Intracoronary guidewire emboli: a unique complication and retrieval of the wire

The breakdown of the guidewire during percutaneous coronary intervention (PCI) and the retention of the broken part inside the coronary or systemic vascular system is a rare complication. With the use of a flexible guidewire, the incidence of these complications has markedly decreased. In this case report, we report the withdrawal of a broken guidewire from the distal coronary during PCI.     

External side-compression of radial artery: a simple technique for successful advancement of guidewires through the radial approach

Background: The transradial approach has several pitfalls that include problems regarding the radial puncture and difficulties with the catheter technique. We evaluated whether external side‐compression of radial artery was helpful to yield the success rate for advancement of guidewires under the presence of side branches or arterial tortuosity. Methods and Results: The study population consisted of 11 patients with unsuccessful advancement of guidewires into the brachial artery. In 7 patients, the J‐tip hydrophilic guidewire was not advanced into the brachial artery because it always directed into the side branch. During external side‐compression of radial artery at the culprit site with a finger of the second operator, the guidewire was successfully advanced into the brachial artery in all patients. In 4 patients, the guidewire was not advanced into the brachial artery because the radial artery was tortuous. During external side‐compression of radial artery at the culprit site, the guidewire was successfully advanced into the brachial artery in 2 patients. In the remaining 2 patients in whom this attempt was unsuccessful, coronary angiography was performed through the right brachial artery. Overall success rate of this technique was 82%. Conclusion: External side‐compression of radial artery is an easy and feasible technique for difficulties in the advancement of guidewires due to the presence of side branches or arterial tortuosity. (J Interven Cardiol 2011;24:397–400)     

Coronary cannulation through mirror-image right aortic arch during right transradial approach: a rare case report with review of literature

Although right aortic arch (RAA) is a rare developmental anomaly, it can create a challenging anatomical situation while cannulating coronaries working through right transradial approach (TRA). We describe a rare adult patient with mirror-image RAA, whose coronary angiogram was performed through right TRA. We have also discussed the challenges encountered because of RAA and technique to enter the ascending aorta.     

Retrieval of dislodged and disfigured transradially delivered coronary stent: report on a case using forcep and antegrade brachial sheath insertion.

We report a case of dislodged and damaged stent during transradial coronary procedure using 6 Fr device, which was successfully retrieved by using a forcep and 8 Fr antegrade brachial sheath. The disfigured and bulky stent can be removed, after their retrieval from the coronary circulation, using a forcep inserted through an 8 Fr brachial artery sheath if the radial artery is deemed too small to accommodate larger sheath.     

Transradial cardiac catheterization in patients with prior brachial artery cutdown.

The safety and efficacy of transradial cardiac catheterization in patients with prior ipsilateral brachial cutdown is not known. Using standard techniques we performed transradial catheterization in 278 consecutive patients, of which 63 had prior brachial cutdown. All patients had a strongly palpable radial pulse and a negative Allen's test. Although patients with prior cutdown were older and had a higher incidence of hypertension and prior coronary artery bypass surgery, there was no significant difference in success rates for transradial catheterization (93.6% vs. 95.3%; P = NS). There were no periprocedural complications. Brachial artery occlusion was responsible for only two unsuccessful catheterization attempts. We conclude that, with careful preprocedural screening, ipsilateral transradial cardiac catheterization can be successfully performed in a majority of patients with prior brachial cutdown.     

Transradial versus transfemoral approach for percutaneous coronary procedures

Selective coronary angiography was originally performed through open brachial arteriotomy. Thereafter, the percutaneous Seldinger technique and the use of preformed Judkins-type catheters popularized the femoral approach. More recently, after the first report of successful coronary angiography by the transradial approach in 1989, the radial artery has been increasingly used as an alternative access site. The main advantage offered by the transradial approach is represented by the very low (< 1%) incidence of relevant vascular access site complications, which on the contrary occur in about 3% to 7% of patients undergoing procedures through the femoral route. The main disadvantage is a higher incidence of procedural failure that leads to a crossover to the femoral route. In this review, we examine the available evidence on transradial and transfemoral approach advantages, disadvantages, and complications in coronary angiography and intervention. Their use in the acute myocardial infarction setting and other situations is described. Vascular closure device usefulness is also considered.     

Interosseous artery as an access artery in case of late radial artery occlusion

We report a new technique of arterial access through the ipsilateral interosseous artery in a case of late radial artery occlusion (RAO). RAO, although not frequent, is a limiting iatrogenic complication after transradial intervention (TRI) and precludes repeat use of the same radial artery for future procedures. Our technique involves obtaining access to the ipsilateral radial artery (RA) in the distal postocclusion segment and use of collateral channel between this segment and the interosseous artery (IOA) for advancing a guidewire and sheath in the IOA lumen and in brachial artery thereafter. © 2017 Wiley Periodicals, Inc.     

