Case Report

Twisted Turns to Traverse — Our Approach to Upper Extremity Tortuosity

Gautam Kumar1,2, MBBS, MRCP(UK), FASE, FACC, FSCAI, Associate Professor of Medicine, and Rajesh Sachdeva2, MD, FACC, FSCAI, Professor of Medicine

1Emory University, Atlanta, Georgia; 2Atlanta VA Medical Center, Decatur, Georgia

Gautam Kumar1,2, MBBS, MRCP(UK), FASE, FACC, FSCAI, Associate Professor of Medicine, and Rajesh Sachdeva2, MD, FACC, FSCAI, Professor of Medicine

1Emory University, Atlanta, Georgia; 2Atlanta VA Medical Center, Decatur, Georgia

Case 1

A 61-year-old man with a past history of coronary artery disease with single-vessel bypass surgery 5 years ago (saphenous vein graft [SVG] to the left anterior descending [LAD] artery), hypertension, cardiomyopathy with baseline ejection fraction (EF) 15-20%, end-stage renal disease on nightly peritoneal dialysis, anemia (hemoglobin [Hb] 7.5 g/dL, baseline 9.6 g/dL) presented to the emergency department with 3 days history of chest pain. He was on dual antiplatelet therapy including aspirin and clopidogrel. Cardiac biomarkers were elevated and upended to a peak troponin I of 0.15 ng/mL (normal values). He was transfused with 2 units of packed red blood cells and his repeat Hb was 8.4 g/dL (inappropriate response). However, there were no active signs of bleeding. He continued to have chest discomfort and was referred for left heart catheterization.

He also has history of a failed arteriovenous fistula in his left arm. Right radial access was selected because of given comorbidities, increasing his risk for bleeding from a femoral access site. Right radial access was obtained with ultrasound guidance and a 6 French (Fr) 10 cm GLIDESHEATH SLENDER® Introducer Sheath  (Terumo) was placed. The left coronary artery (LCA) was engaged with difficulty using a 6 Fr Jacky OPTITORQUE® Diagnostic Catheter (Terumo) (Figure 1, Video 1). This catheter could not engage the right coronary artery (RCA), because of excessive resistance encountered to transmit the torque to the tip of the catheter. Subsequently, several unsuccessful attempts were made to engage the SVG with left coronary bypass (LCB) and Amplatz left 1 (AL1) catheters. The AL1 catheter kinked while torquing (Figure 2). The kink was straightened with  an .035-inch 260 cm GLIDEWIRE ADVANTAGE® Guidewire (Terumo) through this catheter and access to the ascending aorta was re-established (Video 2). Since there was difficulty in catheter manipulation, a 6 Fr 85 cm R2P DESTINATION SLENDER Guiding Sheath (Terumo) was placed in the ascending aorta (Figure 3, Video 3). Subsequently, selective coronary angiography of the right coronary artery and the SVG were performed with minimal difficulty with 5 Fr Judkins right and 5 Fr multipurpose catheters, respectively (Figure 4, Video 4, and Figures 5-6, Videos 5-6).

Following successful coronary and graft angiography, right subclavian digital subtraction angiography was performed via the 6 Fr 85 cm R2P DESTINATION SLENDER Guiding Sheath after withdrawing the sheath distally. The angiography revealed significant subclavian tortuosity with significant ostial vertebral artery stenosis and no evidence of any subclavian injury (Figure 7, Video 7).

The patient was treated with optimization of guideline-directed therapy.

Case 2

A 68-year-old man with a past history of congestive heart failure (EF 40-45%) with no known ischemic workup performed presented to the emergency department with decompensated heart failure and hypertensive emergency (systolic blood pressure ~190 mmHg). His cardiac biomarkers were elevated with peak troponin I of 2.28. He also complained of ongoing central chest pain that did not improve even after control of blood pressure overnight. He was thus referred for left heart catheterization.

