Usefulness of prominently projected aortic arch on chest radiograph to predict severe tortuosity of the right subclavian or brachiocephalic artery in patients aged >44 years undergoing coronary angiography with a right radial artery approach

Although it is well known that certain characteristics, such as older age, female gender, hypertension, and high body mass index, are closely associated with severe arterial tortuosity among patients undergoing transradial coronary angiography, few data are available regarding useful predictors of severe arterial tortuosity among geriatric patients. The purpose of the present study was to evaluate the characteristics of geriatric patients with severe tortuosity of the right subclavian artery or brachiocephalic artery. The coronary angiographic reports of patients with severe tortuosity of the right subclavian artery or brachiocephalic artery and age- and gender-matched control patients were retrospectively evaluated. A total of 847 consecutive patients underwent right transradial coronary angiography. Of these patients, 48 (5.7%) had severe tortuosity (29 women, age 73.4 ± 8.6 years). The factors associated with severe arterial tortuosity were greater body mass index (odds ratio 1.17, p = 0.02), the presence of a prominently projected aortic arch on a chest radiograph (odds ratio 5.62, p <0.01), and lower serum creatinine value (odds ratio 0.05, p <0.01). In conclusion, the presence of a prominently projected aortic arch on the chest radiograph is a useful predictor of severe arterial tortuosity.     

Anatomical consideration of the radial artery for transradial coronary procedures: arterial diameter, branching anomaly and vessel tortuosity

BACKGROUND: The radial artery is currently regarded as a useful vascular access site for coronary procedures. Adequate anatomical information of the radial artery should be helpful in performing the transradial coronary procedure. Therefore, we tried to evaluate the size of radial artery, the incidence and clinical significance of anomalous branching patterns and tortuosity of the radial artery related with transradial coronary procedure. MATERIALS AND METHOD: In 1191 cases, mean radial arterial diameter (RAD) was measured before and after the procedure using a two-dimensional ultrasound and retrograde radial artery angiography was performed before the transradial coronary procedure in all patients. Branching anomaly, tortuosity of the radial artery and procedural characteristics including procedure times and local vascular complications were analyzed. RESULTS: The mean RAD was 2.60 +/- 0.41 mm by two-dimensional ultrasound: 2.69 +/- 0.40 mm in men and 2.43 +/- 0.38 mm in women (p < 0.001). Radial artery occlusion occurred in 0.6% in coronary angiography and 1.4% in coronary intervention. In multivariate analysis, coronary intervention was significantly related to the radial artery occlusion (p = 0.048). Anomalous branching of upper extremity artery was found in 38 cases (3.2%); high origin of the radial artery was most frequent in 28 cases (2.4%). Tortuosity of radial and brachial artery was found in 67 of 50 cases (4.2%). Most common forms of tortuosity were S-shape in 21 cases (31.3%) and Omega-shape in 21 cases (31.3%). And most common site of radial artery tortuosity was proximal third of antecubital fossa (35 cases, 52.2%). Prolonged procedure times and cross-overs to other arteries were related with tortuosity of the radial artery, but not with anomalous branching. CONCLUSION: In our study, radial artery diameter was larger than the outer diameter of 5Fr sheath in 82.7% for transradial coronary procedure. Radial artery occlusion was associated with coronary intervention using larger size sheath than diagnostic angiography using 5Fr sheath. The incidence in branching anomaly and tortuosity of radial artery was not rare in our study. Radial artery tortuosity was associated with old age and prolonged procedure time.     

Randomized comparison of transradial coronary angiography via right or left radial artery approaches

Previous studies have shown that the right radial approach encounters more tortuosity than the left radial approach during transradial coronary angiography. The objective of this study was to compare the procedural difficulty of the right and left radial approaches in the modern era with dedicated transradial catheters. One hundred ninety-three patients scheduled for transradial coronary angiography with normal Allen test results and without histories of coronary artery bypass grafting were randomized to the right or left radial approach. The choice of catheter was left to the discretion of the operator, with the preferred catheter being a dedicated transradial Optitorque catheter. The primary end point was procedural difficulty, defined as (1) hydrophilic or coronary wire use for tortuosity, (2) stiff wire use for the coronary engagement, (3) multiple catheters used, or (4) nonselective injection. The clinical characteristics were similar between the 2 groups. Procedural success was achieved in 98 of 101 (98%) in the right radial group and 91 of 92 (99%) in the left radial group. Procedural difficulty, fluoroscopy time, and contrast use were similar between the 2 groups. The use of a single catheter was more common in the right radial group (73% vs 18%, p <0.001). In conclusion, procedural success and difficulty were similar in the comparison groups. The right and left radial approaches are feasible and effective to perform coronary angiography and intervention.     

