British Journal of Radiology (2004) 77, 831-838
© 2004 British Institute of Radiology
doi: 10.1259/bjr/89933527
Routine transradial access for conventional cerebral angiography: a single operator's experience of its feasibility and safety
D H Lee, MD
1
J H Ahn, MD
1
S S Jeong, MD
2
K S Eo, RT
1 and
M S Park, MD
1
Departments of 1 Radiology and 2 Cardiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Sacheon-myon, Gangneung-si, Gangwon-do, 210-711, Korea
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Abstract
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The purpose of this study is to describe a single operator's experience with the feasibility and safety of transradial access in conventional cerebral angiography. 153 patients were enrolled consecutively. Among them, 20 patients were not suitable for transradial access. A Simmons catheter was used. Haemostasis was achieved using a compressive dressing of the wrist. We analysed the success rates of the arterial puncture and the successful catheterization rate for each supra-aortic vessel as well as all complications. The arterial access was successful in 96.3%. The supra-aortic vessels were catheterized with success rates of 99.2% (127/128) for the left subclavian artery and 100% for the other arteries. The mean procedure time was 19.3 min (range 10–55 min). Haemostasis was successfully achieved in every case. The most frequent complication was arm pain which occurred in 37 patients (28.9%). In conclusion, transradial selective cerebral angiography with a reversed-angle catheter is technically feasible and safe. It might be helpful in imaging follow-up of patients with arterial stenting or coil embolisation of the cerebral aneurysms. Modification of the catheter design is required to improve the selectivity of the supra-aortic branches.
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Introduction
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The need for vascular catheterization for diagnostic purposes has gradually decreased with the advent of non-invasive imaging techniques [1, 2]. Yet conventional digital subtraction angiography (DSA) is still regarded as the diagnostic gold standard for cerebrovascular diseases in many situations. In most institutions, the right common femoral artery is usually chosen as the main vascular access because of the angiographer's familiarity and its convenience for performing cerebral DSA. In addition to catheter-related intravascular complications, transfemoral access also has some local problems [3, 4]. Many patients suffer from haematoma or bruising to the groin. Pseudoaneurysms or arteriovenous fistulae of the puncture site are rare but do occur. To minimize these local problems, the patients should remain in bed for several hours following the procedure in order to obtain haemostasis. The problem is more intense in those patients undergoing antiplatelet and/or anticoagulation treatment.
To avoid these disadvantages, many cardiologists have already exploited the right radial artery as an alternative route not only for diagnostic coronary angiography but even for interventional cardiac procedures [5–9]. Our interventional colleagues have already used the radial arteries as an alternative vascular access when the femoral routes are not suitable for catheterization [10]. For this purpose, the radial artery is preferred to the brachial artery because of its shallowness and the paucity of neighbouring neural structures. If cerebral DSA can easily be obtained via transradial access, indications for transradial access could be broadened. Recently, there have been several reports on the successful application of transradial cerebral angiography [11–15].
The purpose of this study is to describe a single operator's experience with transradial access in cerebral DSA in a consecutive group of patients. We tested the feasibility of the procedure using a conventional Simmons type of diagnostic catheter; we then evaluated the safety of the procedure.
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Patients and methods
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Patients
A total of 153 consecutive patients were enrolled in this study under the permission of our institutional review board between March 2002 and June 2002. There were 75 men and 78 women. The age range was 18–80 years (average 57.5 years). After a 2 month learning period with 25 patients, we shifted the initial access from the right femoral artery to the right radial artery in all patients requiring cerebral DSA. The indications of cerebral DSA are listed in Table 1
. We did not attempt radial access in 20 of these patients for various reasons (Table 2). Informed consents were obtained from the patient and/or next of kin in all patients.
Procedure
The following detailed method evolved during the 4 month study period. The method presented here is the latest version. Before the procedure, the Allen test was performed to check the completeness of the palmar arch. If the test was abnormal, we did not proceed with the radial artery access. The right inguinal area was also draped as well as the right wrist for conversion of the access route from the wrist to the groin if necessary. The radial artery was punctured using a 21 G micropuncture system (Cook, Bloomington, IN) or 20 G Teflon sheathed needles (Terumo, Tokyo, Japan) after subcutaneous infiltration of 1 ml of 2% lidocaine where the pulses were maximally palpated. A 4 F or 5 F vascular sheath (Terumo or Cook) was then introduced. To prevent vasospasm of the artery, a diluted solution of nitrate (nitroglycerine 150–250 µg) and/or calcium-channel blocker (verapamil 150–250 µg) was injected intra-arterially through the sheath, which was then continuously flushed with pressurized, heparinized saline during the procedure.
