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Gilchrist IC 201110


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Anatomical Challenges: Spasm, Loops, Tortuosity

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Gilchrist IC 201110

  1. 1. Anatomical challenges Spasm, loops, tortuosity Ian C Gilchrist, MD, FACC, FSCAI Professor of Medicine Heart & Vascular Institute Penn State/Hershey Medical Center Hershey, PADuke Master 2011
  2. 2. CME Disclosure Statement Nothing Duke Master 2011
  3. 3. Challenges in the Vasculature Anatomic Variability Vascular Disease Iatrogenic Complications Duke Master 2011
  4. 4. The “Normal” Arm Duke Master 2011
  5. 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. 6. Normal Arm Arterial System Axillary Artery Biceps Brachii Muscle Brachial ArteryBrachioradialis Muscle Radial Ulnar Artery Artery Adapted from Jelev L, Cardiovasc Intervent Radiol 2008;31:1008 Duke Master 2011
  7. 7. Normal Arm Angiogram Radial Artery Ulnar Artery Brachial Artery J Invasive Cardiol. 2010;22:536–540 Duke Master 2011
  8. 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. 9. High Axillary Junction J INVASIVE CARDIOL 2010;22:536–540 Duke Master 2011
  10. 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. 11. Spectrum of Crossover Tight Fit Tight Turn Adapted from Jelev L, Cardiovasc Intervent Radiol 2008;31:1008 Duke Master 2011
  12. 12. Angiogram: Accessory RadialAccessory or remnant radial artery Large crossover “loop” Lo, Nolan et al, Heart 2009;95:410-415. Duke Master 2011
  13. 13. Radial LoopsJ Invasive Cardiol 2010;22:536–540 Adapted from Jelev L, Cardiovasc Intervent Radiol 2008;31:1008 Duke Master 2011
  14. 14. Axillary/Subclavian Loops Icg/HMC Cath Lab Duke Master 2011
  15. 15. Challenge #2: Vascular Disease Atherosclerotic Vasospastic Duke Master 2011
  16. 16. Atherosclerotic DiseaseCalcific arteritisArterial stenosis…but don’t confuse with spasmMaybe resolved with angioplasty…if in doubt, change access site Duke Master 2011
  17. 17. Vasospastic DiseaseYoung, anxious, female, coldRaynaud-like Syndromes Treat expectantly before symptomsSevere cases = consider femoral access Duke Master 2011
  18. 18. Challenge #3: Iatrogenic Disease • Post-Trauma • Radiation • Spasm • Dissection • Perforation • Chronic injury Duke Master 2011
  19. 19. Post-Brachial Cut down Icg/HMC Cath Lab Duke Master 2011
  20. 20. Overcoming ChallengesExpect variability,…have a plan before you start…enjoy the challenge…learn to problem solve Duke Master 2011
  21. 21. Solution: Plan for Success1. Well positioned wrist/relaxed patient2. Micropuncture needle access3. Prevent spasm & anticoagulate4. Use your wire as a friend5. If in doubt take a picture6. Maintain central access with your wireThe Radial Is Not a Small Femoral Artery Duke Master 2011
  22. 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. 23. Solution: Hydrophilic Wire Fails to Advance?1. Look under fluoroscopy at position2. Obtain limited angiogram to define the anatomy3. Twisting wrist may straighten forearm vessels, while a deep breath may change more proximal arteries4. Consider smaller flexible wires, the other radial artery, the ulnar artery, or even the femoral Duke Master 2011
  24. 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. 25. Solution: Catheter “Jetting”1. Start with catheter in ascending aorta2. Pass .035” wire (not hydrophilic) into catheter3. Fix wire in place & back catheter to end of wire4. Attached 10cc syringe with fluid on catheter5. Forcefully inject while pulling “jetting” catheter off wire until free from access sheath6. Confirm wire still in central aortic position Hoorntje JCA. Cathet Cardiovasc Diagn 18:284, 1989. Duke Master 2011
  26. 26. Returning with Next Catheter1. Confirm wire is still in ascending aorta2. 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 aorta3. Remove wire and continue procedure Duke Master 2011
  27. 27. Solution: Spasm during procedureUse more pharmacologyUse smaller French equipmentMinimize mechanical manipulationWipe wire, flush catheters, and “jet” withantispasmodic agents (nitrates, Ca++blockers) Warm the arm or room Duke Master 2011
  28. 28. Summary Variety is part of normal arm vasculature Makes radial “fun” Potentially a cause for failure, but… Challenges can be overcome resulting in successExpect it, have a plan, you will succeed Duke Master 2011
  29. 29. Thank you Duke Master 2011