Safety and Efficacy of a Multipurpose Coronary Angiography Strategy Using the Transradial Technique

Transradial coronary percutaneous procedures are associated with reduced entry site complications compared to transfemoral or transbrachial techniques.^1–4 However, the transradial approach is technically more challenging and time-consuming,⁴ which explains its less widespread acceptance as compared to the transfemoral approach. Nonetheless, over the past ten years, considerable improvements have been achieved in catheter configuration and design, and a great variety of transradial-dedicated material is now available. The availability of specifically designed arterial sheaths and catheters has helped to promote a substantial increase in the transradial approach’s popularity over the past few years. A second drawback of transradial procedures is related to the possibility of radial artery damage, which is mostly related to the insertion of oversized sheaths, compared to radial dimensions, but possibly also to catheter exchange.⁵ Potential consequences of arterial injury are spasm and radial artery occlusion. Two technical details may help avoiding excessive radial artery trauma during catheterization: the use of small-caliber catheters and the selection of specific shapes that allow both left and right coronary selective cannulation. Accordingly, following the introduction of transradial approach in our center, one operator adopted a “multipurpose” 4 French (Fr) strategy, using either Judkins Left (JL) 3.5 catheters or another catheter, which was especially designed for transradial or transbrachial procedures, the Brachial Type K catheter, for all diagnostic cases. The present report addresses the safety and efficacy issues of this strategy. Methods Patients. Included in this analysis are all consecutive patients from February 2002 to December 2004 in which a strategy of attempting one single 4 Fr catheter for selective left and right coronary angiography through the transradial approach by the same operator was employed. Patients were selected for transradial approach if there was a palpable radial artery pulsation, good collateral hand supply demonstrated by pulse oximetry, and if there was no previous history of transradial failure. Only those cases in which a guidewire was successfully advanced to the ascending thoracic aorta were analyzed. All patients provided written, informed consent before catheterization. Catheterization procedures. After radial artery puncture using conventional 20 G venous cannulae, short (7 cm long) 4 Fr sheaths were inserted (Radifocus, Terumo Co., Tokyo, Japan). A spasmolytic cocktail was infused intra-arterially in all patients in the absence of contraindications, and contained 2.5 mg of verapamil and 5,000 units of unfractionated heparin. Arterial sheaths were removed immediately after diagnostic or interventional procedures and hemostasis was achieved with elastic bands. Diagnostic catheters used were either the Brachial Type K (Terumo Outlook, Leuven, Belgium) or the Judkins Left 3.5 (Terumo Outlook or Cordis Infiniti, Cordis Corp., Miami, Florida). The selection of diagnostic catheters was not randomized. Rather, selection was made according to temporal changes in operator preferences. Initially, the majority of cases were performed using a single Judkins Left (JL) 3.5 catheter. As the experience with Brachial Type K (BLK) catheters increased, it became the preferred multipurpose catheter for the right radial approach. Due to the initially observed difficulties with left coronary cannulation in the left arm with the BLK catheter, most cases using the left radial approach were performed using the JL curve. Intracoronary dye injection was performed manually. If coronary intervention was indicated after coronary angiography, arterial sheaths were exchanged. Generally, 5 Fr sheaths and guiding catheters were used. In cases of bifurcated, heavily calcified lesions, or when thrombectomy of filter devices were indicated, a 6 Fr strategy was preferred. The BLK catheter (Figure 1) was designed and manufactured by the Terumo Company (Japan) since the year 2000, and until recently, it was only available in 4 Fr diameter. It was designed specifically for use in the brachial or radial approaches. Apart from its special shape and configuration, which addresses both left and coronary selective cannulation, the BLK catheter features a small distal side hole that facilitates manual injection through a 4 Fr catheter. The catheterization technique using the BLK catheter in this study was primarily attempted through the right radial/ulnar approach and is summarized as follows. For the left coronary artery, after advancing the catheter through a conventional 0.035 inch J wire to the right coronary sinus, the catheter was gently pulled 2–4 cm and rotated clockwise 90–180º under fluoroscopy guidance using a shallow (30º) LAO angulation. This rotation is done with the guidewire still inside the catheter to avoid catheter kinking and to facilitate manipulation. Generally, this maneuver orientates the tip of the catheter to the left sinus and allows selective engagement of the left coronary ostium after additional adjustments. For right coronary catheterization with the BLK catheter, a modified left lateral view (95–100º LAO) was generally used. After left coronary angiography, the catheter is pulled until disengagement was observed by fluoroscopy, then a 180º clockwise rotation is applied to achieve a right sinus orientation. To improve torque control, it is useful to apply small back-and-forth movements until the desired orientation is achieved, and also to use a 0.035 inch wire until the primary curve of the catheter is straightened. The technique for left coronary catheterization with the JL catheter is similar to the one described for the BLK, except that when rotating clockwise from a right-cusp position, the catheter usually directly engages the left coronary ostium. For right coronary catheterization, after pulling the catheter from the left coronary position, the straight part of the conventional J-curved 0.035 inch Teflon wire is advanced to the distal part of the catheter, only to straighten its primary curve; the operator must take special care to not allow progression of the potentially dangerous stiff part of the wire beyond the catheter tip. By doing so, the shape of the JL 3.5 is easily converted into a “Judkins Right-like” configuration, thus allowing selective right coronary engagement to be achieved by gentle pullback and clockwise rotation. After right coronary engagement, the JL 3.5 catheter is gently pulled until a good alignment with the direction of coronary flow is observed. Statistics. All cases were entered prospectively in a dedicated database. Use of the BLK or the JL 3.5 followed an “intention-to-treat” strategy once a guidewire was successfully advanced