Navigating the challenges of radial access – Tipps and Tricks and Troubleshooting

Introduction:
Transradial access is the recommended arterial access for coronary angiography and PCI due to lower rates of vascular complications, improved patient satisfaction and decreased overall mortality. However, cardiac catheterization using the radial artery has its unique challenges. Difficult vascular anatomy can drastically impede successful cardiac catheterization.

Case:
A 91-year female patient, with a history of CAD, penetrating aortic ulcer with intramural hematoma and persistent thrombocytopenia presents electively in our center for coronary angiography due to exertional dyspnea and ST segment depression in exercise ECG. Right radial access was obtained without any difficulty, however the standard 0.035 J-tip and a 0.035 hydrophilic wire (TERUMO GLIDEWIRE®) with an angle tip could not be advanced. A floppy 0.014 guidewire (TERUMO RUNTHROUGH) was then successfully advanced in the right subclavian artery and the catheter could then be advanced to the brachial artery. At the level of the proximal brachial artery we faced a loop. Changing to a 0,035 stiff wire (Amplatz Super StiffTM) gave the catheter enough support. By then gently pulling the catheter backwards we were able to straighten the loop and advance the catheter. An elongated and tortuous subclavian artery could also be passed using respiratory maneuvers and catheter manipulation like pull and push. The angiography revealed unchanged CAD with favorable long-term results after BMS- stenting of the RCA. The patient was discharged a day after the procedure.

Discussion:
In some cases, the transradial access can be a challenge. Troubleshooting includes the use of hydrophilic wire, balloon tracking techniques and respiratory maneuvers. During radial access, vascular difficulties are encountered at two anatomic regions. Firstly, the guidewire and guide catheter must pass the radial-ulnar-brachial region. In this region loops, tortuosity and atypical arterial branching can pose potential obstacles. We could successfully wire the entire vascular system of the arm including the loop with a floppy guidewire, after a failed attempt with a hydrophilic guidewire. Advancing the catheter over a less supportive wire can also be an issue. Switching to a stiff J wire may be the solution in the presence of significant tortuosity. Secondly, the guidewire must transverse the subclavian-innominate-aortic region before reaching the ascending aorta. In this region tortuosity, high atherosclerotic burden and aortic arch elongation can complicate the procedure and may result in strokes. We find respiratory maneuvers like deep inspiration while advancing the catheter as well as choosing an undersized catheter (4F) or a special 4F hydrophilic coated catheter (TERUMO GLIDECATHTM) to be very helpful. Once the wire reaches the ascending aorta, every attempt should be made not to lose the wire position. In our experience, navigating a challenging radial access starts with knowing your materials, your potential and limitations.

Conclusion:
Radial access has substantial benefits over the femoral approach and can be successfully used even in the presence of difficult anatomy or advanced vascular disease. As with any procedure, it is important that the operator be aware of possible solutions and complications so patients can undergo safe, efficient procedures. We recommend: while keeping the limitations in mind, trust your materials, yourself and go high.