1. Transradial Access Complication How to Treat and Avoid Howard A. Cohen, MD, FACC, FSCAI Professor of Medicine Director Temple Interventional Heart & Vascular Institute Director Cardiac Cardiac Intervention and Catheterization Laboratories Temple University Health System Howard A. Cohen, MD, FACC, FSCAI Professor of Medicine Director Temple Interventional Heart & Vascular Institute Director Cardiac Cardiac Intervention and Catheterization Laboratories Temple University Health System SCAI FALL FELLOWS COURSE LAS VEGAS, NEVADA DECEMBER 5-8,2012

2. DISCLOSURES NONE RELATED TO THIS TALK

3. History 48 year old male with AP and positive stress test Positive risk factors – cigarette smoking, HTN, hyperlipidemia and + FMH Normal Allen Test right radial artery Uneventful access and delivery of JL3.5 Tortuous subclavian artery and ascending Aorta Difficulty engaging the coronary 48 year old male with AP and positive stress test Positive risk factors – cigarette smoking, HTN, hyperlipidemia and + FMH Normal Allen Test right radial artery Uneventful access and delivery of JL3.5 Tortuous subclavian artery and ascending Aorta Difficulty engaging the coronary

4. Difficulty Torqueing Catheter

5. Next Maneuvers? Try to untorque the catheter, watch pressure Do not try to withdraw the catheter Advance hydrophilic guidewire – soft end and then stiff end. See if the catheter can be easily advanced– if so advance as much as possible. No xs force No success – then what? Inflate BP cuff on upper are > systemic BP and repeat above maneuvers Try to untorque the catheter, watch pressure Do not try to withdraw the catheter Advance hydrophilic guidewire – soft end and then stiff end. See if the catheter can be easily advanced– if so advance as much as possible. No xs force No success – then what? Inflate BP cuff on upper are > systemic BP and repeat above maneuvers

6. Advance Snare Via Femoral Access

7. Snare the Distal End and Untorque

8. Readvance Hydrophilic Guidewire

9. Remove the Catheter

10. BEFORE REMOVING THE CATHETER Before removing the catheter insert a guidewire Do forearm angiogram with wire in place prior to removing the catheter to insure integrity of the artery Gingerly do POBA and/or insert a long sheath only if necessary Before removing the catheter insert a guidewire Do forearm angiogram with wire in place prior to removing the catheter to insure integrity of the artery Gingerly do POBA and/or insert a long sheath only if necessary

11. Difficult Case with Severe Tortuosity 80 year old female Long standing HTN Severe PVD with aneurysm Angina Pectoris Excellent radial pulse with normal Allen Test 80 year old female Long standing HTN Severe PVD with aneurysm Angina Pectoris Excellent radial pulse with normal Allen Test

12. Severe Tortuosity

13. Alternative Solutions Manipulate with 0.035 guidewire in catheter Insert long sheath and manipulate with0.035 guidewire Do not just torque but TRANSMIT the torque to the tip! Manipulate with 0.035 guidewire in catheter Insert long sheath and manipulate with0.035 guidewire Do not just torque but TRANSMIT the torque to the tip!

19. Ao Angio with Run-off

20. SUMMARY Complications are easier to avoid than to treat Have the patient take a deep breath You take a deep breath, stay calm and THINK Move the catheter in and out to transmit the torque Use a stiff guidewire if necessary Use a long sheath if necessary Do not keep torqueing if the tip does not move Have the monitor tech MONITOR the pressure Try a blood pressure cuff in the upper arm Use a snare if necessary Complications are easier to avoid than to treat Have the patient take a deep breath You take a deep breath, stay calm and THINK Move the catheter in and out to transmit the torque Use a stiff guidewire if necessary Use a long sheath if necessary Do not keep torqueing if the tip does not move Have the monitor tech MONITOR the pressure Try a blood pressure cuff in the upper arm Use a snare if necessary

21. THANK YOU