4 F or 5 F Simmons catheters (Cook or Jungsung Medical, Sungnam, Korea) were introduced over a hydrophilic guide wire (Terumo) into the aortic arch where the primary curve of the catheters was made. We primarily used Simmons type 2 catheters. Type 3 catheters were also useful for patients with a large body habitus. The primary curve of the catheters can be easily formed using the inherent shape of the aortic arch. There were two methods of folding the natural reversed curve of the Simmons catheters within the aortic arch. Method 1 was preferred by the authors (Figure 1), however, this method was not suitable for patients with a very tortuous and dilated aortic arch. Method 2 was utilized in these patients (Figure 2).
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Figure 1. A method of folding the Simmons catheter curve using the aortic arch by the looping method (Method 1). (a) The tip of the catheter is negotiated into the descending thoracic aorta with the aid of the distal curve of the catheter and a J-tipped guide wire. (b) The main loop is formed by pushing the catheter into the ascending aortic arch while the guide wire is within the catheter with the tip at the primary curve of the catheter. (c) Now the curve is formed within the ascending aorta ready to select the supra-aortic branches.
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Figure 2. A method of folding the Simmons catheter curve within the ascending aorta (Method 2). In some patients with very tortuous and wide aortic arch, Method 1 cannot be utilized because advancing the guide wire to the descending thoracic aorta is impossible. In such cases, the reversed curve of the Simmons catheter can be made within the ascending aorta. (a) A guide wire loop is made within the ascending aorta with the top of the loop abutting the cusps of the aortic valve. (b) A catheter is then advanced over the loop of the guide wire. The course of the catheter and wire is blurred due to the cardiac motion. (c) Finally the catheter curve is obtained.
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Figure 3 shows the complete catheterization method. For convenience, catheterization of the branch vessels is begun from the left subclavian artery (SCA) (Figure 3a). The ostium of the left vertebral artery (VA) is selected with or without the aid of guide wires. After left vertebral angiography, the catheter is gently retrieved from the left SCA while still retaining the shape of the curve. The left common carotid artery (CCA) is then selected (Figure 3b). If selection of the left internal carotid artery (ICA) is required, the procedure may be challenging in some patients due to the acute angle between the right brachiocephalic artery and the left CCA at the arch. In this case, a stiff guide wire (Terumo) is very helpful to widen the angle between the two arteries allowing advancement of the catheter into the left ICA (Figure 3c). The catheter is then pushed down into the aortic arch to select the right brachiocephalic artery. Selection of the right CCA and subsequently the right ICA is not difficult due to their configuration (Figure 3d). After right carotid angiography, the catheter is retrieved into the right SCA without the primary catheter curve. The right VA is then easily selected with a J-tipped guide wire using a straight catheter shape from the SCA distal to the VA origin (Figure 3e). Selective catheterization of the ICAs and VAs is not performed if there is a significant proximal steno-occlusive lesion of the targeted artery.
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Figure 3. The technique of selective catheterization of the supra-aortic branches. (a) The left subclavian artery is selected first in most cases. The origin of the left vertebral artery is also evaluated. Selective catheterization of the left vertebral artery can be done with the aid of a guide wire. (b) Then the left common carotid artery is selected. (c) If selection of the left internal carotid artery is required, we can easily advance the catheter over a guide wire into the internal carotid artery. In some patients with a very acute branching pattern, use of a stiff guide can be helpful. Once the catheter begins to advance, we can select the internal carotid artery with ease (not shown). (d) Selection of the right common carotid artery is usually not challenging. It is just necessary to pull the catheter gently with its tip within the common carotid artery. The catheter can easily be advanced over the guide wire if selection of the ipsilateral internal carotid artery is necessary. (e) After completion of right internal carotid arteriography, the catheter is pulled back, thereby unfolding the reversed curve. We can select right vertebral artery in this position simply by using a guide wire.
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The sheath is again flushed with vasodilators after removal of the catheter. If there is no significant radial artery vasospasm, the sheath is then removed. Haemostasis of the puncture site is easily achieved by a compressive dressing using a small gauze roll and a plastic bandage. The wrist bandage is removed after 2 h.
