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Radial Approach: White Paper

Transradial Cardiac Catheterizations
Using Optitorque™ Catheters

Jared S. Corriel, M.D.
Cardiology Fellow, Beth Israel Medical Center

Tak W. Kwan, M.D., F.A.C.C., F.A.C.P.
Senior Associate Director of the Cardiac Catheterization Laboratory and Interventional Cardiology, Beth Israel Medical Center, Associate Clinical Professor of Medicine, Albert Einstein College of Medicine

Transradial access for coronary catheterizations has become increasingly popular worldwide.  Compared to the traditional femoral access technique, transradial access results in less major and minor access site bleeding (1). Early ambulation, another benefit of the transradial approach, results in a significant reduction in patient morbidity.  Further, aortoiliac disease, occasionally found in those presenting for coronary catheterization, is not an issue when using transradial access (2,3).

The transradial approach is used in only 7% of coronary angiograms in the United States compared with approximately 50% in Asia, and 40% in Europe. Less widespread adoption in the US may be due to the inability to introduce larger equipment and intra-aortic balloon pumps through the radial artery, arterial spasm, and the need for additional training with the technique.  Radial artery spasm complicates transradial catheterizations in 2-6% of cases (4,5).  Difficulty accessing the relatively narrow radial artery and increased need for catheter manipulation for coronary engagement by less-experienced operators can also result in longer procedure times.

Optitorque Catheter Advantages
Catheters commonly used during cardiac catheterizations are designed for ease of coronary engagement from a transfemoral approach. While these catheters are routinely used for transradial angiography, coronary engagement usually requires more technical skill when used from the radial artery. Optitorque catheter provides a solution to this problem. The design of these catheters, which include the “Tiger Catheter” and “Jacky Catheter” are such that a full coronary angiogram and left ventriculogram can be performed with a single catheter. Reduced catheter exchanges and movements result in less radial artery spasm, radiation exposure and procedure time. Small but important design differences between the catheters should be noted. The “Jacky” has a less acute terminal curve, which has a tendency to sit more coaxial with the left main coronary artery and engage the right coronary artery with fewer movements than the “Tiger Catheter.”

When performing a left ventriculogram, a hand injection via the Optitorque may be inadequate; exchange for a pigtail catheter with a power injector may be necessary. In addition, the Optitorque catheter tip frequently points directly towards the anterior wall of the left ventricle causing ventricular ectopy.

Care must be taken to avoid contrast staining during a hand injection. When engaging the right coronary artery, the Tiger catheter often selectively engages the conus branch of the right coronary artery (Figure 1).

As with all equipment, there is a learning curve.

    Optitorque Figure 1
Figure 1. Selective conus branch of the right
coronary artery by the Optitorque catheter.

Our systematic approach to transradial cardiac catheterizations using an Optitorque catheter begins with a modified Allen’s test to assess the competency of the ulnar artery in supplying the radial artery territory. A waveform on the pulse oximetry monitor while occluding the radial artery indicates suitable dual blood supply of the hand (6). A 5 French Glidesheath is inserted transradially using the counter-puncture technique. A combination of Verapamil 2.5mg, Nitroglycerin 100 mcg, and 2500 units of Heparin is then flushed into the sideport of the sheath (4).

With sheath insertion, a 260 cm wire is advanced via the Optitorque catheter through the radial artery down the ascending aorta to the aortic valve. The catheter is advanced over the wire to the valve, and the wire is passed into the left ventricle. The catheter is then moved into the mid-cavity of the ventricle and turned so the tip is facing the anterior ventricular wall in an RAO projection. A small hand “test” injection insures avoidance of contrast staining of the ventricle (Figure 2A). A left ventriculogram is then performed by hand injection (Figure 2B).

Optitorque Figure 2a
    Optitorque Figure 2b
Figure 2 (A). A small hand test injection of left ventricle by Optitorque (Jacky) catheter.
(B). A left ventriculogram by hand injection of the Optitorque (Jacky) catheter.

The catheter is then pulled back slowly into the aorta and torqued slightly so that the tip is pointing up and to the left. The Optitorque catheter is advanced downward until it approaches the left main artery. The catheter is pulled back slightly with gentle clockwise and counter-clockwise rotations until the left main artery is engaged (Figure 3A and 3B).

Optitorque Figure 3a
    Optitorque Figure 3b
Figure 3 (A). Optitorque (Jacky) engaging the left coronary artery.
(B). Optitorque (Tiger) engaging the left coronary artery.

Once angiography of the left coronary system is complete, the catheter is disengaged by pulling back slightly. With a clockwise torque, the catheter is advanced simultaneously until it points down toward the right cusp. The catheter is advanced until the right coronary artery is engaged (Figure 4).

Following angiography of the right coronary artery, the catheter is disengaged by torquing out of the artery, and the catheter is removed over the wire.

The sheath is then removed and local pressure applied by the TR Band special radial closure bracelet. .

    Optitorque Figure 4
Figure 4. Selective right coronary artery angiogram by the Optitorque (Jacky) catheter.

Personal Experience
Over 400 transradial cardiac catheterizations using Optitorque catheters have been performed at our institution, Beth Israel Medical Center, in New York City with a >95% success rate. In our experience at this academic institution with an active cardiology/interventional cardiology fellowship program, approximately 10 procedures are required for an operator to gain comfort and proficiency with the transradial catheterization using the Optitorque catheter. The procedure time for a simple diagnostic left heart catheterization from guidewire insertion to the completion of the study is typically less than 5 minutes.

In patients with tortuosity of the subclavian artery or aortic arch, Optitorque catheters generally engage the right coronary artery without difficulties (Figure 5A and 5B). In extreme cases, we upgrade to a larger Optitorque (Tiger 4.5 or Sarah) catheter.

Optitorque Figure 5a
    Optitorque Figure 5b
Figure 5 (A). Tortuosity of the aorta. (B). Successful engagement of the right coronary artery by the
Optitorque (Tiger) catheter despite tortuosity of the aorta.

Transradial cardiac catheterizations are an increasingly popular method for coronary angiography. In experienced hands, coronary angiography using an Optitorque catheter with the technique described significantly reduces procedure cost and time, complications, and patient discomfort. Thus, the Optitorque is our first choice for transradial catheterization.



  1. Kiemeneij F, Laarman GJ, Odekerken D, et al. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol. 1997 May;29(6)1269-75
  2. Hildick-Smith DJR, Lowe MD, Walsh JT, et al. Coronary angiography from the radial artery-experience, complications and limitations. Int J Cardiol. 1998 May 15;64(3):231-9
  3. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systemic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004 Jul 21;44(2):349-56
  4. Coppola J, Patel T, Kwan T, et al. Nitroglycerin, nitroprusside, or both, in preventing radial artery spasm during transradial artery catheterization. J. Invasive Cardiol. 2006 Apr;18(4):155-8
  5. Saito S, Tanaka S, Hiroe Y, et al. Usefulness of hydrophilic coating on arterial sheath introducer in transradial coronary intervention. Catheter Cardiovasc Interv. 2002 Jul;56(3):328-32
  6. Barbeau GR, Arsenault F, Dugas L, et al. Evaluation of the ulnopalmar arterial arches with pulse oximetry and plethysmography. Am Heart J. 2004 Mar;147(3):489-93

Published Online: September 15, 2008 -- Angioplasty.Org