Internal mammary arteriography: a new catheter technique by right brachial approach

A side-hole catheter for catheterization of a difficult internal mammary artery

Background The internal mammary artery (IMA) can be a source of hemoptysis in patients with chronic lung disease. Intervention via the IMA can be a challenge due to anatomic variations and lead to excessive contrast use and radiation exposure. Purpose To evaluate safety and efficiency of a new side-hole catheter for the catheterization of the IMA in patients with hemoptysis. Material and Methods From January 2011 to August 2014, a total of 96 transarterial embolization procedures required exact evaluation of the IMA due to chronic lung disease involving the anterior thorax. In 17 cases (18%) of these 96 procedures, the conventional selective IMA angiography failed and instead a novel side-hole catheter as a modification of a cobra-type curved catheter was used. The side hole allowed passage of a micro-wire and catheter. Results Failed catheterizations were due to severe vascular tortuosity, acutely angulated subclavian artery, or abnormal takeoff of the IMA. The Cobra shaped catheter with the microcatheter through the side-hole catheter yielded a technical success rate of 100%. Longer time was required to catheterize the IMA with the Cobra shaped catheter than with the side-hole catheter (17 vs. 2 min, P < 0.05). There were no procedure-related complications. Conclusion Side-hole catheter technique is useful in patients whose internal mammary artery is difficult to access. Further design revisions are needed to improve the ease and speed of IMA catheterization and angiography.

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.

Feasibility and safety of concomitant left internal mammary arteriography at the setting of the right transradial coronary angiography

We investigated the feasibility and safety of concomitant left internal mammary artery (LIMA) angiography at the setting of the right transradial coronary angiography (TRCA). LIMA angiography was performed using a 5 Fr Simmons-type catheter with a newly modified tip in 184 consecutive patients. The catheter was reformed in the descending (new method) or ascending (traditional method) aorta and manipulated to cannulate the left subclavian artery and LIMA orifice. LIMA angiography was performed selectively in 164 patients (89%) and semiselectively (when the catheter tip reached and was directed to the mammary artery orifice) in 20 patients. There were no procedure-related complications. The image quality of all the semiselective angiograms was also determined satisfactory. Total procedural time was 223 +/- 168 sec. The catheter was reformed using the new method in 160 patients (87%). The catheter reformation time and total procedure time were significantly shorter with the new method than with the traditional method (18 +/- 8 vs. 117 +/- 115 sec, p = 0.000; 204 +/- 191 vs. 309 +/- 139 sec, p = 0.021, respectively). In conclusion, LIMA angiography can be performed readily and safely at the setting of the right TRCA using a Simmons-type catheter. The image quality of the LIMA angiograms is sufficient to obviate the need of the second preoperative angiography via another route.

Bilateral selective internal mammary artery angiography via right radial approach: clinical experience with newly designed Yumiko catheter

The radial artery has been increasingly used as a primary access site for coronary angiography and intervention. But the technique for internal mammary artery (IMA) visualization via the right radial artery has not been well described. Therefore, the study was conducted to investigate the feasibility, safety, and adequacy of selective bilateral IMA angiography via the right radial artery using the recently developed Yumiko catheter. From November 1999 to October 2000, both IMA angiographies were undertaken immediately following the diagnostic coronary angiogram taken from right transradial approach in 114 patients. IMA angiography was successfully obtained in 99% (113/114) patients. For left IMA angiography, 73 (64%), 28 (25%), and 12 (11%) imagings were obtained in a selective, a semiselective, and a nonselective way, respectively. After initial periods of 33 left-IMA-only imaging, right IMA angiography was obtained in 81 patients (phase 2). Selective right IMA imaging was done in 73 (90%), semiselective in 6, and nonselective in 2 patients. The reasons for failure of selective or semiselective visualization were severe vascular tortuosity, far distal anatomical origin of left IMA and ulcerative plaque, or acutely angled left subclavian artery. The feasibility and safety of selective and semiselective bilateral IMA angiography were demonstrated using a 5 Fr Yumiko catheter from the right radial approach. Cathet Cardiovasc Intervent 2001;54:19-24.

Lateral origin of the right internal thoracic artery: report of a case

We report herein the unusual case of a patient in whom postoperative angiography following coronary artery bypass grafting (CABG) revealed a lateral origin of the right internal thoracic artery (ITA) and a normal origin of the left ITA, both of which were demonstrated to be patent and did not follow a tortuous course. The CABG had involved revascularization of the left anterior descending artery (LAD) with the right ITA, and the obtuse marginal artery with the left ITA. The patient had an uneventful postoperative course and developed no respiratory symptoms.

Internal mammary angiography: a review of technical issues and newer methods

Up to 90% of coronary bypass operations in some centers now include at least one IMA graft. In parallel with the increased use of IMA grafts, our catheterization laboratory records for 1986-7-8 demonstrate a progressive increase in IMA angiography, both absolutely (11, 28, 48 cases/yr) and as a percent of restudy procedures performed after prior bypass (14, 25, 43%). Unfortunately, these records also show that cannulation of the right and left IMAs may involve substantial technical hurdles, resulting in a mean time of 19 +/- 19 min from catheter insertion to selective IMA angiography. Based on this experience, we review a standard technique for IMA angiography using preformed catheters, and describe alternative methods (including use of PTCA guidewires with or without super-selective catheters, and non-selective angiography utilizing a specially designed balloon occlusion catheter).

Angiography of the internal mammary artery via the contralateral brachial artery

A new technique for angiography of the contralateral internal mammary artery via the brachial artery approach is described. A Simmons (sidewinder) catheter is maneuvered into the ascending aorta and is rotated as to assume its performed shape. The catheter is advanced into the contralateral subclavian artery beyond the internal mammary artery. With the aid of an exchange wire, the Simmons catheter is replaced with a preformed internal mammary angiographic catheter. The internal mammary artery is cannulated, and angiography is performed. Fifty patients were successfully studied by means of this technique without incident. In 20 cases, the ipsilateral internal mammary artery was subsequently visualized. Brachial angiographers may prefer to add this technique to their repertoire.

Atherosclerosis and the internal mammary arteries

One hundred and fifty patients with coronary artery disease (CAD), 14 (9.3%) of whom had coexisting peripheral vascular disease, underwent bilateral internal mammary arteriography to study the incidence and extent of atherosclerosis in these vessels. Significant atherosclerosis of the internal mammary arteries (IMAs) was present in three patients (2%), of whom one had coexisting peripheral vascular disease. Lesions in the IMAs were found either proximally, close to the origin or distally, around the terminal bifurcation. Six of the 14 patients with peripheral vascular disease (4% of total subjects) had significant atherosclerosis of the brachiocephalic arteries. Atherosclerotic involvement of the IMA is very unusual and rarely interferes with the use of these vessels for coronary bypass. More common, however, is atherosclerosis of the subclavian arteries, a contraindication for IMA grafting if the lesion is proximal to the IMA origin.

Radiographic anatomy of the internal mammary arteries

The radiographic anatomy of the IMAs is described based on bilateral selective arteriography in 100 patients with coronary artery disease. The right and left IMAs were identical in caliber in their mid portions in 94% of cases. Fifteen percent of the IMAs measured less than 2 mm in luminal diameter at the level of the fourth costal cartilage. The side branches showed a great deal of variability and asymmetry in their origin and distribution. The understanding of the radiographic anatomy of the IMA and its branches is helpful in preoperative appraisal and is crucial for postoperative evaluation of the IMA grafts.