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Brachial artery angioplasty to allow transradial coronary angiography
Interventional cardiologist Dr. J. Tift Mann III
Center Wake Heart Center, Raleigh, NC, USA
History A middle-aged woman with past history of severe peripheral vascular disease presented with chest pain.  Noninvasive evaluation suggested total occlusion of the abdominal aorta (Figure 1) as well as a total left subclavian.   
  Fig. 1.    Fig. 2
Strategy The transradial approach using standard technique was planned. However, the guidewire could not be passed into the shoulder and subsequent angiography through the sheath revealed severe arteriosclerosis of the brachial artery with a subtotal stenosis just proximal to the bifurcation (Figure 2).  With the absence of other access sites, brachial artery angioplasty in order to perform the catheterization was undertaken. 
Procedure A 0.014 Trooper guidewire was manipulated through the area of disease in the brachial artery and passed into the subclavian (Figure 3). A 3.5 x 20 mm Maverick was then passed across the area of most severe narrowing and serial inflations to 8 atmospheres performed (Figure 4). Subsequent angiography revealed improvement in the area of disease and a 5 French RB LBT guide catheter easily traversed the brachial and was passed into the ascending aorta (Figure 5).  Subsequent angiography revealed normal coronary arteries!  The catheter and sheath were removed without further brachial intervention due to the presence of excellent collateralization.

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Comments Arteriosclerosis in the brachial artery is a very uncommon cause of radial access failure.  Subclavian arteriosclerosis is a more common cause (Journal of Invasive Cardiology 10:596, 2004).  An intervention can be performed in these vessels depending on the need for non-femoral access.