Radial loop and extreme vessel tortuosity in the transradial approach: advantage of hydrophilic-coated guidewires and catheters.

Between October 2000 and October 2001, all transradial cases performed by the author necessitating radial and upper arm angiography because of difficult advancement of standard guidewires or catheters were analyzed retrospectively. Fourteen of 594 (2.4%) transradial cases met the study criteria. Radial loops or stenosis and tortuosity in the subclavian or innominate artery were responsible for the difficult access. Several examples of patients with access problems are presented. A technique using a hydrophilic-coated guidewire and a new hydrophilic-coated guiding catheter is described.     

疑诊冠心病患者经桡动脉冠脉造影术510例分析

目的　探讨经桡动脉径路行冠脉造影的可行性和安全性。方法　 5 10例临床疑诊为冠心病的患者接受了经桡动脉径路冠脉造影术。结果　 5 0 3例获得成功 ,7例失败 ,其中 3例为穿刺失败 ,1例为桡动脉走行畸形 ,2例是由于无名动脉过于迂曲致导管操作极度困难而失败 ,1例为左锁骨下动脉闭塞。所有病例无严重并发症发生 ,只有 1例于术后发生桡动脉闭塞。结论　桡动脉径路行冠脉造影具有止血容易、病人术后无须长时间卧床和并发症少的优点 ,操作成功率高 ,临床应用安全     

Novel use of a GuideLiner catheter to visualize distal LAD after LIMA anastomosis in selective coronary angiography

We report a case of GuideLiner catheter use during transradial intervention for selective coronary angiography of the distal left anterior descending artery (LAD), beyond the left internal mammary artery (LIMA) anastomosis. The lesion within the LAD was located distal to the anastomosis of a very tortuous LIMA, otherwise unable to be visualized due to competitive flow from the LIMA. Stenting by way of the LIMA could not be performed due to this severe tortuosity as well. Alternatively, performance of the intervention without GuideLiner assistance would have required dual access, with injections both through the LIMA graft and the native LAD for angiography and intervention. Use of the GuideLiner served the purpose of selective LAD angiography to visualize the lesion, as well as delivery of the stent through a proximally calcified LAD. Using this single transradial route allowed the intervention to be completed, while reducing complications due to multiple access sites.     

Successful use of an extra-long hydrophilic-coated sheath in enlarged aorta to overcome extreme tortuosity of right subclavian artery via transradial approach during coronary angiography

The transradial approach (TRA) has gained popularity in recent years mainly because of the significantly decreased access-site complications and the greater patient comfort it offers. In this paper, we describe the successful use of an extra-long hydrophilic-coated sheath for coronary angiography via the TRA in the presence of a severely dilated ascending aorta in a patient with severe tortuosity of the right subclavian artery.     

老年患者冠状动脉扭曲临床特征及相关危险因素

目的探讨老年患者冠状动脉（简称“冠脉”）扭曲的病变特点及相关危险因素。方法选取进行冠脉造影检查的304例老年患者为研究对象,回顾性查阅病史资料和影像资料;分析相关危险因素,并对血压水平与冠脉扭曲程度之间相互关系进行分析。结果老年冠脉扭曲阳性率高达55-3％（168／304）,老年女性发病率为60．1％（101／168）,中重度扭曲主要发生在左回旋支（33．9％）,三支病变的扭曲总积分最高;性别与血压是老年患者冠脉扭曲的重要危险因素;血压水平的高低与冠脉扭曲程度呈正相关。结论老年冠脉扭曲发病率高,且与性别、血压密切相关。血压越高造成的冠脉扭曲程度越严重。     

Transradial access in percutaneous coronary interventions

After showing significantly lower complication rates in diagnostic coronary angiography, the radial artery access was successfully introduced as a useful vascular access site for transradial percutaneous coronary intervention in order to enhance patients’ comfort and reduce hospital workload and costs. Moreover, due to the reduced need for antiplatelet therapy cessation as a result of lower bleeding complications, patients treated with transradial access showed a significantly better cardiac outcome in randomized interventional acute coronary syndrome studies. Procedural success and postprocedural radial arteritis or radial occlusions are closely related to anatomical circumstances (e.g., anomalous radial branching patterns, tortuosity, e.g., radial loops and small radial artery diameters), or risk factors for radial spasms (e.g. smoking, anxiety, vessel diameter, age, gender) which can effectively be reduced by the use of smaller catheters (4–5 Fr) and the administration of an adjuvant pharmacological therapy before (3000 U heparin, verapamil, nitroglycerine) and after (ibuprofen) the intervention. For successful radial sheath access and transradial catheterization, it is important to use dedicated radial access needles ≤21-gauge and steel wires ≤0.018 in. In order to pass the brachiocephalic trunk without difficulties or complications and access the ascending aorta, the use of inspiration maneuvers is of central importance.     

