Analysis of Peripheral Arterial Bends that Interfere with Coronary Catheterization

ABSTRACT: Objectives. The aim of this study was to analyze the characteristics of peripheral arterial bends that interfere with coronary catheterization. Background. Complex aortic and peripheral arterial bends are important factors in unsuccessful coronary catheterization. Methods. We classified peripheral arterial bends based on the difficulty of coronary catheterization: no bend, type A: easy; type B1: difficult but possible; type B2: difficult but possible with assistance of a device such as a long sheath; type C: impossible. We analyzed 1,626 consecutive cardiac catheterizations. Results. Reproducibility (± 1 grade) was 98.9% in 256 patients undergoing multiple procedures from the same approach site. Peripheral arterial bend class distribution was as follows: no bend: 76.4%, type A: 12.5%, type B1: 5.0%, type B2: 5.5%, and type C: 0.6%. Fluoroscopy time and contrast volume were significantly greater in type B2/C (9.6 ± 6.26 min versus 13.8 ± 8.9 min, p Conclusions. Peripheral arterial bends are a feature of the individual patient, not of the approach site. J INVASIVE CARDIOL 2010;22:197–203 Key words: transradial approach, coronary catheterization, percutaneous coronary intervention In 1958, Mason Sones established selective coronary angio-graphy as the Sones technique via the brachial arteriotomy access. ¹ The Sones technique remained the standard method until 1967, when Melvin Judkins² and Kurt Amplatz³ reported the use of catheters for a percutaneous method via the femoral artery. The design of the Judkins catheters lent themselves to adaptation of the Seldinger percutaneous transfemoral puncture. This technique avoided brachial arteriotomy, which required repair after the procedure. Subsequently, cardiologists became competent in performing the Judkins technique, and most catheterization laboratories currently use this technique. Subsequently, Campeau described the radial approach for coronary angiography in 1989, ⁴ and Kiemeneij and Laarman described the radial approach for coronary angioplasty in 1994. ⁵ Despite the fact that complications rates were lower with the transradial approach, the transfemoral approach became the technique of choice and remains the gold standard worldwide. ^6–9 Use of the transradial approach is a mere 1.32% in the U.S. ¹⁰ Why is the transradial approach used less frequently than the transfemoral approach? Reasons for this include the following: 1) catheter manipulation with the upper limb approach is more difficult than the femoral approach; 2) arterial bending is sometimes severe in the upper limb approach; 3) puncture is difficult; and 4) backup force is lower in percutaneous coronary intervention (PCI). Our previous studies have shown that a low backup force can be overcome using an appropriate catheter in the transradial approach. ¹¹ However, questions regarding arterial bending have not been solved. In this study, we characterized arterial bends that interfere with catheterization in the transradial and transfemoral approaches.

