COMPLICATION OF TRANS-RADIAL CORONARY ANGIOGRAM

• I.D. 66 year old female presented with recurrent chest pain radiating to the left arm with profuse sweating during the last episode.

• ECG showed signs of LV strain and non specific T changes.

• Risk factors were HTN and Hyperlipidemia.

• Coronary angiogram was planned to rule out ischemia, because the patient was not fit for ETT.

• Trans-radial approach was planned according to the patient’s preference.

• Coronary angiogram did not show any significant stenosis.

• During catheter exchange from JL4 to JR4 the patient developed severe pain in the arm, in addition to pallor of the hand.

• Examination of the arm showed very weak pulses.

Angiogram of the arm after the patient’s complaint (Angiogram through the sheath did not show any significant

disease in the radial and ulnar arteries)

SWITCHING TO TRANS-FEMORAL

APPROACH

• To continue the coronary angiogram and to check the brachial artery we switch the case to the femoral approach.

• The angiogram confirmed occlusion of the R brachial artery.

• This is most likely due to brachial artery dissection induced by the wire.

• There were good flow to the radial and ulnar arteries through collaterals

The angiogram confirmed occlusion of the

R brachial artery

There were good flow to the radial and

ulnar arteries through collaterals

• There was complex tortousity at the origin of the left subclavian artery.

• Brachial angiogram showed occlusion of the artery at the mid segment.

• Medical management was planned over the night since there were good flow to the radial and ulnar arteries through collaterals, but there was no improvement after 12 hours.

• Echo-doppler on the following morning proved the occlusion of the brachial artery.

Re-angiogram of the R brachial artery

on the next day

• 5F Mani catheter (Cordis) was used to navigate through the tortousity of the R subclavian artery over a 260cm-0.035 Terumo wire.

• Total occlusion of R brachial artery was confirmed.

• The plan was to proceed with angioplasty to open the occlusion of the R brachial artery.

Very tortuous Innominate artery and

subclavian artery

ANGIGRAM OF THE BRACHIAL

ARTERY

Angioplasty of the Brachial artery

• The Mani catheter was exchanged to a 6F MP1 guiding catheterover an exchange length 0.035 wire.

• 0.014 PT2 MS (BSC) wire passed through the occlusion down to the ulnar artery.

• Multiple inflations with 3.0x20 Sapphire (OrbusNeich) balloon were done in the brachial and ulnar artery.

BEGINNING OF BRACHIAL

ANGIOPLASTY

3.0x20 balloon multiple inflations

Some flow started to appear through the

ulnar artery.

Better flow was achieved in the brachial and ulnar arteries

with further balloon inflations (But dissection and hazziness were still present at the level of occlusion)

R Brachial Artery R Ulnar Artery

A Larger balloon 5.0x30 was used to dilate the

brachial artery at the level of dissection

Finally, Good flow was achieved in the brachial and

ulnar arteries.

Finally, Good flow was achieved in the brachial and

ulnar arteries.

The R Radial arteries filled retrograde through the palmer arch

• Residual dissection at the level of the total occlusion on the brachial artery was seen, but it was a non flow limiting dissection.

• So it was left to heal spontaneously.

• No Stent was used.

ON THE NEXT DAY

• There was good pulse in both the ulnar and radial arteries.

• Blood pressure in the R arm was similar to that in the L arm.

3 MONTH FOLLOW UP

• Blood pressure in the R arm was similar to that in the L arm.

• There was good palpable pulse in both the ulnar and radial arteries.

• But the patient continued to complain of recurrent vague aching pain in the affected arm (Was that related to the dissection of the artery or was is a musculoskeletal/neuorological pain ?)

CONCLUSION

• With radial approach always use a 260cm 0.035 wire to exchange catheters over it, so that you can avoid traumatic manipulations with the wire and the catheters in the radial and brachial arteries.

• You have to face your complication with courage, i.e. not to flee away and seek others assistance to cover your complication.

• The simpler the intervention in the brachial artery the better.

• Try to avoid stenting of the brachial artery.