Navigate and cross tortuosities and difficult anatomies

1. Navigate and Cross Tortuosity
and Difficult Anatomies
Mauricio G. Cohen, MD, FACC, FSCAI
Director, Cardiac Catheterization Lab
Associate Professor 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 Regado Biosciences / Astra Zeneca
Consulting Fees/Honoraria Abiomed / Terumo Medical / Accumed /
Medtronic / Edwards Lifesciences / The
Medicines Company / Merritt Medical
Major Stock Shareholder/Equity Accumed
Royalty Income None
Ownership/Founder None
Intellectual Property Rights None
Other Financial Benefit None

3. TRA: Mechanisms of Failure
Total number of Failures 98/2100 (4.6%)
Failure of arterial access
Inadequate arterial puncture 13%
Failure to advance catheter to ascending aorta
Radial artery spasm Hydrophylic sheaths not used
34%
Radial artery dissection 10%
Radial artery loop/tortuosity 6%
Radial artery stenosis 1%
Failure to complete PCI due to lack of guide support
Subclavian tortuosity 18%
Inadequate guide backup support 17%
n=2,100
Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064

4. TRA: Predictors of Failure
Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064

5. Radial Anomalies and Procedural
Failure
103
22
Success
Failure
23 34
5 13 7 5
120
100
80
60
40
20
0
High
Bifurcation
Radial Loop Tortuosity Others
Lo TS, et al. Heart 2009;95:410–415
n=1540
7%
2.3%
2.0%
2.5%

6. Cross-over to femoral: Incidence and
RRA (n= 770)
LRA (n= 770)
Lack of radial
canalization
Puncture Failure
TALENT TRIAL
P= 0.70
Radial
P= 0.31
Severe spasm
tortuosity/anomalies
P= 0.31
Subclavian-aortic
tortuosity
Overall 14 puncture and radial failure vs 1 epi-aortic failure, p= 0.0008
5
4
3
2
1
0
Cases
P= 0.41
Radial Failure
Epi-Aortic Failure
classification
Sciahbasi et al. EuroPCR 2010

7. TALENT Trial: Right vs. Left Radial
RRA (n= 732)
LRA (n= 735)
168
P= 0.0025
149
seconds
Fluoroscopy time
170
150
0
(32-1238)
(31-1290)
12.1
P= 0.40
P= 0.004 23.3 23.5
10.7
13
11
0
Dose Area Product (Fluoroscopy)
Gy/cm2
(0.9-229)
(0.8-378)
Dose Area Product (Cine)
25
20
0
Gy/cm2
(6.4-172) (1.9-328)
Results are expressed as median with range in brackets
Diagnostic Group
(n= 1467)
Sciahbasi et al. EuroPCR 2010

8. TALENT Trial: Operator’s Experience
Diagnostic Group
(n= 1467)
260
200
P= 0.001
P= 0.002
Results are expressed as median with range in brackets
SENIOR
9.3
9
P= 0.11
P= 0.26
Dose Area Product (Fluoroscopy)
150
130
10
5
0
Gy/cm2
(0.9-201)
(0.8-197)
140
132
seconds
Fluoroscopy time
0
(32-1238)
(31-1282)
RRA (n= 487)
LRA (n= 478)
FELLOW
256
208
0
seconds
(58-1170)
(35-1290)
Fluoroscopy time RRA (n= 245)
LRA (n= 257)
22.4
17.3
0
30
15
Gy/cm2
(2.2-229)
(1.3-378)
Dose Area Product (Fluoroscopy)
Sciahbasi et al. EuroPCR 2010

9. Navigating the Arm
Wire Choice is Important
• Wire tip
 Angled
• Tends to go into small vessels. Risk of perforation
 Regular J (3 mm)
• Navigates well, but too large for TR – may cause injury
or spasm
 Baby J (1.5 mm)
• Ideal for TR. No need for fluoroscopy. May decrase
radiation.
• Wire Shaft
 Consider stiff shafts to straighten subclavian tortuosity
• Hydrophilic coating
 Allows smoother navigation through tortuous anatomy
with less friction and lower risk of injury.

10. The Baby-J Wire

11. Tortuosity

13. Traversing a Radial Loop
Patel’s Atlas of Transradial intervention – The Basics. 2007

14. Brachial Tortuosity

15. High Bifurcating Radial Artery

19. Balloon Assisted Tracking

20. Razor Effect
Balloon Assisted Tracking
Patel T, et al CCI 2012

21. Axillary Tortuosity

23. Negotiating Subclavian Tortuosity

24. Who Said that Left Radial was
Easier?

27. Another Case…

28. One more case…

29. Arteria Lusoria
Courtesy Dr. Olivier Bertrand

30. CT Angiography

31. Understanding the Relationship with
the Esophagus

32. Conclusions
• Radial angiography requires awareness of anatomical
variations and challenges
• If spasm, use catheters of smaller diameter and more
vasodilators
• Always use exchange length wires
• Stiff hydrophilic wires may be useful with subclavian
tortuosity
• Vascular anomalies are relatively common and a cause of
transradial procedure failure even for experienced
operators
• Retrograde limited radial angiography helps in planning a
strategy to save time and avoid vascular complications
• Left radial access may be a first step for inexperienced
operators during their learning curve
• If resistance, never push! Finesse prevails over muscle!!