• I.D. 66 year old female presented with recurrentchest pain radiating to the left arm with profusesweating during the last episode.• ECG showed signs of LV strain and non specific Tchanges.• Risk factors were HTN and Hyperlipidemia.• Coronary angiogram was planned to rule outischemia, because the patient was not fit for ETT.• Trans-radial approach was planned according to thepatient’s preference.
• Coronary angiogram did not show any significantstenosis.• During catheter exchange from JL4 to JR4 thepatient developed severe pain in the arm, in additionto pallor of the hand.• Examination of the arm showed very weak pulses.
Angiogram of the arm after the patient’s complaint(Angiogram through the sheath did not show any significantdisease in the radial and ulnar arteries)
SWITCHING TO TRANS-FEMORALAPPROACH• To continue the coronary angiogram and to checkthe brachial artery we switch the case to the femoralapproach.• The angiogram confirmed occlusion of the Rbrachial artery.• This is most likely due to brachial artery dissectioninduced by the wire.• There were good flow to the radial and ulnar arteriesthrough collaterals
The angiogram confirmed occlusion of theR brachial artery
There were good flow to the radial andulnar arteries through collaterals
• There was complex tortousity at the origin of the leftsubclavian artery.• Brachial angiogram showed occlusion of the arteryat the mid segment.• Medical management was planned over the nightsince there were good flow to the radial and ulnararteries through collaterals, but there was noimprovement after 12 hours.• Echo-doppler on the following morning proved theocclusion of the brachial artery.
Re-angiogram of the R brachial arteryon the next day• 5F Mani catheter (Cordis) was used to navigatethrough the tortousity of the R subclavian arteryover a 260cm-0.035 Terumo wire.• Total occlusion of R brachial artery was confirmed.• The plan was to proceed with angioplasty to openthe occlusion of the R brachial artery.
Very tortuous Innominate artery andsubclavian artery
Angioplasty of the Brachial artery• The Mani catheter was exchanged to a 6F MP1guiding catheterover an exchange length 0.035 wire.• 0.014 PT2 MS (BSC) wire passed through theocclusion down to the ulnar artery.• Multiple inflations with 3.0x20 Sapphire (OrbusNeich)balloon were done in the brachial and ulnar artery.
Some flow started to appear through theulnar artery.
Better flow was achieved in the brachial and ulnar arterieswith further balloon inflations(But dissection and hazziness were still present at the level of occlusion)R Brachial Artery R Ulnar Artery
A Larger balloon 5.0x30 was used to dilate thebrachial artery at the level of dissection
Finally, Good flow was achieved in the brachial andulnar arteries.
Finally, Good flow was achieved in the brachial andulnar arteries.The R Radial arteries filled retrograde through the palmer arch
• Residual dissection at the level of the total occlusionon the brachial artery was seen, but it was a nonflow limiting dissection.• So it was left to heal spontaneously.• No Stent was used.
ON THE NEXT DAY• There was good pulse in both the ulnar and radialarteries.• Blood pressure in the R arm was similar to that inthe L arm.
3 MONTH FOLLOW UP• Blood pressure in the R arm was similar to that inthe L arm.• There was good palpable pulse in both the ulnar andradial arteries.• But the patient continued to complain of recurrentvague aching pain in the affected arm (Was thatrelated to the dissection of the artery or was is amusculoskeletal/neuorological pain ?)
CONCLUSION• With radial approach always use a 260cm 0.035 wireto exchange catheters over it, so that you can avoidtraumatic manipulations with the wire and thecatheters in the radial and brachial arteries.• You have to face your complication with courage, i.e.not to flee away and seek others assistance to coveryour complication.• The simpler the intervention in the brachial artery thebetter.• Try to avoid stenting of the brachial artery.