Angiographic Evaluation of Right Upper-Limb Arterial Anomalies: Implications for Transradial Coronary Interventions

ABSTRACT: Objectives. Upper-limb arterial anomalies are sometimes encountered during transradial coronary procedures. These anomalies may contribute to procedural failure or to vascular complications, and are a major reason why many operators tend to avoid transradial procedures. We investigated the frequency of right upper-limb arterial anomalies using antegrade arteriography in patients undergoing transbrachial coronary angiography or intervention, and discuss the potential impact of these anomalies on the transradial procedure. Methods. We prospectively studied 163 consecutive patients who underwent right transbrachial coronary angiography or intervention for the first time during the period from May 2007 to December 2007. Following the transbrachial procedure, we performed antegrade transbrachial arteriography of right upper-limb arteries in these patients and investigated the frequency and anatomy of arterial anomalies. Results. A total of 40 upper-limb arterial anomalies were observed in 38 patients (23.3%). These included 8 abnormal origins (4.9%), 2 radio-ulnar loops (1.2%), 25 tortuosities (15.3%), 4 stenoses (2.5%) and 1 loop (0.6%). In patients with congenital lesions (8 patients; 4.9%), abnormal origin of the radial artery was the most common anomaly encountered, and in the acquired group (25 patients; 15.3%), tortuosity was the most common abnormality. Conclusion. Even with a 23.3% incidence of right upper-limb arterial abnormalities, 98.8% of patients were acceptable for transradial coronary intervention except for 1.2% of radio-ulnar loops. J INVASIVE CARDIOL 2010;22:536–540 Key words: upper limb arterial anomaly, transradial coronary intervention, antegrade angiography ———————————————————— In 1989, Campeau reported success in performing coronary angiography using a transradial approach,¹ and in 1993, Kiemeneij reported on 3 patients who had successful stent implantation by transradial intervention (TRI).² Subsequently, the value of the transradial approach in reducing the duration of hospital stays and vascular complications compared with other approaches was clarified in several trials,^3–9 which also showed that the transradial approach is a less invasive procedure. On the other hand, transradial catheterization has several weak points including problems with radial puncture, limitations on catheter size due to small vascular diameters and difficulties with the catheter technique. Furthermore, the presence of upper-limb arterial anomalies or abnormalities is one of the well-known reasons for procedural failure or development of severe vascular complications. Accordingly, it would be useful to know the frequency of occurrence and patterns of arterial anomalies that may be encountered in order to optimize the safety of the procedure. In this study, we investigated the frequency of occurrence of upper-limb arterial anomalies in a consecutive series of 163 patients in whom antegrade brachial angiography of right upper-limb arteries was carried out. Based on these results, we discuss the potential impact of these anomalies on transradial coronary procedures.

Materials and Methods

Study population and protocol. We prospectively studied 163 consecutive patients who underwent right transbrachial coronary angiography (n = 161) and intervention (n = 2) for the first time during the period from May to December of 2007 at the Tokai University School of Medicine. Exclusion criteria were as follows: those without an indication for coronary catheterization, a contraindication to the brachial approach, prior catheterization from the ipsilateral radial artery, a serum creatinine level > 1.5 mg/ml, contrast medium allergy and emergency patients. In this group, we investigated the frequency of occurrence of upper-limb arterial anomalies. Classifications and definitions. Upper-limb arterial anomalies were classified according to the angiographic features shown in Table 1. This classification was based on past typical reports of upper-limb arterial anomalies.^10–15 Figure 1 shows typical angiographic features in normal right upper-limb arteries. The radial and ulnar arteries bifurcate from the brachial artery at the level of the intercondylar line of the humerus in patients with normal anatomy.^16,17Bifurcation at a higher level was defined as an abnormal origin, and was grouped into two classes according to whether the main trunk showed axillary bifurcation or brachial bifurcation. Figure 2 shows a typical example of brachial bifurcation. The Radio-ulnar loop was defined as an anomaly in which the proximal radial artery turns distally and arises from the ulnar artery instead of from the brachial artery, as shown in Figure 3. Tortuosity was defined as angulation in an artery by more than 45 degrees, a representative example of which is shown in Figures 4 and 5. Presence of tortuosity of 360 degrees was defined as a “loop,” as shown in Figure 6. Antegrade arteriography of upper limb. Following coronary angiography or intervention, a sheath was inserted under local anesthesia into the right brachial artery, and antegrade arteriography of the upper limb was performed. The sheath size employed was 5 Fr (n = 161) or 6 Fr (n = 2). Coronary angiography and intervention in all patients were accomplished via the brachial artery by a blind puncture, and upper-limb arterial arteriography was performed via the same inserted sheath. A dose of 2–2.5 mg of isosorbide dinitrate was administrated systemically via the inserted angiographic catheter as a vasodilator during coronary angiography. After this study, the brachial approach is not not routinely used. A solution of 8 ml of contrast medium mixed with 2 ml of normal saline was injected from the side arm of the inserted sheath into the right brachial artery. To visualize the entire radial, ulnar and brachial arteries, as well as the palmar vasculature, angiograms were obtained in an anteroposterior projection. All patients gave written informed consent.

