Facilitating wire advancement into the ascending aorta during right radial cardiac catheterization by instructing turning the head to the left in a tortuous subclavian artery. Second case report

Abstract

Coronary angiography and cardiac catheterization using the right radial arterial access have lower complication rates but are associated with unique challenges that can lead to procedural failure. One of the major challenges can be the wire advancement into the ascending aorta with a tortuous subclavian artery, particularly in the case of arteria lusoria. The deep inspiratory maneuver can help navigate the guiding wire into the ascending aorta. However, in extreme tortuosity or the case of arteria lusoria, it can be very difficult to advance the wire in the ascending aorta. In this manuscript, the second successful case of guide wire advancement in the ascending aorta in a very tortuous subclavian artery is described by instructing the patient to move her head to the left. This maneuver will straighten the subclavian artery, thus facilitating wire advancement into the ascending aorta by reducing the tortuosity of the subclavian artery. This can save radial cardiac catheterization and prevent changing the access route. This report describes this easy-to-perform maneuver in a difficult case of severe subclavian tortuosity, enabling us to complete the right radial cardiac catheterization.

Introduction

Cardiac catheterization via the right radial artery is associated with lower complication rates but has unique challenges. One major challenge is failing to advance a guide wire into the ascending aorta due to subclavian artery tortuosity despite using respiratory maneuvers [1-7]. Inability to advance the guide wire into the ascending aorta can lead to failure of completing radial cardiac catheterization, thus forcing the operator to change the access route, leading to increased time spent, cost, and risk of new access complications to the patient. The use of hydrophilic wire can help to facilitate catheter advancement into the ascending aorta. However, hydrophile wires can lead to life-threatening perforations [7-11] and should be used only as a last resort. It is well known that right radial cardiac catheterization in difficult cases can lead to higher radiation exposure and contrast use [12-14]. Therefore, any simple maneuver that can facilitate wire and catheter advancement during right radial cardiac catheterization can also reduce radiation and contrast use, as another reason to use a simple maneuver to overcome a tortuous subclavian artery. We reported a first case report of a very difficult tortuous subclavian artery, preventing us from advancing the guide wire into the ascending aorta despite instructing the patient to take a deep breath. However, we could complete the right radial cardiac catheterization by instructing the patient to turn her head to the left, thus straightening the course of the subclavian artery into the ascending aorta [15]. In this manuscript, we describe the second successful case of guide wire advancement in the ascending aorta in a very tortuous subclavian artery by instructing the patient to move her head to the left.

Case report

The patient was a 70-year-old female with a history of obesity and long-standing hypertension presenting with increasing shortness of breath. Her myocardial perfusion study revealed a moderate-sized reversible anterior wall defect. The patient was referred to cardiac catheterization for further evaluation. She had normal creatinine, a basic metabolic panel, and hematocrit. Her vitals were stable with baseline hypertension and systolic blood pressure of 156/87. The heart rate was around 70 beats/minute. The right radial arterial access was obtained under ultrasound guidance without any difficulty. A 6-French slender sheath was advanced into the right radial artery. She received a cocktail of 5000 units of heparin, 100 micrograms of nitroglycerin, and 200 micrograms of verapamil into the radial sheath. Next, a 5-French Tiger catheter was advanced into the aorta using a 0.014-inch wire. However, the wire could not be advanced into the descending aorta despite performing respiratory maneuvers due to tortuosity (Figures 1, 2). Finally, the patient was instructed to turn her head to the left, which led to immediate wire advancement into the ascending aorta (Figures 3, 4) followed by the Tiger catheter. Coronary angiography could be completed without much difficulty, showing no significant coronary disease but very tortuous coronaries (Figure 5), which is consistent with her long-standing hypertension and very tortuous subclavian artery. The patient tolerated the procedure and was discharged the next day.

Figure 1.

With the head of the patient in a straight position, the wire is in the descending aorta with the inability to be advanced into the ascending aorta.

