Obstacles encountered during transradial angiography from after Radial Artery puncture to the aortic arch
© Iwasaki et al.; licensee Springer. 2013
Received: 12 June 2013
Accepted: 28 July 2013
Published: 31 July 2013
To elucidate the key points for safe performance of transradial angiography.
Transradial angiography can be performed safely if attention is paid to the following points from after radial artery puncture to reaching the aortic arch: resistance during guide wire operation for sheath insertion after puncture; confirmation of the superficial brachial artery; guide wire resistance while guiding the catheter to the aortic arch; and aortic arch anomalies.
KeywordsTransradial angiography Radial artery Superficial brachial artery Aortic arch anomalies
Transradial angiography (TRA) has a number of advantages compared with transfemoral angiography (TFA), including the fact that postoperative hemostasis can definitely be performed using hemostatic devices rather than manual compression, meaning that anticoagulant therapy need not be discontinued for angiography, and the patient is able to get up immediately after the procedure and is thus more comfortable (Al-Kutoubi et al.1996; Cowling et al.1997; Matsumoto et al.2001; Iwasaki et al.2002; Jo et al.2010). It also has advantages compared with transbrachial angiography, including the fact that anticoagulant therapy need not be discontinued and that the puncture site in the TRA is distant from the median nerve, making it safer than puncturing the brachial artery, which is adjacent to the median nerve (Heenan et al.1996). In coronary angiography, TRA is used not only for diagnosis but also for interventions (Otaki1992; Kiemeneij & Laarman1993), although few institutions use this approach for cerebral (Matsumoto et al.2001; Iwasaki et al.2002; Jo et al.2010) or other angiographies (Al-Kutoubi et al.1996; Cowling et al.1997). Reasons for avoiding TRA include: the narrow diameter of the radial artery, which makes it difficult to puncture; unfamiliarity with the obstacles that can occur along the route to the aortic arch; and the fact that catheter operations in the aortic arch are different from those of TFA. Radiologists engaged in angiography should possess the knowledge required for the safe performance of TRA for angiographic procedures. Focusing on the second reason mentioned above, the objective of this paper is to describe cases selected from around 2700 TRAs for cerebral angiography we performed as illustrative examples, with the aim of contributing to the safe performance of TRA.
1. Sheath insertion
The right radial artery was preferred if the Allen test permitted use of both sides (Iwasaki et al.2002). When the right forearm is set along the torso, the position for the angiographer is almost the same as in the case of a right transfemoral approach. If the right Allen test warned for disconnection between the radial and ulnal arteries, the examination was performed via the left radial artery. After local anesthesia (about 1 or 2 ml of lidocaine 1%), the puncture was performed using a 22G (0.9 mm) puncture needle at the area of 2–5 cm proximal to the radial styloid.
After successful puncture of the radial artery, resistance may be felt when advancing the guide wire (0.025 inch, 0.635 mm) in order to insert the sheath (17 cm length with side holes, Medikit, Japan; 4F or 6F, 6F for the intervention). In such a case, the cause, as described below, must be investigated by confirming the location of the wire tip under fluoroscopy and gently injecting contrast agent from the puncture needle.
Radial artery occlusion
Radial artery vasospasm
Mistaken insertion of the guide wire into the recurrent artery
Radial artery flexion
2. Passing the catheter through the brachial artery
Superficial brachial artery (SBA)
SBA without anastomosis (58.9% of SBAs investigated)
SBA with an anastomosis, SBA is used (31.3%)
SBA with an anastomosis, anastomosis is used (6.1%)
SBA with an anastomosis, neither one can be used (3.7%)
3. Aortic arch
The most frequently encountered anomalies of the aortic arch are aberrant right subclavian artery and right aortic arch.
Aberrant right subclavian artery
Right aortic arch
We have presented illustrative examples of the obstacles that may be encountered along the route from after radial artery puncture until the catheter reaches the aortic arch during the performance of TRA. TRA can be performed safely if attention is paid to resistance during wire operation, confirmation of the SBA, and aortic arch anomalies.
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