Radial Approach: Negotiating Difficult Subclavians and Dilated Aortic Roots

Abstract

The transradial approach for coronary intervention has several obvious advantages. It is, however, associated with distinct technical challenges not usually encountered in the transfemoral approach. In addition to the anomalies of the radial-brachial axis, transradial procedural failure is often due to anatomical variations in the subclavian-brachiocephalic trunk or aortic arch abnormalities. These variations are not uncommon and may be encountered in up to 10 % of patients undergoing transradial catheterization. Within each specific anomalous pattern there is a differential procedural failure rate. The key is in recognizing the anomalies and anticipating associated procedural difficulties. Although in the majority of patients these variations are fairly minor and pose no significant difficulty to the operator, in the case of more complex anatomical variations the procedural failure rate is particularly high. Nonetheless, using specific techniques it is possible to negotiate challenging anatomy and successfully complete the procedure. In some challenging anatomical situations crossover to an alternate vascular access site may be required, particularly in the earlier phase of the learning curve.