Strategies to Overcome Hostile Subclavian Anatomy during Transradial Coronary Angiography and Interventions: Impact on Fluoroscopy, Procedural Time, Complications, and Radial Patency

VASCULAR ACCESS

Strategies to Overcome Hostile Subclavian Anatomy during Transradial

Coronary Angiography and Interventions: Impact on Fluoroscopy,

Procedural Time, Complications, and Radial Patency

GIANLUCA RIGATELLI, M.D., PH.D., E.B.I.R., F.A.C.C., F.S.C.A.I.,1

FABIO DELL’AVVOCATA, M.D.,1 DOBRIN VASSILIEV, M.D., PH.D., F.E.S.C.,2

RAMESH DAGGUBATI, M.D., PH.D., F.A.C.C.,3

ARAVINDA NANJIUNDAPPA, M.D., PH.D., F.A.C.C.,4 MASSIMO GIORDAN, M.D.,1

KHALID AL AZZA, M.D.,5 PAOLO CARDAIOLI, M.D.,1 and THACH NGUYEN, M.D., F.A.C.C.5

From the 1Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Rovigo, Legnago, Italy; 2InterventionalCardiology, National Heart Institute, Sofia, Bulgaria; 3Brody School of Medicine at East Carolina University, Greenville, North Carolina;4CAMC Vascular Center of Excellence, West Virginia University, Charleston, West Virginia; and 5Cardiology Department, St. Mary MedicalCenter, Hobart, Indiana

Background: Hostile anatomy of the subclavian artery (severe tortuosity and/or heavy calcification) remains asignificant obstacle for the transradial approach during coronary angiography and interventions.Objective: To assess impacts on fluoroscopy and procedural times, complications, and radial artery patency inpatients with hostile subclavian anatomy by using multiple catheter‐guide techniques.Methods: We retrospectively reviewed the medical and equipment data of 4,580 consecutive patients (mean age74.4� 26.7 years, 49.5% females) who have been referred for transradial coronary angiography and/orinterventions within the last 3 years (September 2010–September 2013). In order to overcome the strangling hold ofa hostile subclavian artery, 2 techniques have been used: (1) for a coronary angiography‐only procedure, a doublemother and child technique; (2) for percutaneous coronary intervention, a triple mother and child technique.Results: Ninety‐five patients (2.1%) from the entire study population exhibited a hostile subclavian artery. Fifty‐twopatients (1.1%) underwent coronary angiography only and 43 patients (1%) underwent interventions requiring theuse of the above double or triple mother and child techniques, respectively. The 2 techniques were successful in94.7% of patients (90/95 patients). The procedural time was significantly longer in the patients with hostilesubclavian artery while there were no differences in the fluoroscopy time. The radial artery was patent at 30 days in92.6% of patients (88/95 patients).Conclusion: Our data showed that in the presence of hostile subclavian anatomy, the mother and child techniquesappeared safe and effective, allowing for the completion of the intended procedure. (J IntervenCardiol 2014;27:428–434)

Introduction

Hostile anatomy of the subclavian artery, especiallythrough the right arm, remains an important limitationof the transradial approach in coronary angiography

and interventions. This unfavorable anatomy oftendetermines a need to switch to the femoral orcontralateral radial approach in order to complete theprocedure. The major determinants of a hostilesubclavian artery are severe tortuosity of the vesseland/or heavy calcification or congenital anatomicabnormalities, such as arteria lusoria.1 This extremetortuosity and/or heavy calcification of the subclavianartery prevent sufficient advancement and/or effectivetorqueing of the interventional guide or diagnosticcatheter. So the guide or catheter becomes immobilized

Disclosure statement: The authors report no financial relationshipsor conflicts of interest regarding the content herein.Address for reprints: Gianluca Rigatelli, M.D., Ph.D., F.A.C.P., F.A.C.C., F.E.S.C., F.S.C.A.I., Via Mozart 9, 37048 Legnago, Verona,Italy. Fax: þ39‐044220164; e‐mail: [email protected]