Data analysis
We analysed the success rate of radial artery puncture in 133 patients. The success rates of selective catheterization of each of the supra-aortic vessels, i.e. right CCA, right SCA, left CCA and left SCA, were calculated. The success rates of selective catheterization were also calculated in patients with the selection of the branch vessels, i.e. right ICA, left ICA, right VA and left VA. The procedure duration from the initial puncture of the radial artery to the removal of the catheter was measured in each case, and the complications were analysed. The effects of catheter diameter and pre-medication for intra-arterial vasodilatation for the occurrence of local complications were also analysed.
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Results
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Radial access was successful in 128 patients for a success rate of 96.3%. Transfemoral access was performed in the five patients with failed radial artery puncture. The drugs used to prevent local radial artery vasospasm were nitroglycerine only in 78 patients and nitroglycerine and verapamil in 50 patients. The size of the initially inserted catheters was 5 F in 94 patients and 4 F in 34 patients. The method of catheter shaping (folding loop of the Simmons catheter) in the aortic arch was Method 1 in 78 (60.9%) and Method 2 in 50 (39.1%).
The supra-aortic vessels were successfully catheterized with success rates of 99.2% (127/128) for the left SCA, and 100% for the left CCA, right CCA and right SCA. Among the 128 study patients, selective catheterization of the branch vessels was indicated in 69 for the left ICA, 76 for the right ICA, 99 for the left VA and 105 for the right VA. The successful catheterization rates of those branches were 84.1% (58/69) for the left ICA, 96.1% (73/76) for the right ICA, 58.6% (58/99) for the left VA and 95.2% (100/105) for the right VA. The mean time required for the four-vessel DSA study was 19.3 min (range 10–55 min).
Haemostasis was successfully achieved in every case with the compressive dressing of the wrist without manual compression of the puncture site. There was no case of significant haematoma formation, and only three patients developed a mild bruise at the puncture site.
The most frequent complication was arm pain in 37 patients (28.9%) during catheter manipulation. Spasm of the arm vessels was noted in 10 patients (7.8%), nine of whom complained of arm pain during catheterization. The radial pulse, checked 4–24 h after the procedure, was not palpable in 13 patients (10.2%). Only four of the 10 patients with vasospasm became pulseless on immediate follow-up. However, only one of the 13 patients with a pulseless radial artery showed ischaemic hand symptoms, which were tolerable on a 1 month follow-up examination. There was a transient ischaemic complication of the hand in a 45-year-old woman who had severe vasospasm during catheterization, hindering the left SCA selection. There were no cases of haematoma formation at the puncture site.
Aggravation of a pre-existing neurological deficit was noted in a patient who already had cerebral infarction in the right middle cerebral artery territory (Table 3).
Differences in the frequency of complications according to the size of the catheters and use of verapamil are summarized in Table 4. There was a significant difference in the incidence of vasospasm when nitroglycerine and verapamil were used in combination.
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Discussion
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Transradial access has some pitfalls, which have already been reported in studies of transradial coronary angiography or angioplasty. They include a steep and significant learning curve, increased X-ray exposure time, difficulty in catheterizing the branch vessels, increased pain during the procedure, radial artery spasm, limitation of successive access in the same arm [16], and the possible difficulty of anatomic variations of the supra-aortic vessels [17]. These complications also occurred in our series. As such is transradial access preferable? Probably, as there are enough benefits to compensate for these problems.
First, easy haemostasis is the single most important advantage. It is not necessary to compress the puncture site manually, as a simple compression bandage is sufficient for haemostasis, with no case of puncture site haematoma formation in our series. Compared with a groin haematoma formation rate with transfemoral access reported as high as 10% [3]. Transradial accesses allows the patient to be ambulatory immediately after the procedure. This allows cerebral DSA to be easily performed on out-patient basis, useful for the image follow-up of patients after carotid or vertebral artery stenting.
Second, there is no need to stop antiplatelet or anticoagulation treatment, in patients at risk from atherosclerotic or cardioembolic disease. It may be difficult and time consuming to re-adjust the level of anticoagulation after angiography if this has been stopped for the angiogram.
Third, it is possible that the wrist may be a more patient-friendly route, than the conventional transfemoral approach.