经桡动脉穿刺冠状动脉造影后即刻经桡动脉介入治疗

目的探讨冠心病心绞痛患者经桡动脉穿刺冠状动脉造影术后即刻选择经桡动脉行冠状动脉介入治疗的可行性、并发症以及近期疗效。方法选择临床诊断为冠心病心绞痛经桡动脉造影显示明确的冠状动脉病变后即刻采取经桡动脉介入治疗(PCI)的患者117例(桡动脉组),与同期经股动脉途径造影后即刻PCI者(股动脉组,共409例)进行比较,分析两组靶血管病变特征、疗效和并发症,并随访术后1月内心绞痛复发、心肌梗死、死亡等主要心血管事件的发生率。结果桡动脉组PCI成功率为94.0%,与股动脉组(97.6%)相比无明显差异(P>0.05)。桡动脉组造影显示明显病变(管腔狭窄程度≥70%)的血管数量累计为210支,其中182支作为靶血管进行了成功的PCI,病变血管的血运重建率为86.7%,低于股动脉组(93.4%),差异具有显著性(P<0.01)。而且成功PCI者中慢性闭塞病变的所占的比例也明显低于股动脉组,差异具有显著性(P<0.05)。桡动脉组术后与穿刺有关的总的并发症的发生率明显低于股动脉组(P<0.01)。术后平均卧床时间和平均住院天数均明显短于股动脉组。随访PCI术后1个月期间主要心血管事件两组之间无明显差异(P>0.05)。结论经桡动脉穿刺冠状动脉造影术后即刻行冠状动脉介入治疗的成功率较高,并发症少,具有可行性。但对于复杂病变选择经股动脉途径PCI     

经桡动脉行复杂冠状动脉病变的介入治疗

目的探讨经桡动脉行复杂冠状动脉病变介入治疗的可行性。方法将178例左主干开口病变、分叉病变、慢性闭塞病变、长度≥30mm的长病变、纡曲成角病变及严重钙化病变等复杂冠状动脉病变患者经桡动脉途径进行PCI。结果经桡动脉PCI完成率97.2%。因导引导管支撑力不够,采用双导丝技术18例,采用子母导管技术5例,微导管技术6例,锚技术3例。左主干开口病变8处即刻全部成功。左主干分叉病变双支架置入17例,单支架置入9例。其他分叉病变67处,单支架置入47处,双支架置入20处。双支架置入后对吻球囊扩张成功率100%。34处慢性闭塞病变PCI成功27处。长度≥30mm的长病变91处、纡曲成角病变23处、严重钙化病变27处全部PCI成功。术中支架内血栓2例,住院期间亚急性血栓形成2例。死亡1例。穿刺处并发症:桡动脉闭塞8例,前臂肿胀4例,无血肿及神经损伤。结论经桡动脉途径进行冠状动脉复杂病变的PCI有较高的成功率。     

Transradial approach for noncoronary angiography and interventions.

PURPOSE: The purpose of this study was to retrospectively evaluate the feasibility and safety of a transradial approach for non-coronary angiography and interventions. BACKGROUND: Generally, the transradial approach is used for coronary angiography and intervention around the world, and experiences have been widely reported. However, few large studies have examined the transradial approach for vessels other than the coronary or cerebral artery. METHODS: Subjects comprised 329 patients who underwent a total of 400 procedures (285 abdomens, 68 pelvises, and 47 lower limbs) with transradial angiography and interventions between January 1999 and June 2006. Normal Allen test results were confirmed before all procedures. A 130- or 150-cm long 4F catheter modified to our own design was used for angiography and interventions such as transarterial embolization or transarterial chemotherapy. RESULTS: Radial artery access was unachievable in 19 of the 400 procedures (4.8%). The radial artery was injured during 1 procedure (0.2%). In the remaining 380 procedures, sufficient angiography was obtained to grasp the condition of indispensable vessels for diagnosis and interventions scheduled in advance succeeded. Total transradial technical success rate in the series was 95%. Frequency of complications such as radial injury or radial spasm was 1.8%. No cases of local hematoma, hand ischemia, or cerebral infarction were encountered. CONCLUSION: The transradial approach was useful for non-coronary angiography and interventions and offers the advantages of low risk and reduced stress on patients.     