© 2014, Wiley Periodicals, Inc.DOI: 10.1111/joic.12127

428 Journal of Interventional Cardiology Vol. 27, No. 4, 2014

in a strangling hold of an excessive stiff and angulatedsubclavian artery.Hostile subclavian anatomy can be observed more

frequently on the right side,2,3 especially in patientsabove the age of 80. The primary factors associatedwith severe subclavian tortuosity include a greaterbody mass index and the presence of a prominentlyprojected aortic arch on chest X‐ray.4 In order toovercome the strangling hold of a hostile subclavianartery, we proposed the use of a modified double ortriple mother and child technique. The aim of this studywas to assess the impact of these techniques onfluoroscopy and procedural times, complications, andradial artery patency in patients with a hostilesubclavian anatomy.

Methods

We retrospectively enrolled 4,580 consecutivepatients (mean age 74.4� 26.7 years, 2,492 females,Table 1) who had undergone transradial angiographyand/or transradial interventions over the last 3 years(September 2010–September 2013) in our institute. Allcases of difficult subclavian anatomy were reviewed

by 2 independent operators (with an agreement of>99.8%) and subsequently classified as:

– Grade 1: Tortuosity or calcification of thesubclavian artery that can be crossed by a standardnonhydrophilic wire (Emerald 0.03500 CordisEurope, Roden, The Netherlands) facilitatedwith deep inspiration.

– Grade 2: Tortuosity or calcification of thesubclavian artery that can be crossed with ahydrophilic wire (Terumo soft 0.03500 TerumoCorporation Europe, Leuven, Belgium), and astandard diagnostic catheter.

– Grade 3: Tortuosity or calcification of the subclavianartery or congenital anomalies that require a stiff wire(Terumo stiff or Supracor 0.03500 Boston Scientific,Fremont, CA, USA), and a standard catheter.

– Grade 4: Severe tortuosity and/or calcification ofthe subclavian artery or congenital anomaliespreventing the catheter or guide to reach the aorticvalve plane or to engage the coronary ostia with astiff wire (hostile subclavian anatomy).

Only patients with hostile subclavian anatomy(Grade 4) were included in the study group (Table 1).

Table 1. Demographic and Clinical Data

Mean or No. (%)

Control Group N¼ 4,485 Study Group N¼ 95 P‐Value

Demographic informationAge (years) 74.4� 26. 7 78.4� 15. 5 nsFemale gender 2445/4485 (53.4%) 47/95 (49.5%) nsSmoking status 2530/4485 (56.4%) 52/95 (54.7%) nsHypertension 3172/4485 (70.7%) 75/95 (79.0%) nsHypercholesterolemia 2766/4485 (61.7%) 85/95 (89.4%) <0.01Diabetes 1808/4485 (40.3%) 73/95 (76.4%) <0.01

Clinical indicationsACS STEMI 411/4485 (9.1%) 30/95 (31.5%) <0.01ACS NSTEMI 2315/4485 (51.6%) 50/95 (52.6%) ns1‐vessel disease 986/4485 (21.9%) 21/95 (22.0%) ns2‐vessel disease 358/4485 (7.9%) 8/95 (8.4%) ns3‐vessel disease 2377/4485 (53%) 51/95 (53.6%) nsValvular heart disease 1054/4485 (23.5%) 6/95 (6.3%) <0.01Dilated cardiomyopathy 705/4485 (15.7%) 9/95 (9.4%) nsDifficult subclavian tractGrade 1 507/4485 (11.3%) 0/95 (0%)Grade 2 263/4485 (5.8%) 0/95 (0%)Grade 3 230/4485 (5.1%) 0/95 (0%)Grade 4 (Hostile anatomy) 0/4485 (0%) 95/95 (100%)

ACS, acute coronary syndrome; NSTEMI, non ST‐elevation myocardial infarction; STEMI, ST‐elevation myocardial infarction.

