Ultrasound imaging of the arm arteries prior to cardiac catheterization can help anticipate procedural failure and enhance success. In a study of over 2,000 patients, pre-procedure ultrasound identified anatomical anomalies in 9.8% of patients and helped select the largest accessible artery. This led to a procedural success rate of 98.7% and a low 1.3% crossover rate. Pre-procedure ultrasound takes on average 6 minutes and can help reduce radiation time and procedural complications by avoiding difficult arterial access.

1. Anticipating Failure:
ROLE OF ARM IMAGING PRIOR TO
ARTERIAL ACCESS
Sanjay Chugh
MD(Cal.),DM (AIIMS), MRCP(I), FACC, FSCAI(USA)
Principal Consultant, Interventional Cardiology,
Fortis Escorts Heart Institute, New Delhi, India

2. Conflict of Interest Statement
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation
with the organization(s) listed below.
Physician Name Company/Relationship
NONE NONE

3. There`s been a paradigm shift in
interventional Cardiology to
transradial access
because of….
↓ VASCULAR COMPLICATIONS
↑PATIENT COMFORT

4. BUT IF PATIENT INTEREST IS SUPREME
THEN……
• IS A TRIAL & ERROR APPROACH by operators
on their Radial Learning Curve justified even
at the expense of ↑ procedure failure,
complications and patient inconvenience?

5. A SCIENTIFIC APPROACH TO
↓TRIAL & ERROR
in
THE LEARNING CURVE
& HENCE CROSS-OVER, RADIATION
TIME, PATIENT DISCOMFORT
&
PROCEDURE FAILURE
Is therefore needed

6. So What`s the trial & error about ?
In the `Learning Curve`
which may lead to
TR Procedure failure (~5%)
• ACCESS RELATED 52.6%(Guedes et al, J INVASIVE CARDIOL 2010;22:391–7)
• Inability to advance guide catheter to ascending aorta
51% ( Dehghani P et al(JACC Cardiovasc Interv. 2009 ;2(11):1057-64.)
• RADIAL ARTERY SPASM 38% (Circ Cardiovasc Interv. Ball WT, et
al2011e pub)

7. SIZE MATTERS……
•PUNCTURING SMALL ARTERIES IS MORE
DIFFICULT!
•SPASM IS MORE IN SMALLER ARTERIES
“ predictors of failure=
"small radial artery" size
(OR 2.6, 95% CI 1.4 to 5.0;
p = 0.003) or a "difficult
access" (OR 2.5, 95% CI
1.3-4.9; p = 0.006)”.
Guedes et al,
1.7 mm Radial artery RA spasm
J INVASIVE CARDIOL
2010;22:391–397

8. SHORT STATURE (OR:0.97; 95% CI: 0.95 to 0.99, p = 0.02) & AGE>75 (odds ratio [OR]: 3.86; 95%
confidence interval [CI]: 2.33 to 6.40, p = 0.0006) =
INDEPENDENT PREDICTORS OF FAILURE
142 cm
36 kg
1 mm; R
Ao root
1.2 mm U
2.4cm
1.4 mm R;
1.5 mm U
SCAI 2011 Dr Sanjay Chugh. Guide Cath
selection for Transradial PCI

9. OYE Let Go…
Yeow**!
RA Spasm
VARIABLE ALL 783 NO RAS RAS 230 P
553
Female 202 (25.) 115 (20.) 87 (37.8) <0.001
Diabetes 155 (19.8) 97 (17.5) 58 (25.2) 0.018
Height, cm 168.84 ± 9.7 169.6 ± 9.7 166.8 ± 9.5 <0.001
6
Weight, kg 83.65 ± 16.3 85 ± 16.24 80.3 ± 16.32 <0.001
9
BMI, kg/m2 29.27 ± 4.87 29.48 ± 4.95 28.76 ± 4.64 0.05
Wrist 17.24 ± 1.20 17.37 ± 1.17 16.92 ± 1.19 <0.001
circumferen
ce, cm (Rathore S, JACC Cardiovasc Interven 2010;3(5):475)

10. Is it okay to shove any size Guiding
Catheter into any Radial artery ?
eg A 7F GUIDE INTO A 1.7 mm ARTERY ?

11. Of course not! (SHEATH / GUIDING ) > 1:1 : (RA)
initiates spasm
SPASM MAKES CATHETER
MANIPULATION DIFFICULT--->
Saito et al.CCI 46, 1999:173
LEADS TO RADIAL OCCLUSION