老年急性心肌梗死患者经桡动脉和股动脉介入治疗的对比分析

目的分析老年急性心肌梗死患者经桡动脉直接PCI治疗的成功率、并发症以及应用经验。方法选择行直接PCI治疗的老年急性ST段抬高心肌梗死患者96例,根据PCI操作途径分为桡动脉组(50例)和股动脉组(46例),比较两组的手术成功率和手术结果,分析手术并发症以及住院期间预后。结果桡动脉组和股动脉组手术成功率相似(92.0%vs91.3%,P>0.05),桡动脉组有两例患者交叉到股动脉组手术成功,两组手术时间、穿刺时间和第一次球囊扩张时间均无显著差异(P>0.05),但桡动脉组透视时间显著延长(P<0.05),住院期间主要心血管不良事件两组无显著差异,桡动脉组穿刺局部出血并发症显著降低(2.0%vs10.8%,P<0.05)。结论经桡动脉直接PCI在老年急性心肌梗死患者中有较好的安全性和有效性。     

Bilateral selective internal mammary artery angiography via right radial approach: clinical experience with newly designed Yumiko catheter.

The radial artery has been increasingly used as a primary access site for coronary angiography and intervention. But the technique for internal mammary artery (IMA) visualization via the right radial artery has not been well described. Therefore, the study was conducted to investigate the feasibility, safety, and adequacy of selective bilateral IMA angiography via the right radial artery using the recently developed Yumiko catheter. From November 1999 to October 2000, both IMA angiographies were undertaken immediately following the diagnostic coronary angiogram taken from right transradial approach in 114 patients. IMA angiography was successfully obtained in 99% (113/114) patients. For left IMA angiography, 73 (64%), 28 (25%), and 12 (11%) imagings were obtained in a selective, a semiselective, and a nonselective way, respectively. After initial periods of 33 left-IMA-only imaging, right IMA angiography was obtained in 81 patients (phase 2). Selective right IMA imaging was done in 73 (90%), semiselective in 6, and nonselective in 2 patients. The reasons for failure of selective or semiselective visualization were severe vascular tortuosity, far distal anatomical origin of left IMA and ulcerative plaque, or acutely angled left subclavian artery. The feasibility and safety of selective and semiselective bilateral IMA angiography were demonstrated using a 5 Fr Yumiko catheter from the right radial approach. Cathet Cardiovasc Intervent 2001;54:19-24.     

Safety and feasibility of transradial coronary angioplasty in elderly patients.

BACKGROUND: The aim of this study was to assess the safety, feasibility and efficacy of transradial coronary angioplasty in elderly (> or = 70 years) vs younger patients (< 70 years). METHODS: We studied 1125 consecutive patients submitted to transradial coronary angioplasty by a single operator. An angiography of the arteries of the upper limbs was performed before and after the procedure. The presence of the radial pulse was assessed at 1 month of follow-up. RESULTS: At angiography, elderly patients (n = 323) were found to have a higher incidence of radial and brachiocephalic trunk anatomical tortuosity compared to younger subjects (35.3 vs 17.3%, p < 0.05; 10.5 vs 5.3%, p < 0.05, respectively). Radial access was successful in 98.8% of elderly and in 99% of younger patients (p = NS). The procedural success by radial access did not significantly differ between the two groups (97.5 vs 98.7%; p = NS). The cannulation time (from skin anesthesia to arterial cannulation) and the total procedure time (from patient arrival at the catheterization room to the completion of the procedure) were not significantly different between the two groups (1.5 +/- 0.8 vs 1.6 +/- 0.4 min, p = NS; 57 +/- 23 vs 56 +/- 12 min, p = NS, respectively). There were no access site bleeding complications in younger and only one (0.4%) such a complication in elderly patients. In all patients, there was no case of forearm ischemia and the incidence of asymptomatic loss of the radial pulse during the 30-day follow-up period was not different between the two groups (1.5 vs 1.4%, p = NS). CONCLUSIONS: Performed by experienced operators, transradial access constitutes a safe and feasible approach for coronary angioplasty in elderly patients. The results are similar to those observed in younger patients.     