Results

Patients and procedural characteristics. The series included a total of 163 patients (108 males and 55 females) who were studied consecutively. Baseline demographic and clinical characteristics are summarized in Table 2. The mean patient age was 64.9 ± 12.1 years. Upper-limb arterial anomaly. As shown in Table 3, no abnormality was present in 125 patients (76.7 %). Abnormal origin of the radial artery was the most common upper-limb arterial anomaly in the congenital group (8 patients; 4.9%), and tortuosity was most the common upper-limb arterial anomaly in the acquired group (25 patients; 15.3%). Two patients had two upper-limb arterial anomalies, one with brachial stenosis and radial tortuosity, and the other with both brachial and radial tortuosities.

Discussion

When coronary angiography and interventional procedures are performed by the transradial approach, upper-limb arterial anomalies may be encountered. Some reports have concluded that these anomalies have a significantly higher rate of procedural failure than in cases of no anomaly.^12,14 However, not all upper-limb arterial anomalies contribute to a high rate of procedural failure or to vascular complications, and prior reports have suggested that only certain anomalies are associated with these risks. Recognition of the presence of an upper-limb arterial anomaly prior to a transradial procedure, coupled with extensive knowledge on the part of the operator, may lead to a decline in procedural failure and vascular complications. Table 4 provides a summary comparing the findings from other studies^12–14,18 with those in the current study. Despite the low rate of puncture failure (0%), the literature indicates that a radio-ulnar loop has the highest rate of procedural failure (16.7%)¹⁸ due to the difficulty in manipulating the wire across the loop. Louvard and Yokoyama et al reported that the presence of a radio-ulnar loop may be considered a contraindication to attempting a transradial interventional procedure, which should instead be undertaken in patients with this anomaly via the femoral artery.^13,19 However, it may be difficult to detect this anomaly by preprocedural evaluation. Knowledge of the patient’s anomaly can help reduce complications during the procedure. Abnormal origin is the most common anomaly both in other reports and in our study. This is an especially important anomaly for TRI, and its high frequency contributes to the high rate of procedural failure, which is reported as ranging from 3.2–4.6% of cases.^14,18 There are some reports in which a dual radial artery is classified as an anomaly.^12,20,21 We did not include a dual radial artery as an upper-limb arterial anomaly in this study because its definition is somewhat vague and can in many instances be classified as a “no-anomaly” subtype. However, it should be noted that the radial artery in many patients bifurcates into a superficial or deep palmar branch at the level of the distal epiphysis of the radius. In such cases, there may appear to be two radial arteries at the radial puncture site, i.e., “dual radial arteries.” The vascular diameter of the radial artery with these branches may become smaller distally, and there is some risk of puncture failure and mismatch with sheath size. Although most patients have ulnar-artery tortuosity around the styloid process of the ulna, it was thought that ulnar artery tortuosity had no clinical importance. Therefore, ulnar-artery tortuosity was not included in upper-limb arterial anomalies in this study. Study limitations. There are several limitations to this study. First, patients with chronic kidney disease (CKD) were excluded from this study. Patients with CKD might have a different RA diameter distribution than patients without CKD. This limitation might influence the results of the analysis. Second, because we analyzed only right upper-limb vascular anatomy and included no data on left upper-limb angiography, we could not discuss the higher frequency of left upper-limb anomalies reported in the literature.^12,22,23 Third, limitations of angiography depicting arteries two-dimensionally may have led to an underestimation of tortuosity. The relationship between tortuosity and procedural failure has varied in prior reports from 1.1–23.3%,¹⁸ and may be attributable to different definitions of “tortuosity” and to whether or not reports included the radial “loop” category in the “tortuosity” category.

References

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———————————————————— From the Division of Cardiology, Tokai University School of Medicine, Isehara, Japan. The authors report no conflicts of interest regarding the content herein. Manuscript submitted June 1, 2010, provisional acceptance given July 18, 2010, final version accepted July 26, 2010. Address for correspondence: Yuji Ikari, MD, PhD, Assistant Professor of Medicine, Division of Cardiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Japan. E-mail: ikari@is.icc.u-tokai.ac.jp