Experience with Transradial and Transulnar Abdominal Angiography and Intervention.
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SIR 2007
Original Scientific Research Poster
ONOCOLOGY: / Embolization
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1. Purpose

In coronary angiography and angioplasty, transradial approach ( [ã‚¹ãƒ©ã‚¤ãƒ‰2.jpg] TRA ) has currently been accepted as
an alternative catheterization method to transfemoral (TFA) or transbrachial approach (TBA). We started abdominal
angiography and intervention transradially in 1999. We have reported its clinical experience at SIR. And we have also started
transulnar approach (TUA) in patients with weak radial pulsation in 2002.The purpose of this study is to report practical andclinical applicability of these methods in abdominal angiography and intervention.

2. Material and methods

Between February 1999 and August 2006, 382 abdominal examinations were tried transradially or transulnarly in 225 cases.
151 cases were liver or gall bladder tumor, 48 cases were other abdominal tumor, 26cases were gastrointestinal bleeding oraneurysm, 3 cases were renal or superior mesenteric arterial thrombosis and 1 case was ulcerative colitis. 310 examinations
were with transarterial embolization.( [ã‚¹ãƒ©ã‚¤ãƒ‰1.jpg] Table1 , [ã‚¹ãƒ©ã‚¤ãƒ‰5.jpg] Table2 )Methods:
1. Before procedure, Allen's test was done to assess radial or ulnar arterial circulation of the hand. In some cases of weakradial pulsation, ulnar puncture was done. If both arterial pulsation was extremely weak, ipsilateral brachial puncture orcontralateral radial puncture was chosen.
2. 1 tablet of Diclofenac Sodium25mg or 1 tablet of Diazepam 5mg was taken per orally almost one hour before examination.
3. Under local anesthesia, left radial or ulnar artery was punctured with 20G 4cm plastic needle and a 4F 23cm long introducer
was inserted.
4. Intravenous injection of 2,000-3,000 units of heparin was done.
5. A 4F 120cm long [ã‚¹ãƒ©ã‚¤ãƒ‰3.jpg] TOMO1 or JL4 catheter was proceeded to descending aorta and selectivecatheterization was done. TOMO1 catheter is designed for inserting left gastric artery or inferiorphrenic artery (Fig.2).
Superselective catheterization was done with guidewire directing method or with 2.4F 150cm long microcatheter.
6. After examinations, puncture site was compressed by [ã‚¹ãƒ©ã‚¤ãƒ‰4.jpg] compression instrument (Radispo,Xemex) for
6 hours (Fig.3). We did not compress manually. Patients were free from bed rest just after the examination.

3. Results

1.Puncture:
Radial puncture was failed in 12 examinations (3.0%) and changed to ipsilateral brachial puncture. 5 examination were triedulnar puncture because of weak radial pulsation. 29 cases were examined twice, 19 cases were examined 3 times, 10 cases
were examined 4 times, 8 cases were examined 5 times, 2 case was examined 6 times, 5 cases were examined 7 times, 1 casewas examined 9 times and 1case was examined 10 times during this period transradially( [ã‚¹ãź©ã‚¤ãź‰6.jpg] Table3 ).
Though 3 patients (0.8%) was complained forearm pain at insertion of the introducer to radial artery, some of them did notcomplain forearm pain at next examination.
2. Catheterization & intervention:
In early days, catheter buckling to ascending aorta was sometimes seen. In 2 cases, pigtail catheter was needed to proceed
guidewire to descending aorta. After we started to use TOMO1 or JL4 catheter, no catheter exchange was needed to proceed
catheters to descending aorta. Selective catheterization was successful in all patients as we did transfemorally. In HCC
patients, superselective catheterization to subsegmental branches and transarterial chemoembolization were done. Catheters
were easily inserted to replaced right hepatic artery, right inferior phrenic artery and left gastric artery using TOMO1 catheter
except some difficult cases.
In 2 cases of superiormesenteric arterial branch aneurysm, one case of hepatic arterial aneurysm and one case of splenicarterial pseudoaneurysm, successful coil embolization was done. In one case of renal angiomyolipoma, embolization withabsolute ethanol using balloon occlusion method was done successfully.
Femoral approach was needed for superselective catheterization another day in 2 cases. In one case of omental arterial
aneurysm, femoral approach was needed for complete embolization another day because microcatheter was not long enough to2/9

reach one of the feeding arteries.ã€€(Case1)
3. Complication:
No puncture site hematoma was seen after examinations. Subcutaneous hemorrhage was sometimes seen in patients withsevere liver cirrhosis after removal of tourniquet. Though no radial arterial stenosis was noted just after the procedure, weakradial pulsation was found in 5 cases at next examination(1.3%). And 3 cases were examined transulnarly and 2 case wasexamined transbrachially at next examination. No radial arterial obstruction or thrombosis was noted. No cerebrovascular
trouble was noted.
4.Clinical cases (Difficult cases):Case1: [ã‚¹ãź©ã‚¤ãź‰7.jpg] Fig1 , [ã‚¹ãź©ã‚¤ãź‰8.jpg] Fig2
Case2: [ã‚¹ãź©ã‚¤ãź‰9.jpg] Fig1 , [ã‚¹ãź©ã‚¤ãź‰10.jpg] Fig2 , [ã‚¹ãź©ã‚¤ãź‰11.jpg] Fig3 , [ã‚¹ãź©ã‚¤ãź‰12.jpg]
Fig4

4. Conclusion

Discussion:
After we started TRA, 55 to 88 % of procedures were done with TRA in each year. Most of the patients examined with TFAor TBA were hemodialysis patients as nephrologists asked us not to examine transradially (Table 1).
TRA has recognized as a low invasive and safe catheterization method in cardiac angiography and intervention. Advantages ofthis procedure are low incidence of puncture site trouble and few limitation of patient's movement after the procedure. Patientsare free from bed rest just after the examination. Disadvantages of this procedure are technical difficulty using long sized
equipments, technical difficulty to puncture small arteries and potential risk of cerebrovascular trouble during theexamination. Technical difficulty can be solved to be familiar with this procedure and using appropriate equipments.
Cerebrovascular trouble could be a critical event if it happens. We think that cerebrovascular trouble can be prevented withsystemic heparinization during the procedure and avoiding frequent catheter exchange during procedure.
Though radial artery is rather small artery, incidence of arterial injury is not high. In most of the cases, we can use radial arteryseveral times. We could puncture 10 times in one case. As radial arterial stenosis happened in about 1.4% of cases,
pre-procedural assessment is important. Ipsilateral brachial or contralateral radial approach should be chosen at that time.
Conclusion:
In our experience, abdominal angiography and interventions can be performed safely, effectively and comfortably with TRAand TUA. We believe that these procedures should be an alternative catheterization methods in wide variety of angiographic
examinations.

5. References

1)Kayashima Y, Sato T, Ito K: Usefulness of transradial angiography and interventional angiography for abdominal
diseases:comparison with transfemoral or transbrachial approach. Nippon acta radiologica 61:25-28,2001.
2) Campeau L: Percutaneous radial approach for coronary angiography. Cathe cardiovasc diagn 16: 3-7, 1989.
3) Otaki M: Percutaneous transradial approach for coronary angiography. Cardiology 81: 330-333, 1992.
4) Kiemeneij F and Laarman GJ: Percutaneous transradial artery approach for coronary stent implantation. Catheterization andCardiovascular diagnosis 30:173-178,1993.

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