Methods

Peripheral arterial bends classification. We defined classification of peripheral arterial bends that interfere with coronary catheterizations. The classification was determined based on the difficulty of coronary catheterization as follows: no bending; type A, easy; type B, difficult; and type C, impossible. Those classified as “no bending” showed no unusual arterial bend by fluoroscopy or angiography, and insertion of a catheter and a guidewire was easy; there were no problems with manipulating a catheter. Type A had an unusual arterial bend, but insertion of a catheter and a guidewire was easy; there were no problems with manipulating a catheter. Type B was further split into two classes: type B1, difficult but possible without any assistance and type B2, difficult but possible with some assistance with a device such as a stiff guidewire in a catheter or changing from a short sheath to a long one. The peripheral arterial bend was classified into five categories as shown in Table 1. The classification was named according to the INA BAUER classification (INtervention Application for Bended Arterial roUtE with Resistance). The INA BAUER classification was assessed by a physician experienced in PCI immediately after the procedure without any information on any previous catheterization. Figure 1 shows the examples of peripheral arterial bends . Investigators of peripheral arterial bends by INA BAUER classification. Five experienced interventionists at our hospital classified peripheral arterial bends according to the INA BAUER classification. They were educated about the INA BAUER classifications without any special training. This classification was done after the procedure based on the fluoroscopic/angiographic images and the “feel” when maneuvering catheters. They classified and judged arterial bends based on their subjective and hands-on experience. Study population. From August 2006, to December 2007, 1,626 consecutive cardiac catheterizations consisting of 1,073 diagnostic and 553 interventional procedures were performed in 1,214 patients that comprised the study population. This population contained patients who underwent a single procedure (n = 830) and multiple procedures (n = 384). Among patients with multiple procedures, 256 underwent same limb approach catheterizations for a total of 533 procedures. In contrast, 128 patients underwent different limb approach catheterizations for a total of 263 procedures. A total of 1,214 procedures consisting of single procedures (n = 830) and primary procedures in a series of multiple procedures (n = 384) were used for the analyses of arterial bend distribution and predictors of arterial bending. The patient flow chart is shown in Figure 2. Approach site selection. On arrival of the patient in the catheterization laboratory, femoral, brachial and radial artery pulses were checked and the Allen’s test was performed. In this hospital, when the patients had no contraindication for an upper limb approach, the first-line approach site was chosen as the right brachial artery for coronary angiography (CAG) and the right radial artery for PCI. On the other hand, the femoral artery was selected as the first-line approach site for patients with hemodialysis, cardiac shock, those requiring greater than 7 Fr size guiding catheters, or if the upper limb approach was judged inadequate by the operator. In cases where the radial artery pulse was absent, the Allen’s test result was abnormal, or if the sheath cannulation failed at the first-line approach site, a second approach site was used. The second-line approach site was either the left upper limb or either of the femoral arteries at the operator’s discretion, and data were included from the second (successful sheath cannulation) approach site. Femoral and brachial artery cannulation. The percutaneous transluminal technique was used in all patients. After local anesthesia with 1% procaine hydrochloride, the brachial or the femoral artery was punctured with an 18 gauge needle such as the Radifocus® Introducer H (Terumo, Somerset, New Jersey and Tokyo, Japan) or the Super Sheath® Introducer (Medikit, Tokyo, Japan). A 0.035 inch guidewire was introduced through this system, followed by insertion of a catheter ranging from 4–8 Fr with an 11 cm sheath. Radial artery cannulation. After administration of local anesthesia with 1% procaine hydrochloride, the anterior wall of the radial artery was punctured with a 20 gauge needle, Radifocus® Introducer H (Terumo). A 0.018 inch guidewire was introduced through the needle, followed by the insertion of catheter ranging from 4 to 6 Fr with a 16 cm sheath. Coronary artery cannulation. For CAG, a bolus dose of 1,500 IU of heparin was administered intravenously and no additional dose was given during or after the procedure. For CAG, a 4 Fr or a 5 Fr Judkins-type left or right catheter (Heartcath®, Terumo) was introduced after a 0.035 inch Radifocus® J-type wire (Terumo) or a 0.035 inch J-wire (Cook, Bloomington, Indiana) was inserted into the ascending aorta. For PCI, a bolus dose of 100 IU/kg of heparin was administered intravenously and an additional dose of 2,000 IU of heparin was given during the procedure once every hour. Guiding catheters used were 5 Fr to 7 Fr Heartrail® (Terumo), or 5 Fr to 8 Fr Vista Brite Tip® (Cordis Corp., Miami Lakes, Florida). A guiding catheter was selected with an appropriate curve, providing stable backup support during PCI at the operator’s discretion. Coronary artery cannulation