Figure 2.

Turning head to left reorient wire toward ascending aorta.

Figure 3.

The guide wire is now successfully advanced into the ascending aorta after turning the head to the left.

Figure 4.

Successful wire advancement in the aortic root.

Figure 5.

Tortuous left anterior descending and circumflex arteries.

Discussion

Left heart cardiac catheterization is an indispensable invasive procedure for cardiac workup and treatment of patients with atherosclerotic heart disease, including acute coronary syndrome such as myocardial infarction or unstable angina. Other indications include coronary angiography for severe stable angina, resistance to medical therapy, cardiomyopathy of unknown origin, before valve surgeries, or cardiac workup for myocardial or pericardial disease. Radial arterial access site is now the preferred route for cardiac catheterization with proven reduction in major complications. One major challenge is failing to advance a guide wire into the ascending aorta due to subclavian artery tortuosity. Numerous respiratory maneuvers are published to facilitate wire and balloon delivery during coronary angiography or intervention. The deep inspiratory maneuver is useful for radial catheterization to advance the guide wire into the aorta and stent advancement in the native coronaries [1-3]. Expiratory maneuver (reverse Movahed Maneuver) is useful for balloon or stent delivery in tortuous vein grafts [4,5]. In our case, respiratory maneuvers alone could not advance the guide wire into the ascending aorta. However, instructing the patient to turn her head to the left saved the day with the successful completion of right radial left heart catheterization. Turning the head to the left will straighten the subclavian artery connection into the aortic arch. Once the patient has turned the head to the left, the guide wire should be cautiously advanced toward the ascending aorta in an anterior-posterior X-ray projection with the guidance of a guide catheter (usually right Judkins or Amplatz catheters). Once the guide wire is in the ascending aorta, the guide catheter can then be advanced into the aortic sinus in order to complete coronary angiography. Failure to complete the right radial cardiac catheterization will cost a substantial amount of time, cost, and utilization of a second access, usually the femoral arterial route, which is associated with much higher major complications [16-18]. Therefore, every effort should be made to complete the procedure if possible. To our knowledge, this is the second case report describing the details of using this maneuver in a tortuous right subclavian artery. Based on these cases, we recommend utilizing this maneuver during right radial cardiac catheterization in difficult cases of the tortuous subclavian artery in order to facilitate wire and catheter advancement into the ascending aorta.

There are not many published manuscripts describing any details about the head position for facilitating wire advancement into the ascending aorta. Casazza [7] described a successful case of wire advancement into the ascending aorta using expiration after inspiratory maneuvers failed the wire advancement. The left head-turning maneuver was not performed in that case. Patel et al. [7] published detailed descriptions of anatomical challenges occurring during left heart catheterization, such as tortuosity, loops, stenosis, and congenital aberrancy, such as arteria lusoria. Numerous techniques and solutions were described to overcome those challenges, including the use of hydrophilic wire, balloon tracking techniques, and respiratory maneuvers. Again, they did not mention the left-head-turning maneuver in their publication. Turning the head to the left straightens the subclavian artery and leads to a more direct route of the subclavian artery into the descending aorta. The degree of success in using the left turn maneuver is not known. The presence of arteria lusoria introduces a similar challenge as a tortuous subclavian artery during right radial cardiac catheterization. We believe that the left-head turn technique can facilitate ascending aorta access. Future case reports can inform us if the left-hand turn maneuver can be helpful in patients with arteria lusoria. Using a hydrophilic wire can facilitate guidewire advancement into the ascending aorta, but it is associated with a higher risk for life-threatening perforations [8-11]. It is very important to educate cardiologists who perform cardiac catheterization and intervention via the right radial artery about this important maneuver.

Conclusions

This case elaborates an easy-to-perform maneuver that can save right radial cardiac catheterization by instructing the patient to turn the head to the left, thus straightening the aorta, leading to ease of wire advancement.

Disclosure of conflict of interest

None.