Gilchrist IC 201110
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This document discusses various anatomical challenges that can be encountered when performing radial artery catheterization, including spasm, loops, tortuosity, and variations in arterial anatomy. It provides examples of anatomical variations like radial loops, high junctions, and accessory radial arteries. It also discusses challenges posed by vascular diseases like atherosclerosis and vasospasm, as well as iatrogenic complications. Potential solutions for overcoming challenges are proposed, such as maintaining wire position, using smaller wires and catheters, preventing spasm, and considering alternative access sites if needed.
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Gilchrist IC 201110
- 1. Anatomical challenges Spasm, loops, tortuosity Ian C Gilchrist, MD, FACC, FSCAI Professor of Medicine Heart & Vascular Institute Penn State/Hershey Medical Center Hershey, PA Duke Master 2011
- 2. CME Disclosure Statement Nothing Duke Master 2011
- 3. Challenges in the Vasculature Anatomic Variability Vascular Disease Iatrogenic Complications http://www.ohcaptain.com/2010/05/insights-from-road.html Duke Master 2011
- 4. The “Normal” Arm Duke Master 2011
- 5. Challenge #1: Anatomical Variability Expect variability 1540 patients-96.8% success, high-volume radial operators, United Kingdom Catheter in accessory radial Brachial artery Radial Loop Tortuosity Accessory Radial (2.3%) (2.0%) (7.0%) Anatomic variation associated with >3/4 of procedural failures Lo, Nolan et al, Heart 2009;95:410-415. Duke Master 2011
- 6. Normal Arm Arterial System Axillary Artery Biceps Brachii Muscle Brachial Artery Brachioradialis Muscle Radial Ulnar Artery Artery Adapted from Jelev L, Cardiovasc Intervent Radiol 2008;31:1008 Duke Master 2011
- 7. Normal Arm Angiogram Radial Artery Ulnar Artery Brachial Artery J Invasive Cardiol. 2010;22:536–540 Duke Master 2011
- 8. Varied Radial Connections Unusual courses, no effect on passage Radial-Axillary Junction Radial-Brachial Junction Superficial Radial With High Junction Adapted from Jelev L, Cardiovasc Intervent Radiol 2008;31:1008 Duke Master 2011
- 9. High Axillary Junction J INVASIVE CARDIOL 2010;22:536–540 Duke Master 2011
- 10. High Radial Junction with Crossover No crossover Crossover: Potential for difficult passage & complications Adapted from Jelev L, Cardiovasc Intervent Radiol 2008;31:1008 Duke Master 2011
- 11. Spectrum of Crossover Tight Fit Tight Turn Adapted from Jelev L, Cardiovasc Intervent Radiol 2008;31:1008 Duke Master 2011
- 12. Angiogram: Accessory Radial Accessory or remnant radial artery Large crossover “loop” Lo, Nolan et al, Heart 2009;95:410-415. Duke Master 2011
- 13. Radial Loops J Invasive Cardiol 2010;22:536–540 Adapted from Jelev L, Cardiovasc Intervent Radiol 2008;31:1008 Duke Master 2011
- 14. Axillary/Subclavian Loops Icg/HMC Cath Lab Duke Master 2011
- 15. Challenge #2: Vascular Disease Atherosclerotic Vasospastic Duke Master 2011
- 16. Atherosclerotic Disease Calcific arteritis Arterial stenosis …but don’t confuse with spasm Maybe resolved with angioplasty …if in doubt, change access site Duke Master 2011
- 17. Vasospastic Disease Young, anxious, female, cold Raynaud-like Syndromes Treat expectantly before symptoms Severe cases = consider femoral access Duke Master 2011
- 18. Challenge #3: Iatrogenic Disease • Post-Trauma • Radiation • Spasm • Dissection • Perforation • Chronic injury Duke Master 2011
- 19. Post-Brachial Cut down Icg/HMC Cath Lab Duke Master 2011
- 20. Overcoming Challenges Expect variability, …have a plan before you start …enjoy the challenge …learn to problem solve Duke Master 2011
- 21. Solution: Plan for Success 1. Well positioned wrist/relaxed patient 2. Micropuncture needle access 3. Prevent spasm & anticoagulate 4. Use your wire as a friend 5. If in doubt take a picture 6. Maintain central access with your wire The Radial Is Not a Small Femoral Artery Duke Master 2011
- 22. Solution: Failure of Wire to Advance during initial access 1. Insert sheath to gain partial access – Confirm arterial access – Treat spasm 2. Load hydrophilic .035” wire in catheter & try to advance into central system 3. If successful, advance vascular sheath in place over cardiac catheter & advance coronary catheter. Duke Master 2011
- 23. Solution: Hydrophilic Wire Fails to Advance? 1. Look under fluoroscopy at position 2. Obtain limited angiogram to define the anatomy 3. Twisting wrist may straighten forearm vessels, while a deep breath may change more proximal arteries 4. Consider smaller flexible wires, the other radial artery, the ulnar artery, or even the femoral Duke Master 2011
- 24. Solution: Wire is your friend • Maintain wire or catheter position as central as possible (don’t retreat) • Use a standard .035” angiographic wire to hold position or help reposition catheters • Exchange over a long wire or “jet” exchange over standard length wires Do Not Retreat from Success Duke Master 2011
- 25. Solution: Catheter “Jetting” 1. Start with catheter in ascending aorta 2. Pass .035” wire (not hydrophilic) into catheter 3. Fix wire in place & back catheter to end of wire 4. Attached 10cc syringe with fluid on catheter 5. Forcefully inject while pulling “jetting” catheter off wire until free from access sheath 6. Confirm wire still in central aortic position Hoorntje JCA. Cathet Cardiovasc Diagn 18:284, 1989. Duke Master 2011
- 26. Returning with Next Catheter 1. Confirm wire is still in ascending aorta 2. Advance flushed catheter over wire until wire exits catheter’s hub – Ectopy indicates wire pushed into ventricle – Fluid should drip from catheter as the wire displaces flush, if not, wire may have prolapsed down descending aorta 3. Remove wire and continue procedure Duke Master 2011
- 27. Solution: Spasm during procedure Use more pharmacology Use smaller French equipment Minimize mechanical manipulation Wipe wire, flush catheters, and “jet” with antispasmodic agents (nitrates, Ca++ blockers) Warm the arm or room Duke Master 2011
- 28. Summary Variety is part of normal arm vasculature Makes radial “fun” Potentially a cause for failure, but… Challenges can be overcome resulting in success Expect it, have a plan, you will succeed Duke Master 2011
- 29. Thank you Duke Master 2011