was defined as successful when both left and right coronary arteries were cannulated. When there was peripheral arterial bending that interfered with catheter manipulation, we used a 0.035 inch guidewire for supporting catheters or changed the short sheath for a 25 cm long sheath (Medikit) for enhancing the catheter manipulation as necessary. Reproducibility of INA BAUER classification. Reproducibility of an INA BAUER classification was investigated in 256 patients who underwent same-limb approach catheterizations at least twice in this period. The operator was blinded to any prior INA BAUER classification. The difference in INA BAUER classification between the first and second catheterization was analyzed. Assessments of severity of arterial bend by fluoroscopy time and contrast volume. Assessment of the severity of peripheral arterial bend was investigated in 706 patients who underwent a single procedure of CAG and left ventriculography (LVG) only. For each patient, three views were analyzed for the right coronary artery, six or seven views for the left coronary artery and two views for LVG. Bypass arteries were not included in the analysis. The fluoroscopy time and the contrast volume were compared for INA BAUER classifications. Difficulty of each approach site. Patients who underwent multiple procedures at different approach sites were analyzed for difficulty of each approach site. The INA BAUER classification was compared among the left upper limb, right upper limb and femoral sites. Factors determining peripheral arterial bends. Patients who underwent a single or multiple procedures were analyzed for the factors that determined the INA BAUER classification. Primary procedures in a series of multiple procedures (n = 384) were used for the analyses of predictors of arterial bend. Statistical analyses. The power calculation required 1,214 cases to detect 2% of difference between a femoral approach and an upper limb approach in terms of frequency of INA BAUER types B2 and C (from 5% to 7%) with α = 0.80 in a two-sided test. The target enrollment was set at 1,214 cases. For continuous variables, the Student’s t-test was used for comparison of groups. Fischer’s exact test was used to evaluate the categorical variables. To test whether initial differences between the two groups influenced the results, stepwise logistic regression analysis was performed after controlling the variables that were significantly different at baseline. All continuous variables are described as mean ± standard deviation. All analyses were two-tailed, with clinical significance defined as a p Results Baseline characteristics. A total of 1,626 catheterization procedures, including 1,073 diagnostic catheterizations and 553 coronary interventions, were performed in 1,214 patients. The patient population in this study had elevated risk factors for cardiovascular disease (Table 2). Reproducibility of INA BAUER classification. Because the INA BAUER classification was based on the subjective opinion of each operator, we first tested the accuracy. An identical INA BAUER class was found for the same approach site for the first and the second catheterizations in 175 patients (68.4%). A difference of plus or minus one grade was found in 78 patients (31.5%) and a difference of plus or minus two or more grades in 3 patients (1.2%) (Figure 3). The reproducibility of INA BAUER classification within one grade was 98.8%. Thus, we inferred that INA BAUER classification plus or minus one grade was accurate as an indication of difficulty of coronary catheterization because of the high reproducibility. Assessment of severity of peripheral arterial bends. We attempted to correlate fluoroscopy time and contrast volume with the INA BAUER classification in 706 procedures with routine diagnostic coronary angiography without PCI (Figures 4A and B). The contrast volume was not significantly different between INA BAUER classifications, but the fluoroscopy time was significantly longer in types B2 and C. Thus we determined that types B2 and C as critical bends. Both the fluoroscopy time and the contrast volume were significantly higher in types B2 and C than in no bend, types A and B1 (Figures 4C and D). No-bend, type A and type B1 were classified as “non-critical groups”, type B and C were classified as “critical groups”. Peripheral arterial bends distribution. Figure 5 shows the distribution of peripheral arterial bends for each approach site of the 1,214 patients. Critical (types B2 and C) bends comprised 6.5% of femoral, 6.1% of right upper-limb and 5.0% of left upper-limb approach patients. Comparison among different approach sites. Table 3 shows comparison between the upper limb approach and the femoral approach. In the patients’ backgrounds, the upper-limb approach group had a higher rate of dyslipidemia, the femoral-approach group had significantly higher rates of diabetes, hemodialysis, previous heart failure and previous peripheral artery disease. Critical (types B2 and C) bends comprised 6.0% of the upper-limb approach and 6.5% of the femoral-approach patients. The peripheral arterial bend was investigated in 128 patients (263 procedures) who underwent multiple catheterizations using more than two different approach sites (Figure 6). Comparing upper-limb and femoral approaches (n = 90), 82.3% of patients had a similar degree of difficulty (within 1 grade). Patients with a difficult femoral approach (> 1 grade) comprised 5.6%, and patients with a difficult upper-limb approach (≤1 