to the ascending aorta. Numerical variables are expressed as mean ± standard deviation and were compared with a 2-paired Student’s t-test for independent samples. Comparison of categorical variables was performed with the Fisher’s exact test. SPPS versus 11.5 was used for statistical analyses. Results Study population. A total of 657 catheterization procedures in 642 patients were included in this analysis. The JL 3.5 curve was used in 194 cases, and the BLK catheter in 463 cases. The mean patient age was 64.4 ± 11.9 years; 26.3% were female. General clinical data are summarized in Table 1. Procedures. The right radial artery was selected in 612 procedures (93.2%). Overall, 572 cases (87.1%) were performed with only one diagnostic coronary catheter, and 57 (8.7%) with two catheters. There were no cases of crossover to the contralateral radial artery or femoral artery. Left ventriculography was performed in 354 cases (54% of the cases), and in all cases, a 4 Fr pigtail catheter was used. There were no aortic or coronary dissections and no major access site complications (requiring prolonged hospitalization, transfusion or surgery). From the initial 657 procedures, 212 percutaneous coronary interventions were performed immediately after diagnosis. In 118 cases (56%), a 6 Fr sheath and guiding catheter were inserted, and in 94 cases (44%), the angioplasty was performed using a 5 Fr system. Success of angioplasty procedures was achieved in 98%. No cases of crossover to femoral procedures were registered. In Tables 2 and 3, detailed information from catheterization diagnostic procedures is provided. Subgroup analysis. When gender was analyzed as a specific subgroup, there were no significant differences in success between the BLK (86% in men versus 81% in women; p = 0.22) and the JL 3.5 (91% in men versus 94% in women; p = 0.58) as the sole catheter used for both right and left coronary angiography. The efficacy of the JL 3.5 was found to be superior on the right side (94% from the right radial versus 83% from the left radial approach; p = 0.05). The BLK shape was used in only 16 cases from the left radial approach, and was effective as the only diagnostic catheter in only 9 cases (56%; p = 0.005) when compared to the right radial approach. Discussion The present report shows that by using a specifically designed transradial catheter, the Terumo BLK, it is possible to successfully perform both left and right coronary angiography in approximately 85% of the cases. If the initial multipurpose angiography was not successful, at least one coronary ostium was selectively engaged in approximately 95% of this series of patients. Moreover, using a more widely available catheter, the 4 Fr JL 3.5 shape, with a modified technique for right coronary catheterization, it is possible to achieve bilateral coronary injections more than 90% of the time. In this single-operator report, there were no instances of aortic or coronary dissection and the manipulation of diagnostic catheters apparently did not lead to excessive spasm, since there was no need for femoral or contralateral radial puncture. The strategy of using one single catheter for left and right coronary selective angiography was described for the first time by Dr. F. Mason Sones in 1959.⁶ When the transfemoral technique gradually became the most frequent left heart approach for diagnostic and interventional procedures, most centers adopted a “Judkins strategy” of using dedicated left and right catheters. Although a modified Sones catheter is still available, the majority of operators have not been trained in the Sones technique, and may find newly designed catheters for multipurpose coronary angiography, such as the BLK, more “user-friendly”. To our knowledge, ours is the first report of the efficacy and safety of this new diagnostic catheter. Although the BLK curve’s usefulness is clear in right transradial procedures, it is important to emphasize that from our experience, the BLK catheter does not appear to be useful in the left arm approach. Previous publications have shown high engagement rates (91%) with another dedicated transradial catheter (Kimny) for interventional procedures, although it was used for both coronary interventions in only 27 cases.⁷ The use of Amplatz Left 2 as multipurpose catheters has been described as highly efficacious and safe,⁸ but in our own experience (not reported), this strategy can frequently lead to aggressive right coronary intubation, requires more manipulation of the ascending aorta and requires a longer learning curve compared to the BLK or JL 3.5 catheters. A similar experience with the JL 3.5, 6 Fr catheter was recently reported; it involved 100 consecutive patients with a success rate of 94% for catheterization of both coronary ostia, and had no significant complications.⁹ Although it may seem that the JL 3.5 catheter achieves higher success rates than the BLK, it is important to recognize that the present study is not a randomized comparison between two different strategies. In fact, the study groups were not homogenous and significant differences were present at baseline in that there were more female patients and a higher mean age in the JL 3.5 group. However, it is our impression that left coronary engagement is indeed easier with the JL 3.5 catheter, although right coronary alignment is superior and probably safer with the BLK catheter, since Judkins Left curves frequently assume an excessive cranial orientation when oriented to the right coronary ostium that may favor the direct impact of the high-velocity jet toward the coronary wall. Furthermore, the side hole provided with the BLK catheter improves injection efficiency and helps to stabilize catheter position during angiography.¹⁰ One important practical limitation with this single-catheter approach for coronary angiography involves the necessity to exchange the catheter for left ventriculography or aortography. In these cases, although the BLK may theoretically be useful for a low-volume/low-flow injection, a pigtail catheter provides more appropriate, and probably safer, imaging. However, even if another catheter is required for left ventriculography or ad hoc angioplasty, using two catheters or performing only one catheter exchange is probably better than the systematic use of three catheters or two exchanges in terms of radial artery manipulation and optimization of costs in the catheterization laboratory. In summary, diagnostic multipurpose coronary angiography with the transradial technique with 4 Fr catheters, using either BLK or JL 3.5 catheters, represents an attractive strategy that can be performed with high success and very low complication rates. Acknowledgement. We are indebted to Josefa Lariño from Terumo, Spain, for providing detailed information regarding Brachial Type K catheters.

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