We present a case demonstrating the importance of careful advancement of wire and catheter through the upper limb arteries when performing transradial catheterization.
A 91-year-old ADL [activities of daily living] independent female was referred to the cardiac catheterization laboratory for evaluation of symptomatic severe aortic stenosis, based upon a transthoracic echocardiogram demonstrating a mean aortic gradient of 26mmHg and aortic valve area by continuity equation of 0.8 squared centimeters. The catheterization was performed to evaluate and treat coronary artery disease prior to proceeding for transcatheter aortic valve implantation (TAVI). Due to the increased risk score for bleeding, radial access was preferred.
A 6 French (Fr) and a 5 Fr Glidesheath (Terumo) were placed in the right radial artery and right basilic vein, respectively, to perform left and right heart catheterization. Right heart catheterization was performed first, using a 5 Fr Swan catheter (Arrow International). A 0.035-inch, 260 cm “J” tip wire was advanced over a Judkins right (JR) 4.0 catheter through the radial sheath, with resistance appreciated as the wire approached the axillary artery. A selective right brachial angiogram was performed that demonstrated axillary stenosis (Figure 1). The J wire was then exchanged for a 0.035-inch, 150 cm angled Glidewire (Terumo) to advance past the lesion under fluoroscopy. During the Glidewire advancement, there was a subclavian dissection, confirmed by subclavian angiography through the JR catheter (Figure 2). Subsequently, a “Y” connecter was used and a Glidewire was carefully advanced through the true lumen, confirmed by subclavian angiography performed through the 6 Fr JR 4 catheter placed at the distal axillary artery (Figure 3). The remainder of the left heart catheterization was performed over a 260 cm J wire, with the coronary arteries free of any severe stenosis. After completing the intended procedure, selective right brachiocephalic, subclavian, and axillary artery angiograms were performed, demonstrating persistence of a dissection flap. A 0.014-inch standard angioplasty wire was kept in the ascending aorta through a “Y” connector, with sequential pull back of a JR 4 catheter to perform axillary and subclavian artery angiograms (Figures 4a and 4b). The worst aspect of the dissection was located in the axillary artery and was flow-occlusive, with a 50 to 60 mmHg gradient and severely diminished radial artery wave form measured from the sheath. Since the dissection had caused reduced perfusion to the radial artery, a 5.0 x 80 mm self-expanding Complete SE stent (Medtronic) was deployed into the right axillary artery (Figure 5). The stent was post dilated with a 5.0 x 40 mm balloon with very good final angiographic result, resolution of the gradient, and normal radial artery pressure (Figure 6). The radial sheath was removed and a hemostatic band was applied per the patent hemostasis protocol. A follow-up appointment 2 weeks after the procedure demonstrated 2+ radial pulses bilaterally, without any complaints. The patient was successfully treated 3 weeks later with a TAVI procedure.
It is well known that diagnostic cardiac catheterization procedures have associated risk and possible complications that may occur. It is therefore prudent that we always evaluate the risk versus benefit, and use the utmost caution, as well as the safest approach, when performing this procedure. Despite caution, complications will arise and the management of vascular complications remains an important component of interventional cardiology. The extent of complications can range from not-uncommon localized femoral artery dissection to dissection of coronary vessels, left main, and the aorta during diagnostic and interventional procedures.1-5 However, the complication of subclavian artery dissection during diagnostic and interventional cardiac procedures has been described, but is fairly uncommon and usually occurs most often when attempting to cannulate internal mammary artery grafts.6 The management strategy for the associated subclavian dissections can range from either a conservative7 or interventional8 approach based upon the side branch vessels involved and flow distal to the dissection. This case demonstrated compromised flow to the radial artery with a severe gradient present across the dissection in the diseased axillary artery. The dissection in the subclavian artery did not demonstrate a severe gradient or progression of the dissection, and was treated conservatively.
Subclavian dissection while performing transradial cardiac catheterization is very rare from anecdotal experience (2 out of approximately 5000 cases). The following tips can help readers prevent and manage this rare complication:
- Initially, use a J-tip 0.035-inch wire for every case and watch the wire advancing under fluoroscopy at least to the subclavian level.
- Whenever resistance is felt at the axillary artery, advance the catheter to the point of resistance and define the anatomy by angiogram.
- Use a “Y” connector and a steerable 0.035-inch angled wire or 0.018-inch/0.014-inch shapeable wire to cross the tortuous anatomy or disease.
- If a dissection is noted, carefully enter the true lumen with a wire guided by contrast injection. Advance the catheter beyond the dissection area and complete the intended procedure. The dissection that was caused by the wire is a retrograde dissection and most of the time, it is not flow limiting and only requires conservative management.
Disclosure: The authors report no conflicts of interest regarding the content herein.
The authors may be contacted via Dr. Kintur Sanghvi at firstname.lastname@example.org
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