12. HOW DO WE DECIDE IF THE ARTERY IS
BIG ENOUGH TO SAFELY TAKE WHAT
YOU WANT TO SHOVE INTO IT ?
SIZE IT

13. RA Sizing
ASE 2007
SCAI 2011 Dr Sanjay Chugh. Guide Cath
13
selection for Transradial PCI

14. FAILURE: (1) SMALL ARTERY SIZE AND SPASM :
(2) LOOPS / ANOMALIES/ STENOSIS
•7% of procedural failure& CROSSOVER (Jolly SS, et alAm Heart J. 2009
Jan;157(1):132-40 in transradial intervention is due to radial artery
tortuosity, loops, or stenosis (Dehghani P ,et al.JACC Cardiovasc Interv. 2009
BRACHIAL Nov;2(11):1057-64.)
ULNAR
RADIAL
•Inability to advance the wire or catheter through the brachial artery accounts for
up to 73% of procedural failure (Guedes et al, JIC 2010).

15. CAN WE ANTICIPATE FAILURE
& HENCE
ENHANCE SUCCESS BY AVOIDING
THESE BY PRE-PROCEDURE
IMAGING?

16. YES, BY KNOWING THE HAND
BEFORE-HAND !
ENHANCE SUCCESS BY ANTICIPATING
FAILURE

17. Feasibility and Utility of Pre-
procedure Ultrasound Imaging of
the Arm to facilitate Trans-Radial
Coronary Diagnostic and
Interventional Procedures.
TCT 2011 (In Press)

18. • Pre-procedure ultrasound assessment of the Right and Left Radial, Ulnar, and
Brachial arteries, using a linear probe in all patients.
• Endpoints:
Incidence and Correlates of :
* Arterial anomalies
* Procedure success
* Crossover to alternate access
* Fluoroscopy time
* Ultrasound assessment time.
• Patient Demographics, Medical history, and Procedural characteristics , angiographic
assessment of arm arteries were recorded

19. • Prospective Single center Registry
• Consecutive patients undergoing diagnostic
and interventional procedures (2006 to 2011).
• Institutions: Fortis Escorts Heart Institute New
Delhi, (including Fortis Escorts Kalyani Heart
Centre, Gurgaon) India,

20. Methods:

21. Linear, transducer with the frequency
L 12-3 MHz (Philips Medical Systems,
IE 33 & HD7, USA)

22. MEASURING RADIAL ARTERY
DIAMETER

23. NORMAL BIFURCATION

24. PARALLEL RADIAL AND ULNAR

25. HIGH ORIGIN OF RADIAL FROM BRACHIAL: OFTEN RADIAL
ARTERY IS OF SMALL DIAMETER

26. HIGH ORIGIN OF RADIAL FROM BRACHIAL: OFTEN
RADIAL ARTERY IS OF SMALL DIAMETER

27. RADIAL ARTERY LOOP

28. While radial artery loops and tortuosity may be
easily traversed with 0.014” guidewires, doing so
increases procedure time and radiation exposure
to the patient and operator, and also may result in
significant spasm and discomfort for the patient.

29. NORMAL TRIPHASIC FLOW

30. BIPHASIC FLOW MEANS UPSTREAM
BLOCK

31. Stenosis in upstream RA can cause
procedural delay or failure & crossover
(CAN BE PICKED UP BY DOPPLER PRE-PROCEDURE)
PLETHYSMOGRAPHY MAY
NOT PICK THIS UP!
Stenosis in Radial
artery------------------
Why diversify ?

32. NEVER NEEDED TO LOOK FOR UPSTREAM
OBSTACLES EXCEPT ONCE
BECAUSE WE WERE IN AN ACCESSORY SMALL
RADIAL INSTEAD OF ULNAR ARTERY

33. Access Artery (Radial/Ulnar) Selection
for Angiogram or PCI
(BRACHIAL NEVER USED)
• 5F in ≥ 1.6mm for angio; 6F≥1.8 mm for PCI
Knowledge of the arm anatomy allowed us
to choose :
• The Biggest artery
• Without anomaly/abnormality

34. PREFERENCE ORDER FOR ACCESS SIDE
• RIGHT SIDE PREFERRED IN MOST
• LEFT ACCESS PREFERRED in PCI to Shepherd
crook/ tortuous/ calcific RCA
• Access opposite to arm with previous injury
scar/fracture /Venous cannula/phlebitis

35. PREFERENCE ORDER FOR CHOICE OF
ACCESS ARTERY
(RRA >LRA>RUA>LUA)
• RADIAL OVER ULNAR
• ULNAR PREFERRED only IF
*LOOP OR PARALLEL RADIAL & ULNAR
*IF BOTH RADIALS WERE SMALL
(PROVIDED ULNAR CONSIDERED EASY TO COMPRESS
MANUALLY FOR HEMOSTASIS)
• Groin was used if both arteries in both arms were
unsuitable because of small size or anomaly.