Prevalence of abnormal upper limb arterial anatomy and its correlation with access failure during transradial coronary angiography

ObjectiveThe study aimed at to find out prevalence of abnormal upper limb arterial anatomy and its correlation with access failure during transradial coronary angiography.MethodThis was a prospective observational study of 1512 patients who had undergone transradial coronary angiography (CAG). Angiographic assessment of upper limb arterial tree was performed when the angiographic guidewire or the diagnostic catheter followed an abnormal path or got stuck in its course.ResultsAbout 5.29% patients (80/1512) were noted to have abnormal upper limb arterial anatomy. The most common abnormality detected were radio-ulnar loop in 22 (1.46%) patients, tortuous upper limb arteries 19 (1.25%) and abnormal high origin of radial artery 10 (0.66%) patients. Access failure was encountered in 4.4% (67/1512) of total patients and 64.17% (43/67) access failure was due to abnormal upper limb arterial anatomy.ConclusionAbnormal upper limb arterial anatomy was the most common cause of access failure in transradial coronary angiography in this study.     

Successful transradial coronary angioplasty and stenting using a self-expandable RADIUS stent to the anomalous left main coronary artery

Stenting of anomalous coronary artery is technically challenging both from the femoral and radial approaches because of difficulty in cannulating the artery by the guiding catheters with enough back-up support for delivering the stent. We report the first case in the literature of transradial coronary angioplasty and stenting to an anomalous left main coronary artery originating from the right sinus of Valsalva. Left Amplatz guidance from the radial approach provided an adequate platform to advance the stent using a dummy guidewire technique, and a self-expandable RADIUS stent was successfully deployed in a tortuous lesion of the anomalous artery.     

Retrieving a deformed stent during transradial intervention: An alternative femoral approach using guide catheter shortening

Stent dislodgment during percutaneous coronary intervention is a rare complication. We report a case of successful retrieval of a deformed coronary stent through alternative transfemoral approach while performing transradial procedure when the stent could not be retrieved safely from transradial route.     

Successful fenestration using a chronic total occlusion-dedicated guidewire in a patient with catheter-induced dissection of the right coronary artery

Guiding catheter-induced coronary artery dissection is a rare, but hazardous complication of percutaneous coronary intervention (PCI) and is associated with the potential risk of impairment of coronary blood flow. Therefore, occurrence of this complication mandates a prompt revascularization procedure. A 68-year-old female patient with acute myocardial infarction caused by total occlusion of the proximal right coronary artery (RCA) underwent PCI. After revascularization by thrombus aspiration, catheter-induced dissection of the ostium of the right coronary artery (RCA) occurred when the guiding catheter and guidewire were accidentally removed. An attempt to engage the guiding catheter and guidewire into the true lumen failed because of total occlusion of the right coronary ostium. A chronic total occlusion (CTO)-dedicated guidewire was then used to create a fenestration of the intimal flap, and after it penetrated into the distal true lumen, a low-profile balloon catheter was dilated, and coronary flow from the false to the true lumen was established. After balloon dilatation, stents were deployed at both the dissection site and in the distal lesion. The final angiogram revealed restoration of coronary blood flow. We propose that application of a CTO-dedicated guidewire to create a fenestration of the intimal flap in the region of the coronary dissection is a feasible and effective alternative to conventional procedures.     

Myocardial and pericardial staining by transradial Optitorque Jacky shape catheter during left ventriculogram

A 69-year-old male presented with inferior wall ischemia. Transradial coronary angiogram with an Optitorque Jacky shape catheter showed unobstructed coronary arteries (Terumo Medical Corporation). Left ventriculography was complicated with myocardial and pericardial contrast staining. The catheter was pulled back. The patient experienced sharp chest pain that resolved in 20 minutes. Stat transthoracic echocardiogram was unremarkable. The patient remained hemodynamically stable. Transthoracic echocardiogram the next morning revealed trivial pericardial effusion. Patient was asymptomatic on outpatient follow-up. The Optitorque transradial catheter, with Jacky and Tiger tip shapes, is the preferred multipurpose catheter for transradial coronary angiogram. Potential complications of ventriculogram catheters are myocardial staining, myocardial rupture, cardiac tamponade, and arrhythmias caused by improper position of the catheter tip. It is imperative to check the position of the catheter tip with a small amount of contrast injection prior to left ventriculography (even though we checked our position with a small test injection) to avoid these types of complication. This case illustrates the value of careful manipulation and placement of transradial catheter during left ventriculography.     