Vol. 27, No. 4, 2014 Journal of Interventional Cardiology 429

STRATEGIES TO OVERCOME HOSTILE SUBCLAVIAN ANATOMY DURING TRANSRADIAL CORONARY

In response to hostile subclavian anatomy and in linewith our institutional protocol, 2 techniques werepreferred:

1. For diagnostic angiography without intervention(Figs. 1 and 2), the strategy was to use a modifieddouble mother and child combination of (1) a6F coronary guide OR a left catheter such asthe Extra‐Back Up (EBU, Medtronic, Inc.,Minneapolis, MN, USA), OR a catheter for theright coronary artery such as those from theAmplatz Right (AR) or the Amplatz Left (AL)family (Medtronic, Inc.), and (2) a 4F diagnosticmultipurpose catheter over (3) a high support0.03500 wire (Abbott Vascular Inc., Santa Clara,CA, USA)5;

2. For PCI, the strategy was to use a triple motherand child combination with (1) a 6F 90 cm longhydrophilic sheath (Bloogminton, IN, USA), (2)a 6F guide EBU or AR, and (3) a 4F diagnosticmultipurpose catheter over (4) a strong support0.03500 wire (Figs. 3 and 4). After engagement ofthe coronary ostium by the multipurpose catheter,the guiding catheter was gently advanced whilethe diagnostic catheter was withdrawn whereasthe long sheath stabilized the entire system. Thenthe PCI proceeded as usual (Table 2).

Dose area product (DAP‐fluoroscopyþ angiogra-phy), as calculated automatically by the radiologicalequipment (GE Medical System Innova 2100 2000–2000

Flat Panel), was recovered for all cases. All unfavorable

Figure 1. Graphic representation of the double mother and child technique for coronary angiography: (A) A diagnostic 4F or 6F left coronarycatheter is inserted into a 6F 90 cm long sheath over a stiff guidewire to engage the left coronary ostium. (B) A diagnostic 4F or 6F right coronarycatheter is inserted into a 6F 90 cm long sheath over a stiff guidewire to engage the right coronary ostium.

Figure 2. Selective right coronary angiography with modified motherand child technique: (A) Hostile anatomy: a strong support Supracorwire was advanced through a 6F guide. (B) The guide acted as an outercatheter, whereas a 4F diagnosticWilliam right catheter acted as an innercatheter over a strong support 0.03500 wire. Injection was made throughthe inner catheter demonstrating an occluded right coronary artery.


RIGATELLI, ET AL.

events including coronary or subclavian dissection orrupture, aortic dissection or perforation, bleeding ofany grade, acute or late radial artery occlusion, and allminor and major strokes5 were tabulated and recorded.The radial artery patency was evaluated immediatelyafter removal of the hemostasis device (Transradial[TR] band, Terumo, Japan), and after 30 days byclinical examination and Doppler scan in all patients.

Definition. The presence of a hostile anatomy wasdefined as a vascular anatomy through which it wasimpossible to reach the aortic valve plane using thestandard wire‐catheter technique or to engage properlythe coronary origin due to (a) excessive tortuosity of thevessel at or distal to the transition with the aortic arch;(b) extremely heavy calcification, and excessiveangulation; (c) congenital anomalies such as arterialusoria. All tortuous subclavian arteries, which couldbe crossed with a standard catheter and hydrophilicwire and if the guide or catheter could reach thecoronary ostium, were not considered as hostileanatomy. Success of the techniques was defined asthe ability to provide a sufficiently opacified coronaryvessel for a diagnostic angiography or the ability toaccomplish PCI through the selected access without ashift to the femoral or contralateral radial approaches.Procedural time was defined as the mean time from theinitiation of the arterial puncture and the removal of thesheath (in our catheterization laboratory, it wasimmediately prior to moving the patient from thetable), while the mean fluoroscopy time was calculateddirectly using radiological equipment (Innova Flat‐Panel 3100 and 4100, GE, Germany).Statistical Methods. Chi‐square, Student’s t‐test,

and Wilcoxon no parametric test were used to comparefrequencies and continuous and noncontinuous varia-bles between the groups. Statistical analysis was

Figure 3. Left coronary artery percutaneous coronary intervention with a modified triple mother and child technique in patients with a chronicallyoccluded left anterior descending coronary artery and a sub‐occluded 1st diagonal branch. In order to increase stability during the interventionalprocedure, a 6F 90 cm long sheath was advanced over a strong supportive 0.03500 wire beyond the subclavian artery‐aortic route transition. A 6Fguide was advanced through the sheath over the same guide left in place. An additional inner 4F multipurpose catheter allowed selectiveengagement of the coronary ostia. The guide catheter was very gently advanced over the soft 4F multipurpose and (once in place) into the ostium.The inner catheter and the wire were then withdrawn and the procedure was completed using standard techniques.

