Anatomical variations from wrist to aorta and impact on transradial procedures

1. Anatomical variations
from wrist to aorta and
impact on transradial
procedures
Hristo Pejkov, Biljana Zafirovska, Oliver Kalpak, Sasko Kedev
University Clinic of Cardiology, Skopje - Macedonia
pejkovh@yahoo.com

2.  All authors have nothing to disclose

3. RA Anomalies
 TRA is technically more challenging approach
mostly due to anomalies of the arm arteries and
aorta, which influence the success rate of
angiographic procedures
 Published data about the presence of RA anomalies
reported percentages ranging from 7%-22%
 The exact influence of these anomalies on TR
success is still under investigation

4. RA Anomalies

5. Data from our database
 Total number of 10504 consecutive patients were analysed
over a period of 2 years (March 2011 – Juli 2013)
 Retrograde radial arteriography was performed to define
the radial artery anatomy from mid forearm to ulnobrachial
anastomosis making a roadmap for the intervention.

6. Total Number of patients
(10502 pts)
RA without anomalies
N=9388 (89,4%)
RA anomalies group
N=1114 (10,6%)
High bifurcating origin of the radial artery (733 )
Radial artery loop (360°) (105)
Radial artery tortuosity(152)
Hypoplastic radial artery (17)
Loop of the brachial/axillary/subcl. (113)
Anomalies of the aortic arch Retroesophageal
right subclavian artery (a.Lusoria) (6)
Cross-over
(52)

7. Anatomical variants Number of patients
Total Number of patients with anomalies 1114 (10,6%)
High bifurcating origin of the radial artery from the
733 (7%)
brachial or axillary arteries
Radial artery loop (360°) 105 (1%)
Radial artery tortuosity 152 (1,4%)
Hypoplastic radial artery 17 (0,16%)
Loop of the brachial/axillary/subclavian artery 113 (1,0%)
Anomalies of the aortic arch
Retroesophageal right subclavian artery (a.Lusoria)
6 (0,05%)
Anatomical variants

8. High take off RA from BA
 7% according to our
data
Crossover 2%

9. Radial artery loop
 1% according our data
 22% crossover
 The loop consists of a tight
retrograde bend of the radial
artery before joining the ulnar
artery in the forearm

10. Complex loop with remnant artery and
high degree spasm

11. Tortuosities of RA & Hypoplastic
 Pts without previous interventions
 0,16% according to our data
 17% crossover
 1,4% according to our data
 Most prone to spasm
 Crossover in 6,5%

12. a.Lusoria wire and catheter advancement
 A.Lusoria 0,03% according to our data, 0% crossover

13. RA Crossover
TR Access site crossover
Number of
patients
High bifurcating origin of the radial artery from the
brachial or axillary arteries
15 (2%)
Radial artery loop (360°) 23 (22%)
Radial artery tortuosity 10 (6,5%)
Hypoplastic radial artery 3 (17,6 %)
Loop brachial/axillary/subclavian artery 0 (0%)
a.Lusoria 0 (0%)

14. Crossover direction
TR Access site crossover direction
Incidence and
prevalence N=52 pat.
Right transulnar access 23 (44,2%)
Left transradial access 26 (50%)
Right transfemoral access 3 (0, 5%)

15. Complications & Success
Complications
RA anomalies group
N=1114 (10,6%)
RA without
anomalies
N=9388 (89,4%)
P
Value
Clinical radial artery spasm 167 (15%) 255 (2,7%) <0,001
Access site bleeding
complications
145 (13%) 850 (7,5%) <0,001
Procedural success 1062 (95,3%)
Cross-over 52 (4,7%)
Haemathoma grade 1 61(5,4 %)
Haemathoma grade 2 53 (4,7%)
Haemathoma grade 3 32 (2,9%)
Haemathoma grade 4 7 (0,6%)
Haemathoma grade 5 2 (0,2%)
Major vascular complications 0

16. Conclusion
 Failure of transradial procedures is associated with
anatomical variants located from wrist to aorta.
 Pre-procedural radial artery angiography gives the
operator a chance to successfully plan the strategy for
crossing the anomaly.
 High volume transradial centers with experienced
transradial operators have lower transradial cross-over
rate due to anatomical variations.

17. Conclusion
 For broad application of transradial angiography or
intervention, operator need learning curve and
knowledge about technique and devices
 We can overcame problems and doing well in the future
with advancement of skills and device techniques