Coronary Angiography Through the Interosseous Artery: Expanding the Limits of the Wrist Approach

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Summary

In this challenging case of a 59-year-old man with diabetes undergoing coronary angiography due to acute coronary syndrome, we encountered difficulties in obtaining arterial access. The distal radial artery was used as the access site, however, the radial artery was occluded just after providing a carpal branch to the interosseous artery. We describe the performance of coronary angiography via the interosseous artery by using the post-occlusion segment of the distal radial artery and the collateral carpal branches. This technique provides safe and effective access to the central arterial tree.

A 59-year-old man with diabetes and a history of numerous coronary angiographies (CAs) and peripheral artery disease underwent CA due to a non-ST elevation myocardial infarction. Femoral, radial, and ulnar arteries were unpalpable.

Doppler ultrasound detected flow in the right distal radial artery (dRA), which was chosen as the access site. A 6-French (Fr) sheath was used to cannulate the dRA but was advanced up to the mid-part because of resistance. Contrast injection depicted radial artery occlusion (RAO) and patent carpal branches to the interosseous artery (IOA) (Figure A, Video 1). After administration of the spasmolytic cocktail (2500 IU heparin, 2.5 mg verapamil, 200 μcg nitrates), a 0.014-inch coronary wire failed to cross the RAO through a 6-Fr Judkins Right 4 (JR4) catheter. The coronary wire was redirected to the carpal branch, which served as a collateral channel for placing the wire in the IOA (Figure B, Video 2).  A 4-Fr JR4 catheter was advanced to the IOA and the 0.014-inch wire was exchanged for the J-tip 0.035-inch wire. To prevent catheter-induced ischemia of the forearm, we used 4-Fr diagnostic catheters in the IOA to allow adequate blood supply to the palm and fingers. CA revealed patent left circumflex and in-stent chronic total occlusions of all other coronary arteries. Hemostasis was achieved with the application of a TR Band (Terumo) (Figure C).

The clinical course was uneventful (Figure D), and the patient was referred for bypass surgery. In cases of radial artery occlusion, accessing the IOA through the dRA provides a safe and effective approach to the central arterial tree.

Affiliations and Disclosures

From the Department of Interventional Cardiology, Asklepeion General Hospital, Athens, Greece.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement:  The authors confirm that informed consent was obtained from the patient for the intervention described in the manuscript and to the publication thereof.

Address for correspondence: Andreas S. Triantafyllis, MD, PhD, EAPCI Certified, Department of Cardiology, Asklepeion General Hospital, Leoforos Vasileos Pavlou 1, PC 16673, Voula, Athens, Greece. Email: andtridoc@yahoo.gr