Figure 4. Graphic representation of the triple mother and childtechnique for coronary percutaneous interventions. A diagnostic 4Fleft or right catheter is inserted through a coronary left or right guidingcatheter within the 6F long sheath. The diagnostic catheter isadvanced to engage the ostium of the coronary artery, and while theguiding catheter is advanced to reach the ostium, the diagnosticcatheter is gently and slowly withdrawn to facilitate cannulation ofthe ostium by the guiding catheter.



performed using a statistical software package (SAS forWindows, Version 8.2; SAS Institute; Cary, NC, USA).A probability value of <0.05 was considered statisti-cally significant.

Results

Ninety‐five patients (2.1%) from the entire popula-tion harbored a hostile subclavian artery; of these, 52patients (1.1%) underwent only transradial angiogra-phy, and 43 patients (1%) underwent transradialpercutaneous intervention (PCI) requiring the doubleand triple mother and child techniques, respectively.Patients with hostile anatomy had higher cardiovascu-lar risks compared to the control population (Table 3).The 2 techniques were successful in 94.7% of patients(90/95). For patients who switch to the femoral or

contraradial access, they did so because of extremelytortuous and heavily calcified subclavian artery(Table 4). One patient (1%) suffered a minorstroke during the procedure, most likely caused byexcessive manipulation of the standard equipmentinside the subclavian track before to use the modifiedmother and child technique. No other unfavorableevents were observed. The radial artery was patent at30 days in 92.6% of patients (88/95). All patients withoccluded radial arteries were asymptomatic at 30 days.

Discussion

Our results suggested that hostile anatomy of thesubclavian artery remained a significant challengeduring transradial angiography and transradial inter-vention procedures. The suggested mother and childtechniques offered a safe and effective option forcompletion of the planned diagnostic or interventionalprocedures. These techniques helped to avoid the needfor a shift to an alternate access route, which wasusually time‐consuming and potentially harmful for thepatients due to an increased risk of bleeding, especiallyin the emergent setting and through the femoralapproach. Our findings also showed that not only theright radial but also the left radial approach can besubjected to a difficult subclavian track, suggesting thatthe reason for a shift to an alternative approach wasrelated to a combination of severe tortuosity andextreme calcification of the subclavian artery. Severetortuosity of the subclavian arteries has been found in6–10% of patients undergoing a transradial approach.

Table 2. Step‐by‐Step Approach after First Attempt with Standard Technique Failed to Advance the Diagnostic Catheter Till theAortic Valve Plane

Step Maneuvre

1. The standard wire is exchanged for a stiff guidewire (Supracor .03500) over the diagnostic catheter.2. Standard sheath and catheter were removed.3. A 90 cm 6F long sheath (Cook or Terumo) is advanced carefully over the stiff guidewire and left into the middle ascending aorta.4. A diagnostic left or right 4F is advanced over the same stiff guidewire out of the long sheath.5. Coronary angiography is carried out.�

or (in case of PCI)4. A unit composed by a 6F left or right guiding catheter and a diagnostic 4F catheter is advanced over the stiff guidewire out of the tip of

long sheath.5. The diagnostic catheter is advanced to engage the coronary ostium, and while the diagnostic catheter is gently and slowly withdrawn, the

guiding catheter is advanced, to facilitate guiding catheter engagement of the ostium.�

�Crossover to alternative route may be selected if with the modified technique the engagement of the coronary ostia is not possible or the position ofthe catheter is considered not stable enough to allow a safe procedure.