grade) comprised 12.2% of the total. The difference between these two approaches was not statistically significant. Comparing right upper- and left upper-limb approaches (n = 45), 80.0% of patients had a similar degree of difficulty (within 1 grade). Patients with a difficult left upper-limb approach (≤ 1 grade difference) comprised 8.8%, whereas 11.1% had a difficult right upper-limb approach (> 1 grade difference). There was no significant difference in the arterial bend distribution in a particular patient for a particular approach site. Predictive factors of peripheral arterial bends. Univariate analysis showed the following factors were predictors for arterial bends: age, short stature, body mass index (BMI), diabetes, hypertension, hemodialysis, prior coronary artery bypass grafting (CABG), low hemoglobin, creatinine and estimated glomerular filtration rate. However, the choice of upper-limb approach had no relation to difficult catheterization due to bends. The following factors, hemodialysis, age and BMI were evaluated in relation to critical arterial bends (types B2 and C) (Table 4). Stepwise logistic regression modeling selected the following factors as predictors of arterial bends. Hemodialysis (OR 4.449, 95% CI 2.117–9.353; p Discussion There are a number of reports comparing right and left upper-limb approaches for coronary catheterization. Saito et al¹² reported that the left radial approach was associated with a greater number of procedure failures due to radial artery anatomic anomalies and left subclavian tortuosity. However, Wu et al¹³ and Kawashima et al¹⁴ reported a higher frequency of failures with the right radial approach, attributable to right subclavian tortuosity, which impeded the procedure or lengthened fluoroscopy time. These reports analyzed the failure rate of catheterization. However, judgment of failure varies depending on the individual operator’s skills for the specific approach site. In this study, we employed the INA BAUER classifications, which predict stepwise severity of arterial bends in order to analyze in detail the arterial bends that interfere with coronary catheterization. Difficulty of catheterization was better represented by types B2 and C, not by failure (INA BAUER type C). To begin with, we confirmed the reproducibility of INA BAUER classification. We considered that INA BAUER class plus or minus one grade is a reliable indication because of its high reproducibility (98.8%). Furthermore, this classification was correlated with fluoroscopy time and contrast volume. This means that arterial bends have an impact on the complexity of catheterization procedures. The main findings of this study are that the distribution of critical arterial bends (INA BAUER types B2 and C) were almost equivalent for right upper-limb (6.4%), left upper-limb (5.0%) and femoral (6.1%) approaches. The difficulty of catheterization for upper-limb and femoral approaches, or between right and left upper-limb approaches were similar in the individual patients. This means that the difficulty of catheterization due to the arterial bending in the majority of cases is not determined by the approach site. We should consider that peripheral arterial bends are an individual patient’s arterial characteristic. Predictive factors of arterial critical bends were arteriosclerosis risk factors or arteriosclerotic cardiovascular disease risk factors except for height. If atherosclerosis is a proliferative disease of the artery, three types of disease may be explained: 1) stenosis due to inside proliferation; 2) aneurysm due to outside proliferation; and 3) arterial bends due to longitudinal proliferation. Thus, it is a reasonable finding that predictors of arterial bends are the same as atherosclerotic risk factors. If the same longitudinal arterial elongation occurs, an individual with small stature is likely to produce more severe bends than one with higher stature. There are other factors besides arteriosclerosis that we need to take into account for the congenital anomaly of arteries. An aberrant right subclavian artery is a congenital anomaly. It is also called the retro-esophageal right subclavian artery and its frequency in the population is from 0.5–2%.^15–17 If this anomaly has great impact on the difficulty of catheterization, the right upper-limb approach should be the only difficult approach. However, our data showed atherosclerotic risk factors had greater impact. Study limitations. This study has the inherent limitations of a non-prospective randomized study. A limitation specific to this study was that the right upper-limb approach was the usual default access site, and all others were used when the right upper-limb approach could not be used, which may have biased comparisons of bends in the right upper-limb approach versus other sites.

Conclusions

Peripheral arterial bends are unique features of each patient, not of the approach site used.

References

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_______________________________________________ From the Department of Cardiology, Tokai University School of Medicine, Isehara, Japan. The authors report no conflicts of interest regarding the content herein. Manuscript submitted September 3, 2009, provisional acceptance given September 29, 2009, final version accepted February 1, 2010. Address for correspondence: Yuji Ikari, MD, PhD, Professor, Department of Cardiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193 Japan. E-mail: ikari@is.icc.u-tokai.ac.jp