Intercoronary communication between right and left coronary artery with bidirectional flow--a rare angiographic finding

Intercoronary artery continuity is a rare variant of coronary circulation. Here we report a case where we found an intercoronary communication between the left and the right coronary artery. Right coronary angiogram showed filling of the left coronary artery and the left coronary angiogram showed filling of the distal right coronary artery, demonstrating bidirectional flow. The coronary arteries were free of atherosclerotic occlusive disease. The case is reported for its rarity.     

Successful transradial intervention by switching from 6 French to 5 French guiding catheter

We report a case of percutaneous coronary intervention (PCI) where a 6 French (Fr) guiding catheter could not be advanced through extremely tortuous subclavian and brachiocephalic arteries with a right transradial approach. Downsizing from a 6 Fr to 5 Fr guiding catheter was effective to reach to the coronary cusp, and we successfully performed transradial PCI without access-site crossover. When a catheter cannot be advanced in a tortuous vessel during transradial intervention, downsizing the catheter is an option to reduce resistance and enable successful PCI without access-site crossover.     

Importance of a hydrophilic coronary wire in anatomically challenging transradial access: an extended case series

Anatomic variations during transradial (TR) procedures are relatively common and represent a significant cause of technical failure, even for experienced radial operators. In this study, we present an interesting alternative technique to overcome these anatomical anomalies. A significant amount of TR procedures in various and challenging anatomical conditions were successfully completed with the use of a 0.014″ hydrophilic coronary guidewire.     

Transradial renal angioplasty: initial experience.

We report our early experience of a new technique of renal angioplasty utilizing the radial approach. Certain anatomic considerations continue to make access from above via the arm the preferable approach in selected patients in renal artery stenosis. We have utilized the transradial technique for renal artery angioplasty and stenting successfully in four patients. The development of coronary guidewire (0.014")-based peripheral balloons and stent delivery systems has miniaturized equipment sufficiently to make the transradial approach attractive. Present equipment allows for stenting of renal arteries of up to 7 mm with the use of 6 Fr guiding catheters. Present equipment length remains a limitation in taller patients. The transradial approach should be considered in those patients with renal artery or aortoiliac anatomy favoring an approach from the arm.     

Coronary artery fistula with a giant aneurysm treated by percutaneous transradial embolization

Coronary artery fistulas are rare anomalies that are very rarely accompanied by an aneurysm. The minimally invasive method of percutaneous transradial embolization, using a thin guiding catheter, was used to treat a coronary artery fistula with an associated giant aneurysm. This technique, not previously described for this type of application, is presented as a case report. The successful outcome of this procedure demonstrated that transradial coronary interventions are useful for treating coronary artery fistulas with an associated giant aneurysm, especially in patients at high risk for conventional surgery or transfemoral interventions. © 2012 Wiley Periodicals, Inc.     

经桡动脉普通导引导管7F无鞘技术治疗冠状动脉复杂病变

目的 评价经桡动脉普通导引导管7F无鞘技术治疗冠状动脉复杂病变的安全性、可行性.方法 纳入2013年11月至2014年4月,经桡/尺动脉置入6F桡动脉鞘造影后,需要用7F导引导管行介入治疗的患者31例.在桡动脉鞘内置入长260 cm,直径0.036 in（1 in=2.54 cm）非亲水涂层导丝至升主动脉;撤出桡动脉鞘,将6 F 110 cm猪尾管插入7 F 100 cm导引导管内,猪尾管头端突出于导引导管外;将猪尾管和导引导管呈一体,穿入长260 cm,直径0.036 in导引导丝,通过皮肤切口逐次进入桡动脉,导引导管到位后撤出猪尾管.结果 31例导引导管均成功通过桡动脉,到达靶冠状动脉开口,完成介入治疗后撤出导引导管.术后观察24 h,所有患者桡动脉穿刺处无出血,穿刺侧上肢未发生血肿、感觉障碍.术后1个月随访,未发生桡动脉闭塞.结论 经桡动脉普通导引导管7F无鞘技术是治疗冠状动脉复杂病变可选用的相对安全、有效的途径.     

Prevalence and clinical predictors of severe tortuosity of right subclavian artery in patients undergoing transradial coronary angiography

We investigated the prevalence and clinical predictors of severe tortuosity of the right subclavian artery (RSA) in 2,341 consecutive patients who underwent transradial coronary angiography as well as the feasibility and safety of a technique to complete transradial catheterization. Severe tortuosity of the RSA was seen in approximately 10% of these patients, and clinical predictors included systemic hypertension, female gender, older age, nonsmoker, short stature, and high body mass index. Guidewire replacement with a stiff guidewire is reliable and safe for completing transradial angiography in most patients with a tortuous RSA.