To BAT or Not to BAT

Dear Editor:

We would like to congratulate Deora et al¹ on the use of their novel technique for overcoming radial artery loops during transradial interventions. However, we have the following concerns regarding its safety and utility:

1. The benefit of balloon-assisted tracking (BAT) in overcoming difficult radial artery loops may be challenged by a safer and more user-friendly alternative, the preprocedure ultrasound of arm arteries (PPUAA) technique.²PPUAA helps detect the absence of a normal bifurcation at the level ofthe antecubital fossa, in turn suggesting either the presence of a radial loop at (prevalence of 0.9% in our series), above, or below it; or a high and often narrow origin of the radial artery from the brachial artery (prevalence of 4.7% in our series). Thus, with the use of PPUAA, these anatomical variations that increase the risk ofprocedure failure and complications can be avoided.
2. Although radial loops can be crossed using various techniques, attempting to cross such loops may be associated with longer procedural time, greater radiation exposure, increased arterial spasms, patient discomfort, difficultyduring catheter manipulations, risk of perforation or dissection, andenhanced procedural failure. All of these complications can be obviated by choosing the ipsilateral ulnar, the contralateralradial, or ulnararteries for access  in patients with radial artery loops identified by PPUAA² as described above.
3. The authors have not presented follow-up data on the occlusion rates of radial artery following the use of BAT, which are likely to be high due to abrasive injury³ to the arterial intima, caused by pushing a partially inflated balloon (used in BAT) through the vessel lumen.

These factors foster the need for analyzing the safety and utility of BAT in patients with radial artery loops. Even though a randomized study is not yet available, the benefit of using a simple technique like PPUAA in identifying and thus circumventing the need for traversing radial artery loops in favor of an alternative access, as discussed above, cannot be denied. This may help avoid the use of a potentially traumatic technique such as BAT to gain access to the coronaries.

References

1. Deora S, Shah S, Patel T. Balloon-assisted tracking in dealing with radial artery loop by transradial approach: a technical report. J Invasive Cardiol. 2014;26(5):E61-E62.
2. Kumar Chugh S, Chugh S, Chugh Y, Rao SV. Feasibility and utility of preprocedural ultrasound imaging of the arm to facilitate transradial coronary diagnostic and interventional procedures (PRIMAFACIE-TRI). Catheter Cardiovasc Interv. 2013;82(1):64-73.
3. Mamas MA, Fraser DG, Ratib K, et al. Minimising radial injury: prevention is better than cure. Eurointervention. 2014 Jan 30 (Epub ahead of print).

From the Institute of Heart and Vascular Disease, Jaipur Golden Hospital, Delhi, India.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Address for correspondence: Sanjay Chugh, MD, DM, FACC, FSCAI, Chief Interventional Cardiologist, HOD Cardiology, Chairman Cardiovascular Sciences, Institute of Heart and Vascular Disease, Jaipur Golden Hospital, Delhi-110084, India.

Email: skchughcardiology@yahoo.com

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Authors’ Reply:

We have read with great interest the letter by the author commenting and criticizing the use of balloon-assisted tracking (BAT) in dealing with radial artery loop. There are a few points that we want to highlight about the BAT technique in difficult radial artery anatomy, including the radial loops.

1. It appears from the reply that the authors are more focused and enthusiastic in explaining and promoting the use of preoperative ultrasound rather than explaining about the demerits of the BAT technique. The authors are trying to propose an alternate to BAT technique by advising the use of the so-called “PPUAA” (preprocedure ultrasound of arm arteries) technique. Although the PPUAA technique appears appealing in diagnosing radial artery anatomy in theoretical aspects and helpful for classroom teaching, its practical utility in interventional cardiology practice and catheterization laboratory appears limited even for radial artery access.¹ Radial artery loop is present in ~1% cases; it is not justified to perform ultrasound for all patients going for intervention to diagnose this anatomical complication, and would increase costs.
2. “Longer procedural time, greater radiation exposure, increased arterial spasm, patient discomfort, difficulty during catheter manipulation, risk of perforation or dissection, and enhanced procedural failure” — these same criticisms were initially leveled at all radial operators. With increases in operator experience, these initial difficulties melted away gradually; it is hoped that these initial hindrances to the BAT technique will also disappear. Yes, we do agree that all interventions can’t be completed if radial loop is present, but diagnostic coronary angiography with 5 Fr catheter and some selective coronary intervention can be performed. In complex cases, if problems appear during the procedure, alternate routes (including contralateral radial or ulnar) are always there, but to diagnose the radial loop with PPUAA before even starting the procedure appears impractical.
3. Any new technique is always first reported with a few case reports, then case series, followed by well-conducted large studies. As we are in the infancy phase of this new technique, there are no data on the occlusive rate of radial artery post BAT; we will therefore need further studies to address this issue. Regarding the abrasive injury to the arterial intima by this technique, we feel that this point has been well explained and replied earlier.^2-4

Sincerely,

Surender Deora, MD, DM, Sanjay Shah, MD, DM, and Tejas Patel, DM, FACC

Department of Cardiovascular Sciences, Sheth V.S. General Hospital,

Smt. N.H.L. Municipal Medical College, Gujarat University, Ahmedabad, Gujarat, India.

Email: drsdeora@gmail.com

References

1. Zaremski L, Quesada R, Kovacs M et al. Prospective comparison of palpation versus ultrasound-guided radial access for cardiac catheterization. J Invasive Cardiol. 2013;25(10):538–542.
2. Seto A, Kern M. Balloon-assisted tracking for transradial catheterization: Beating the curve. Catheter Cardiovasc Interv. 2014;83(2):221-222.
3. Patel T, Shah S, Pancholy S, et al. Balloon-assisted tracking: a must-know technique to overcome difficult anatomy during transradial approach. Catheter Cardiovasc Interv. 2014;83(2):211-220.
4. Patel T, Shah S, Pancholy S. Rebuttal: balloon assisted tracking: a double edged sword. Catheter Cardiovasc Interv. 2014 Jun 4 (Epub ahead of print).

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