Lastly, the effectiveness and convenience of this access for coronary angiography have already been proven [7, 8]. Cardiologists already choose this access not only for diagnostic angiography but also coronary artery angioplasty and stenting.
If vasospasm occurs in a patient with an incomplete palmar arch, ischaemia of the hand can be problematic. It is mandatory to perform the Allen test before the procedure. The Allen test checks the completeness of the collaterals between the ulnar artery and the radial artery. The examiner compresses the patient's radial and ulnar arteries at the wrist. The patient is then asked to open and close the hand rapidly until the palm appears white. The examiner then releases either the radial or the ulnar artery with the test then repeated for the other artery. We considered the test abnormal if the hand did not recovered its colour within 5 s.
Initially, we not infrequently encountered local complications especially the problems of arm pain and vasospasm. However, the frequency of those complications significantly decreased after changing to use 4 F catheters and verapamil as a vasodilator together with nitroglycerine. We believe that the use of smaller bore catheters and the liberal local use of short-acting, potent vasodilators will help to decrease the incidence of local complications. Recently, there was a report on the successful use of 3.3 F diagnostic catheters for transfemoral neuroangiography [4]. These catheters can also be used via the transradial route. We also recommend the use of pressurized, heparinized saline for the continuous flushing of the introducer sheath in order to prevent thrombosis, which can cause occlusion of the punctured radial artery after removal of the sheath. The application of a lidocaine cutaneous patch along the course of the radial artery or the use of low-profile, hydrophilic-coated introducer sheathes, can also be helpful in the reduction of local complications [18].
The success rate of selective catheterization is relatively low especially for the left VA and left ICA. It was not a serious obstacle in vascular evaluation because in most cases the target vessels were successfully visualized with the proximal left SCA injection and/or the right VA injection. However, this can be a limitation of this method if selective angiography of the left VA is critical. In some patients with very tortuous supra-aortic branches or bovine-type left CCA, who might need Simmons or other specialized catheters for transfemoral access, the branches were easily catheterized without exchanging the catheter. If one is accustomed to using reversed curve diagnostic catheters such as Simmons catheters, transradial DSA can easily be performed. Improvement in vessel selectivity via transradial access, will require modification of the catheter design for the left ICA and left VA.
Initially, we were concerned with the problem of an aberrant right subclavian artery (arteria lusoria), as was previously reported [17]. There was one patient with this anatomic variation in our series. However, in the patient the catheterization procedures were performed without difficulty.
Some angiographers warn of the danger of procedure-related embolism with a reversed angle catheter such as a Simmons. They suggest that the whirling motion of the bulky catheter within a tortuous atheromatous aorta is dangerous. There was one patient in our series whose neurological symptom was aggravated the day after catheterization, suggesting a caused relationship of this symptom to the angiography. However this complication rate is comparable with that of transfemoral DSA [19]. Although it is clearly important that there is gentle catheter manipulation in the aortic arch to reduce the likelihood of disturbing atheromatous plaques.
The indications for transradial cerebral DSA might include: (a) imaging follow-up of patients after carotid artery, intracranial or vertebral artery stenting as well as those patients with coil embolisation of the cerebral aneurysms because CT angiography or MR angiography are not adequate for this purpose in some patients; (b) cerebral angiography on an out-patient basis; (c) poor femoral access; and (d) patients on antiplatelets or anticoagulation therapy. This access route may also be used for vascular intervention. We believe that local cerebral thrombolysis can be performed via this route, and that the patient can be anticoagulated immediately after the procedure. Vertebral artery angioplasty or stenting also may also be performed [20]. The transradial route is also very useful in patients with significant tortuosity or ectatic changes of the aortic arch and in patients with acute right VA course from the SCA.
The number of patients with transient ischaemic attacks or ischaemic strokes was larger in our patient cohort than in most series of vascular imaging. This was because the quality of MR angiography in our institute was suboptimal at that time. In most institutions MR angiography is able to provide superb images of both the intracranial and the supra-aortic arteries.
In conclusion, transradial selective cerebral angiography with reversed angle catheters is technically feasible and safe. Modification of the catheter design will be required to improve the selectivity of the supra-aortic branches.
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Footnotes
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Current address for Dr D H Lee, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poongnap-2dong, Songpa-gu, Seoul, 138-736, Korea. 
Received for publication June 13, 2003.
Revision received November 14, 2003.
Accepted for publication June 22, 2004.
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Abstract
Introduction