使用MPA导管经桡动脉行双侧颈动脉造影方法可行性探讨

目的研究经桡动脉途径行双侧颈动脉选择性造影新的常规造影方法。方法对广东省人民医院2011年1月至2011年3月期间32例经桡动脉应用MPA造影导管行双侧颈动脉选择性造影患者进行回顾性分析。结果桡动脉穿刺成功率100%,经桡双侧颈动脉选择性造影成功率100%,无并发症发生。结论本方法行双侧颈动脉选择性造影操作可行、安全,可做为常规颈动脉造影方法。     

经皮穿刺桡动脉冠状动脉造影46例分析

目的 探讨经桡动脉冠状动脉造影的可行性、安全性及评价其效果。方法 经桡动脉冠状动脉造影患者46例，术前常规行改良Allen试验，阳性者行经右桡动脉冠状动脉造影术。结果 手术成功率为95．7％，2例失败，无出血、夹层、血肿等血管并发症发生，术后随访无桡动脉闭塞。结论 经皮穿刺桡动脉冠状动脉造影术是一种安全、可行的冠状动脉介入诊断新途径，具有止血容易、术后无须卧床休息和并发症少的优点。     

Safety and feasibility of transradial approach for coronary bypass graft angiography and intervention

The transradial approach (TRA) is commonly applied for coronary catheterization. However, there are few reports on the safety and feasibility of transradial catheterization in patients with prior coronary artery bypass graft (CABG) surgery. We retrospectively evaluated 124 consecutive patients who underwent graft angiography and intervention via the transradial (TRA group, n = 68) or transfemoral approach (TFA group, n = 56). The baseline clinical characteristics between the 2 groups were similar except for prior myocardial infarction. No significant difference (P > .05)was observed in procedure time, the success rate of puncture, angiography, and intervention procedure between the 2 groups. There was no significant difference in major adverse cardiac and cerebrovascular events during hospitalization. However, the vascular access site complications were significantly lower (P = .021) and the duration of hospitalization was shorter (P = .007) in the TRA group. The TRA for coronary bypass graft angiography and intervention was safe and feasible.     

Occasional-operator percutaneous brachial coronary angiography: first, do no arm.

The percutaneous brachial approach to coronary angiography is perceived, rightly or wrongly, to be the easiest of the arm approaches. Predominantly femoral operators may therefore be encouraged to use the percutaneous brachial approach as an occasional procedure. We decided to investigate prospectively whether this was a reasonable strategy by examining outcome in patients who underwent percutaneous brachial cardiac catheterization by occasional brachial operators. Between October 1997 and 2000, 55 patients underwent percutaneous brachial coronary angiography (0.6% of coronary angiographies), aged 66 +/- 10 years, of whom 40 (73%) were male. Chief indications for a brachial approach were peripheral vascular disease in 35 (64%), failed femoral approach in 10 (18%), and orthopnoea in 5 (9%). The procedure was completed successfully in 46 patients (84%). Reasons for failure were failure of access (two), brachial artery spasm (one), inability to negotiate brachial/subclavian tortuosity (two), dissection of the brachial artery (two), and inability to intubate a vein graft (two). Six patients required catheterization from an alternative site (brachial arteriotomy in two, percutaneous transradial in two, femoral in two), with success in all. There were complications of varying severity in 20 patients (36%). Major complications were false aneurysm requiring surgical repair (one), large brachial hematoma requiring surgical exploration and arterial repair (one), and hematoma with clinical median nerve dysfunction for one month. Minor complications included need for repeat coronary angiography via alternative approach (six), weakness of radial pulse < 24 hr (two), brachial artery dissection without clinical sequelae (two), brachial artery spasm terminating procedure (one), and wound oozing (three). Percutaneous brachial coronary angiography is a hazardous procedure when undertaken by occasional brachial operators. Complications are unacceptably frequent. As with all practical procedures, complication rates are likely to be inversely proportional to operator volumes. Patients requiring an arm approach should be referred to operators with high-volume brachial or radial experience.     

Routine transradial coronary angiography in unselected patients

OBJECTIVES: To measure and compare the results of changing from routine transfemoral to routine transradial coronary angiography performed by a single operator. DESIGN: A learning period of 3 months for the transradial procedure with 43 selected patients was followed by a 12-month routine period with 243 unselected patients. The success and complication rates, contrast volumes, catheter and X-ray times were measured and compared to results of a preceding period where the transfemoral approach was used. Follow-up was performed in the transradial groups 1.5-25 months after the procedure. RESULTS: Of the non-selected patients, 9% were deemed unsuitable for the radial procedure. In the remaining 91% in which the transradial route was attempted, success was achieved in 91%. The complication rate was 2.7%. Increased operator experience reduces catheter and fluoroscopy times. At follow-up, 4.7% of the radial arteries were occluded, but the patients were without clinical sequelae. The occlusion rate was significantly higher with an unsuccessful procedure. CONCLUSIONS: Transradial coronary angiography can be performed safely and with acceptable image quality in non-selected patients after a learning period of 43 cases. Total procedure time is shorter than with the transfemoral approach. There were no bleeding complications and no procedure-related complications that required treatment.