Right radial access was obtained with ultrasound guidance and a 6 Fr 10 cm GLIDESHEATH SLENDER® Introducer Sheath was placed. Resistance was encountered in the arm while advancing an .035-inch 260 cm Rosen J-wire (Cook Medical); the 6 Fr Jacky OPTITORQUE® Diagnostic Catheter was advanced to the lower arm and digital subtraction angiography was performed with a 30% mixture of iodixanol and saline (Figure 8). A high origin of the right radial artery with significant tortuosity was recognized. An .035-inch 260 cm GLIDEWIRE ADVANTAGE® Guidewire was advanced through this catheter with minimal difficulty into the right subclavian artery (Video 8). The catheter was advanced into the ascending aorta easily, but catheter manipulation was impossible due to significant subclavian tortuosity (Figure 9, Video 9). Therefore, an .035-inch 260 cm GLIDEWIRE ADVANTAGE® Guidewire was placed in the ascending aorta and a 6 Fr 75 cm R2P DESTINATION SLENDER Guiding Sheath was advanced into the ascending aorta over this wire through both radial and subclavian arterial tortuosity (Figure 10A-B, Video 10).

Coronary angiography was performed with minimal difficulty with 6 Fr Judkins left 3.5 and 6 Fr Judkins right 4 catheters (Figures 11-14, Videos 11-14). The 6 Fr 75 cm R2P DESTINATION SLENDER Guiding Sheath was then withdrawn distally. Final angiography demonstrated no evidence of subclavian injury with significant tortuosity (Figure 15).

Discussion

Upper extremity arterial tortuosity can be benign, or can offer a significant barrier to this access route for coronary and graft angiography and percutaneous coronary intervention.

In general, the approach to tortuosity is as follows:

1. Recognition

The first step is to recognize that there may be an issue. If there is any resistance to advancement of an .035-inch J-tipped wire, it is essential to perform fluoroscopy of the suspected area. If gentle rotation and withdrawal and re-advancement of the wire does not succeed, it is important to move to the next step.

2. Angiography

Following advancement of a catheter just distal to the area where resistance is encountered, angiography is usually performed. Tortuosity is generally evident at this point. The radial loop is usually encountered in the forearm and severe tortuosity of the radial artery is encountered in the arm especially where the origin of the radial artery is high in the axilla.

3. Traversing the tortuosity

The area of significant tortuosity is traversed using a hydrophilic wire such as the .035-inch Terumo GLIDEWIRE ADVANTAGE® Guidewire, which provides a stiff rail for the delivery of the catheter past this region. Occasionally, a smaller diameter wire has to be used first to traverse this area.

4. Assessment of catheter maneuverability

Once the catheter reaches the ascending aorta, a rapid assessment is made regarding its maneuverability. This can be complicated, especially if multiple grafts exist. Aggressive catheter manipulation can result in radial artery spasm or worse, kinking of the catheter in the subclavian artery requiring additional maneuvers or occasionally even snaring via another access to remove.

5. Usage of long sheaths

In the past, some operators have advocated using a 6 Fr 90 cm PINNACLE® DESTINATION® Guiding Sheath (Terumo) that can traverse the subclavian tortuosity and reach the ascending aorta. However, in several cases, the usage of this sheath would result in inadequate maneuvering length for standard (110 cm) coronary catheters and would necessitate the use of 125 cm catheters that may not be available. The PINNACLE® DESTINATION® Guiding Sheath is also not advised for these situations due to its larger outer diameter and lack of full hydrophilic coating. Even if 125 cm catheters were available, difficulties in balloon and stent shaft lengths would be encountered for more distal lesions. The next shorter sheath length available was 65 cm, which was sometimes woefully inadequate to extend past the subclavian artery. The availability of the new 6 Fr 75 cm and 85 cm Terumo R2P DESTINATION SLENDER Guiding Sheaths has been a significant game-changer in facilitating this approach. These sheaths are of the appropriate length, have an excellent profile, and are kink resistant.

Conclusion

A radial approach is now considered the standard of care for cardiac catheterization in the United States. Infrequently, interventional cardiologists encounter anatomical challenges with a radial approach. Knowledge of vessel tortuosities and vigilance during the procedure, along with use of the right tools, can make the procedure seamless and successful. 

This article is supported by Terumo Interventional Systems.

Disclosure: The authors have not received any support/ compensation from Terumo for this article and have no conflicts to disclose regarding the content herein.

The authors can be contacted via Gautam Kumar, MBBS, MRCP(UK), at gautam.kumar@emory.edu

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