of 7,412 consecutive diagnostic cardiac catheterizations were performed between January 1990 and December 2000 and prospectively assessed in a registry. There were a total of 63 complications, of which 40 were minor and 23 major. Thus, the overall complication rate was 0.8%, with a mortality rate of 0%. Univariate analysis showed lower overall complication rate of senior physicians (> 500 coronary angiographies performed; OR = 0.58; 95% CI = 0.34-0.98; P = 0.04), smaller catheter size (< 6, 6, > 6 Fr: OR = 2.6; 95% CI = 1.53-4.41; P = 0.0004), and a higher rate in patients having left and right heart catheterization (OR = 2.62; 95% CI = 1.46-4.7; P = 0.003). Major complications were associated with larger catheters (< 6, 6, > 6 Fr: OR = 2.35; 95% CI = 1.0-5.51; P = 0.05), whereas vascular complications occurred more often with higher body weight (per 10 kg: OR = 1.4; 95% CI = 1.01-1.95; P = 0.04). Overall complication rate in diagnostic coronary angiography is very low and related to the experience of the performing cardiologist and catheter size. The only predicting risk factors for major complications in coronary angiography were catheter size and body weight.

Coronary angiography in the fully anticoagulated patient: the transradial route is successful and safe

The radial approach to coronary angiography is intuitively attractive for fully anticoagulated patients (INR > 2) but no data exist concerning efficacy or safety of this procedure. The consensus view is that the femoral approach is contraindicated in fully anticoagulated patients, and though some operators undertake femoral catheterization in such patients and use closure devices, there are no data to suggest that it is safe to do so. At our institution, the radial approach for coronary angiography is reserved for patients in whom there is a relative contraindication to the femoral route. We have undertaken over 600 radial coronary angiograms in such patients since 1996, 66 of whom underwent transradial catheterization specifically because of anticoagulation status (INR > 2). Thirty-eight patients (58%) were male, average age 67 +/- 11 years. All 66 patients had an INR > 2 but < 4.5. The approach was left radial in 26 (39%), right radial in the remainder; sheath size was 4 Fr in 4 (6%), 5 Fr in 13 (20%), and 6 Fr in 49 (74%). Seven operators in total were involved, though two operators undertook the majority of cases (47; 71%). Success rate was 97%, with no failure of access, and only one minor postprocedural hemorrhage. Failures were due to radial artery atherosclerosis (1) and subclavian tortuosity (1). The radial approach to coronary angiography is safe and to be recommended in the fully anticoagulated patient.

Transradial coronary angiography in patients with contraindications to the femoral approach: An analysis of 500 cases

The transradial approach to coronary angiography is considered by some to be a route of choice, by others to be a route that should be used only where there are relative contraindications to the femoral approach. We present the largest series to date of patients in whom transradial coronary angiography was undertaken specifically because of contraindications to the femoral approach. Since 1995, patients at this cardiothoracic center have been considered for a transradial approach to coronary angiography if there were relative contraindications to the femoral route. Data from 500 patients was prospectively collected. Patients were aged 66 +/- 9 years; 72% were male. Indications for the radial approach included peripheral vascular disease (305), therapeutic anticoagulation (77), musculoskeletal (59), and morbid obesity (32). Sixty-eight patients (14%) required a radial procedure following a failed femoral approach. Access was right radial 291 (58%), left radial 209 (42%). Eighteen operators were involved, but two operators undertook 355 (71%) of the cases. Catheter gauge was 6 Fr (n = 243; 49%), 5 Fr (219; 43%), and 4 Fr (29; 6%). The procedure was successful in 463 cases [92.6%; 88.2% for nonmajority vs. 94.4% (P < 0.05) for the two majority operators]. Success in males (93.6%) significantly exceeded that in females (90.1%; P < 0.05). In-catheter-laboratory duration was 45 +/- 17 min; fluoroscopy time, 7.5 +/- 6 min; radiation dose, 40 +/- 23 CGy. The procedure was without incident in 408 cases (82%). There were procedural difficulties in 18% of cases, including radial artery spasm (12%) and vasovagal response (5%). The incidence was higher with 6 Fr catheters (23%) than with 5/4 Fr (15%; P < 0.05). Major procedural complications occurred in three cases: brachial artery dissection in one and cardiac arrest in two. Postprocedure major vascular complications numbered three: claudicant pain on handgrip in one, ischemic index finger (with subsequent terminal phalanx amputation due to osteomyelitis) in one, and ischemic hand for 4 hr in one. Patients with contraindications to the femoral approach form a high-risk group. In these patients, transradial cardiac catheterization can be performed successfully and with a low risk of major complications. Minor adverse features remain frequent, occurring in one in five cases, though difficulties are minimized both with increasing operator experience and smaller sheath diameter.

Occasional-operator percutaneous brachial coronary angiography: first, do no arm

The percutaneous brachial approach to coronary angiography is perceived, rightly or wrongly, to be the easiest of the arm approaches. Predominantly femoral operators may therefore be encouraged to use the percutaneous brachial approach as an occasional procedure. We decided to investigate prospectively whether this was a reasonable strategy by examining outcome in patients who underwent percutaneous brachial cardiac catheterization by occasional brachial operators. Between October 1997 and 2000, 55 patients underwent percutaneous brachial coronary angiography (0.6% of coronary angiographies), aged 66 +/- 10 years, of whom 40 (73%) were male. Chief indications for a brachial approach were peripheral vascular disease in 35 (64%), failed femoral approach in 10 (18%), and orthopnoea in 5 (9%). The procedure was completed successfully in 46 patients (84%). Reasons for failure were failure of access (two), brachial artery spasm (one), inability to negotiate brachial/subclavian tortuosity (two), dissection of the brachial artery (two), and inability to intubate a vein graft (two). Six patients required catheterization from an alternative site (brachial arteriotomy in two, percutaneous transradial in two, femoral in two), with success in all. There were complications of varying severity in 20 patients (36%). Major complications were false aneurysm requiring surgical repair (one), large brachial hematoma requiring surgical exploration and arterial repair (one), and hematoma with clinical median nerve dysfunction for one month. Minor complications included need for repeat coronary angiography via alternative approach (six), weakness of radial pulse < 24 hr (two), brachial artery dissection without clinical sequelae (two), brachial artery spasm terminating procedure (one), and wound oozing (three). Percutaneous brachial coronary angiography is a hazardous procedure when undertaken by occasional brachial operators. Complications are unacceptably frequent. As with all practical procedures, complication rates are likely to be inversely proportional to operator volumes. Patients requiring an arm approach should be referred to operators with high-volume brachial or radial experience.

The problem of arteria lusoria in right transradial coronary angiography and angioplasty

The retroesophageal right subclavian artery (arteria lusoria) is one of the anatomical abnormalities encountered by interventional cardiologists who perform right transradial procedures. We report on 11 patients with arteria lusoria in whom 14 right transradial coronary angiography or angioplasty procedures were attempted among a series of 3,730 consecutive right transradial attempts. This abnormality can be easily detected by angiographic visualization, in the anteroposterior projection, of the angle of the catheter when it engages the ascending aorta, and by manual angiography at the ostium of the right subclavian artery. In such a case, catheterization of the ascending aorta may be difficult or even impossible (7.1%). Selective catheterization of both coronary arteries is more difficult, takes longer, and requires more catheters. The Judkins catheters are recommended, although they are seldom used for the left coronary artery via the right radial approach, for both arteries. All catheter exchanges should be performed on long guidewires.