Table 3. Procedural Findings of the Study Group

No. (%)

Severe vessel tortuosity 95/95 (100%)Vessel calcification 63/95 (66.3%)TRA 82/95 (86.3%)Diagnostic only 44/95 (46.3%)PCI 38/95 (40%)

LRA 13/95 (13.7%)Diagnostic only 8/95 (8.4%)PCI 5/95 (5.3%)

TRA, right radial approach; PCI, percutaneous coronary interven-tions; LRA, left radial approach.


RIGATELLI, ET AL.

Clinical predictors included systemic hypertension,female gender, older age, nonsmoking, short stature,and high body mass index.6 Congenital anomalies ofthe subclavian artery course, such as arteria lusoriawhich is the retroesophageal right subclavian artery,have been reported with a prevalence of 0.3% inpatients undergoing transradial coronary angiography.7

This abnormality can be easily detected by angio-graphic visualization of the angle of the catheter in theanteroposterior projection when it engages the ascend-ing aorta, and by angiography at the ostium of the rightsubclavian artery. In our series, not only the right butalso left hostile subclavian anatomy was encountered,whereas arteria lusoria was seen too rarely. The firsttechnical manipulation proposed to overcome severetortuosity or anomalies of the subclavian artery was touse a stiff hydrophilic wire8 and hydrophilic longsheath, both in order to straighten the subclavian route.9

The second technical manipulation advocated the useof a combination of a long sheath and diagnosticcatheter to facilitate engagement of the coronaryostia.10 Both techniques were potentially harmfulwith an increased risk of vessel perforation, and oftencould not solve the difficulties presented by a truehostile subclavian anatomy.In our study, we proposed the double and triple

mother and child techniques with a combination of stiffwires, guides then diagnostic catheters with a long

sheath. The combination of multiple coaxially mountedequipment in a mother and child fashion helped theguide and catheter to be advanced into the aortic rootand engage the coronary artery ostium. The minimalmanipulation of the outer guide once it reached theaortic root might explain the minimal rate of cerebralevents in our series, as well as the good patency rate ofthe radial access site. With the guide in the aortic root,the diagnostic catheter in a telescopic fashion could beadvanced and torqued in order to safely engage thecoronary artery even in cases of widely dilated aorticroot.11 Thus, the double or triple mother and childtechniques helped to break the strangling hold of anextremely tortuous and heavily calcified subclavianartery and allow free movement and torqueing of thediagnostic or interventional equipment. As a collateralresult the mean time between the puncture of the arteryand the first balloon dilation in patients who presentedin our series with acute myocardial infarction isaffected, but only mildly (about 4minutes), by theuse of these techniques by a properly trained team.Globally, we believe that the impact of the use of thesetechniques on the procedural, fluoroscopy times, andDAP value in our series may be considered more thanacceptable.However, crossover to the contralateral radial artery

or the femoral access remained also in our series afeasible alternative that can be selected when with the

Table 4. Technical Results and Complication Rates

Mean or No. (%)

Control Group N¼ 4485 Study Group N¼ 95 P‐Value

Procedural success 4,398/4,485 (98.1%) 90/95 (94.7%) nsShift to femoral not due to hostile subclavian anatomy§ 87/4,485 (1.9%) 0/95 (0%) <0.01Mean procedural time (min)Diagnostic only 12.6� 2.8 16.9� 4.1 0.03PCI 25.8� 15.8 29.1� 16.4 0.03

Mean fluoroscopy time (min)Diagnostic only 1.5� 0.8 1.6� 0.7 nsPCI 10.7� 11.4 11� 10.1 nsMean P2B time (min, primary PCI) 6.0� 1.8 9.5� 3.1 0.03Dose area product (cGycm2) 2,195� 89.3 2,375� 90.8 nsDiagnostic only 3,720� 90 3,960� 92.1 nsPCI 9�/4,485 (0.2%) 1/95� (1%) nsCerebral events 12°/4,485 (0.3%) 0/95 (0%) ns