36. Aortic root 3.8 cm
LT RADIAL 1.8 Cm
ULNAR 2.1 Cm
Rt Radial 1.8 cm
Ulnar 1.7 cm

37. Spasm was recorded as per the
following grades:
• Grade-4: Severe pain and spasm disallowing any catheter movement
necessitating crossover.
• Grade-3: Moderate pain and spasm restricting catheter movement &
necessitating a pause in procedure and > 2 doses of additional intra-
arterial Diltiazem or Verapamil> 5mg and/ or > 1 mg of intravenous
Midazolam .
• Grade-2: Mild pain and spasm not restricting catheter movement ; no
pause in procedure but > 1 dose of (additional) intra-arterial Diltiazem (or
Verapamil) of 5mg and / or 0.5 mg of intravenous Midazolam .
• Grade-1: Mild pain and spasm not restricting catheter movement ; no
pause in procedure and only 1 dose of either or both intra-arterial
Diltiazem (or Verapamil) of 5mg and/or > 0.5 mg of intravenous
Midazolam.

38. RESULTS

39. Illustration-5
N=6125
Presented for
Angiogram/PCI* (2006-
2011)
2344
Complete ultrasound data
on arm arteries
12.9% (n=279) unsuitable
8.9% (n=193) unsuitable
for trans- radial / trans-
for even for an angiogram
Remaining 1872 patients
ulnar PCI*(because of small underwent a transradial /
because of small radial &
diameter of bilateral radial transulnar procedure
Ulnar arteries
and ulnar arteries)
*PCI=Percutaneous Coronary Intervention

40. PATIENT DEMOGRAPHICS
1.Sex
1179(63%) M;
693(37%) F
2.Mean age (yrs) 51.6 (±23.7)
RISK FACTORS
1.Diabetic 569(30.4%)
2.Tobacco abuse 624(33%)
3.Hypertensive 649(34.6%)
4.Dyslipidemia 702(37.5%)
•

41. CLINICAL DIAGNOSIS
Stable Angina including 711(38%)
Post MI *
& patients with positive
Stress test
Unstable Angina/ACS 1161(52%)

42. ARM IMAGING (ULTRASOUND) TIME
• The mean time (bilateral forearm )=
6.4 min ± 1.8min(95% confidence interval).

43. Our ultrasound strategy only required
a minimum of effort and time
• 62% in the inpatient setting (Coronary care
Unit and Wards);
• in 33% patients our protocol could be
implemented on the day of the procedure in
the pre-procedure area.
• 5% of the ultrasound studies were performed
in the clinic setting

44. Doppler assessment of anomaly was
accurate in all cases
on
COMPARISON WITH ANGIOGRAPHIC
ASSESSMENT

45. SIZE OF RADIAL & ULNAR
ARTERY ON THE 2 SIDES
SIZE OF RADIAL & ULNAR ARTERY MEAN
ON THE 2 SIDES Diameter (mm)
Left Radial Artery Male 1.8±0.29
Female 1.7±0.26
Left Ulnar Artery Male 1.8±0.30
Female 1.7±0.3
Right Radial Artery Male 1.9±1.12
Female 1.7±0.29
Right Ulnar Artery Male 1.8±0.30
Female 1.6±0.28

46. Table-II: +ve Correlations of Radial
artery with Ulnar artery size
Left Radial Artery Left Ulnar Artery
Left Radial Artery Pearson Correlation 1 .404(**)
Sig. (2-tailed) 0.000
Left Ulnar Artery Pearson Correlation .404(**) 1
Sig. (2-tailed) 0.000
**. Correlation is significant at
the 0.01 level (2-tailed).
Right Radial Artery Right Ulnar Artery
Right Radial Artery Pearson Correlation 1 .416(**)
Sig. (2-tailed) 0.000
Right Ulnar Artery Pearson Correlation .416(**) 1
Sig. (2-tailed) 0.000

47. Table III- 9.8 %
Incidence of Anomalies in Radial Artery in the study
population
Anomalies Radial Artery
Intimal thickness 3.6%
Parallel Radial and Ulnar suggesting 4.7%
possibility of high origin of radial
from Brachial or Radioulnar loop or
similar anomaly
Loop seen at Cubital Fossa 0.9%
Blocked artery 0.6%

48. Illustration-4
mm mm 5F mm 6F mm 7F mm 8F

49. SPASM
• Insignificant spasm (≤grade -2) occurred in
19.5%,
• while significant spasm (grade -3) occurred in
1.5%.
• Spasm grade-4 occurred in 1 patient .

