Complication of Transradial Coronary Angiogram (Waleed Kadro, MD, The Golden Cardiovascular Center)

1. COMPLICATION OF TRANS-RADIAL
CORONARY ANGIOGRAM

2. • 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.

3. • 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.

4. 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)

5. 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

6. The angiogram confirmed occlusion of the
R brachial artery

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

8. • 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.

9. 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.

10. Very tortuous Innominate artery and
subclavian artery

11. ANGIGRAM OF THE BRACHIAL
ARTERY

12. 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.

13. BEGINNING OF BRACHIAL
ANGIOPLASTY

14. 3.0x20 balloon multiple inflations

15. Some flow started to appear through the
ulnar artery.

16. 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

17. A Larger balloon 5.0x30 was used to dilate the
brachial artery at the level of dissection

18. Finally, Good flow was achieved in the brachial and
ulnar arteries.

19. Finally, Good flow was achieved in the brachial and
ulnar arteries.
The R Radial arteries filled retrograde through the palmer arch

20. • 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.

21. 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.

22. 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 ?)

23. 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.