BleedingRadial patency 30‐day 4,419/4,485 (98.5%) 88/95 (92.6%) 0.01

P2B, artery puncture to balloon time; PCI, percutaneous coronary interventions. §Radial artery loop or spasm. �Minor stroke in all cases. °Bleedingfrom femoral access site.



modified mother and child technique the engagementof the coronary ostia is still difficult or instability of theguiding catheter does not allow to safely perform theprocedure. Even if there are no data reported inliterature, we should take into account that often, whena hostile subclavian track is present, even thecontralateral radial route and also the femoral routemight be elongated and tortuous as a result of theatherosclerotic and aging process that usually involvesall the vascular segments.Finally, the patency in the study group was slightly

worse than that in the control group, probably becausethe long sheath used and the friction during the tortuoustrackmay cause some grade of intimal damage favoringthe vessel thrombosis; measures going forward to avoidthis complication might be an increased dose of pre‐procedural heparin or periodic occlusion of the ulnarartery while measuring the oxygen pulse during vesselcompression in order to ensure patency of the vessel.

Conclusion

Despite the significant limitations such as theretrospective design and the small number of patients,our study suggests that despite technical improvements,hostile subclavian anatomy remains a great challengefor today’s transradial coronary angiography or inter-vention procedures. When faced with patients exhibit-ing a hostile subclavian anatomy (heavy calcificationand severe tortuosity), the proposed strategy to use thedouble and triple mother and child techniques in orderto complete the transradial coronary angiography orintervention appears safe with good outcomes, shortfluoroscopy times, and low complication rate.

References

1. Abhaichand RK, Louvard Y, Gobeil JF, et al. The problem oflusoria in right transradial coronary angiography and angioplas-ty. Catheter Cardiovasc Interv 2001;54:196–201.

2. Freixa X, Trilla M, FeldmanM, et al. Right versus left transradialapproach for coronary catheterization in octogenarian patients.Catheter Cardiovasc Interv 2012;80:267–272.

3. Norgaz T, Gorgulu S, Dagdelen S. A randomized studycomparing the effectiveness of right and left radial approachfor coronary angiography. Catheter Cardiovasc Interv 2012;80:267–272.

4. Nishizaki Y, Yamagami S, Haga K, et al. Usefulness ofprominently projected aortic arch on chest radiograph to predictsevere tortuosity of the right subclavian or brachiocephalic arteryin patients aged >44 years undergoing coronary angiographywith a right radial artery approach. Am J Cardiol 2012;110:203–207.

5. Brott TG, Halperin JL, Abbara S, et al. ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the management of patients with extracranialcarotid and vertebral artery disease. JACC 2011;57:1002–1044.

6. Kawashima O, Endoh N, Terashima M, et al. Effectiveness ofright or left radial approach for coronary angiography. CatheterCardiovasc Interv 2004;61:333–337.

7. Cha KS, KimMH, Kim HJ. Prevalence and clinical predictors ofsevere tortuosity of right subclavian artery in patients undergoingtransradial coronary angiography. Am J Cardiol 2003;92:1220–1222.

8. Barbeau GR. Radial loop and extreme vessel tortuosity in thetransradial approach: Advantage of hydrophilic‐coated guide-wires and catheters. Catheter Cardiovasc Interv 2003;59:442–450.

9. Tomassini F, Gagnor A, Varbella F. Successful use of an extra‐long hydrophilic‐coated sheath in enlarged aorta to overcomeextreme tortuosity of right subclavian artery via transradialapproach during coronary angiography. J Invasive Cardiol2011;23:E56–E57.

10. Slaba S, Sfeir S, Nassar‐Slaba J, et al. Stiffened triple axialcatheterization of tortuous cervivoencephalic vessels. J Mal Vasc2005;30:118–121.

11. Rigatelli G, Giordan M, Mantovani R, et al. “Telescopic”technique for selective coronary angiography in severely dilatedascending aorta. Catheter Cardiovasc Interv 2007;69:1078–1079.


RIGATELLI, ET AL.

Documents

Strategies to Overcome Hostile Subclavian Anatomy during Transradial Coronary Angiography and Interventions: Impact on Fluoroscopy, Procedural Time, Complications, and Radial Patency