50. Angiography
( Transradial(85.8%);Transulnar(14.2%)
62%=right; 38%=left Access
• Crossover : 1.3%
• Radiation time :2.1min for TRCA/TUCA
(R=1.9min;L=2.3min)
• Successful : 98.7%

51. VESSEL & LESION TYPE
(n=570)
SVD* MVD** LAD RCA LCX
72% 28% 42% 32% 26%
A+B1 B2 C
*SVD=SINGLE
VESSEL 58% 32% 10%
DISEASE
**MVD=
ACC/AHA LESION TYPE
MULTI-VESSEL
DISEASE

52. PCI
TRANSRADIAL (90%);TRANSULNAR (10%)
55%=left; 45%=right access
• CROSSOVER =2.4%
• RADIATION TIME: 12.6 ± 9 mins (for 1V TRI)
(Left radial:14.4 min
Right Radial: 11.1 min;
P<0.01).
• Success= 97.6%

53. We may have prevented failure, access site crossover,
or patient discomfort in nearly 30% of our cases with
Pre-procedure Arm Imaging

54. Success & Crossover
In our study
• Left Access
55% PCI & 38% Angiograms
• SUCCESS >97.6 %
(> Success of 95% in RIVAL)
• Crossover = 2.4%
( <7.6%in RIVAL & = crossover from Femoral to arm (2%)!)

55. RIVAL
TRI
Radial Femoral P
(n=3507) (n=3514)
PCI Success 95.4 95.2 0.83
Access site Cross-over (%) 7.6 2.0 <0.0001
PCI Procedure duration (min) 35 34 0.62
Fluoroscopy time (min) 9.3 8.0 <0.0001
Preference (%) 90 49 <0.0001

56. ACCESS ARTERY SPASM Comparison
Our Study
• Significant spasm (grade -3) = 1.5%.
• PROCEDURE FAILURE B/O Spasm = 1 patient .
• PROCEDURE FAILURE B/O SPASM=38%
(Circ Cardiovasc Interv. Ball WT, et al2011e pub )

57. LIMITATION-1
• We did not randomize patients to an
ultrasound-based strategy or usual care;
therefore, our comparisons of radiation
times , procedure success and access site
crossover are with the published literature
rather than direct comparison

58. A journey of a 1000 miles begins with
the 1st step…..
• The purpose of our study was to describe our
experience, which is the first using a routine
pre-procedure ultrasound evaluation of the
arm arterial structures.

59. LIMITATION-2
• One operator performed all of the ultrasound
procedures, and
• One separate operator performed all of the
coronary procedures.
• It is difficult to generalize our results to other
operators who may have varying levels of
experience with ultrasound imaging or radial
procedures.

60. COST IMPLICATIONS
• Cost -effectiveness OF PRE-PROCEDURE ARM
IMAGING was not studied.
• THE COST OF PRE PROCEDURE ULTRASOUND
MAY BE OFFSET BY REDUCTION IN RADIATION
TIME, PROCEDURAL COMPLICATIONS &
FAILURE

61. Impact on RA /UA Occlusion
• not tested in our study,
• is being done as a part of an on going study at
our Institution.
.

62. CONCLUSION

63. This single center prospective registry shows
PRE-PROCEDURE ULTRASOUND IMAGING
OF ARM ARTERIAL STRUCTURES IS
*FEASIBLE,
**REQUIRES MINIMUM TIME AND EFFORT,
***PROVIDES INFORMATION ON ARTERIAL
SIZE AND ANATOMICAL VARIANTS
****THUS FACILITATING TR & TU PROCEDURES
& REDUCING
SPASM, CROSSOVER, PROCEDURE FAILURE
& PT .DISCOMFORT

64. RANDOMIZED STUDY NEEDED
BUT….
WOULD I EVER DO A TRANSRADIAL
WITHOUT PRE-PROCEDURE ARM
IMAGING;
NEVER !

65. Thanks