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 Table of Contents  
LETTER TO THE EDITOR
Year : 2019  |  Volume : 5  |  Issue : 3  |  Page : 221-222

Navigating an Extremely Tortuous and Diseased Subclavian Artery: Use of an Altered Tiger Catheter


Department of Cardiology, Apex Heart Institute, Ahmedabad, Gujarat, India

Date of Submission02-Sep-2019
Date of Decision03-Sep-2019
Date of Acceptance24-Sep-2019
Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Pradyot Tiwari
Apex Heart Institute, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_52_19

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How to cite this article:
Tiwari P, Shah S, Patel T. Navigating an Extremely Tortuous and Diseased Subclavian Artery: Use of an Altered Tiger Catheter. J Pract Cardiovasc Sci 2019;5:221-2

How to cite this URL:
Tiwari P, Shah S, Patel T. Navigating an Extremely Tortuous and Diseased Subclavian Artery: Use of an Altered Tiger Catheter. J Pract Cardiovasc Sci [serial online] 2019 [cited 2020 Jul 6];5:221-2. Available from: http://www.j-pcs.org/text.asp?2019/5/3/221/273744



Dear Editor,

Transradial approach to cardiac catheterization has revolutionized the realm of intervention cardiology as it is associated with reduction of access-site complications, earlier patient mobilization, reduction of hospital costs, and better clinical outcomes. However, radial access failure is often related to its more complex and frequent anatomic variants, which still limits its more widespread adoption. Severe subclavian and innominate tortuosity and loops have a reported frequency of 10%,[1] and hypertensive, elderly, and obese patients are the usual subsets. Atherosclerotic narrowing of subclavian arteries is also not rare in patients undergoing coronary procedures.[2] Most of these patients with atherosclerotic disease of the subclavian–innominate arteries have a relatively mild stenosis, so catheterization is not prohibited. Here, we describe a 60-year-old male with an extremely tortuous and stenosed subclavian artery which was navigated via the use of an altered Tiger catheter.

Our patient was a 60-year-old male who presented to us with exertional angina for the past 1 year, resistant to guideline-directed medical therapy. Diagnostic catheterization with intent for revascularization was undertaken. After radial artery puncture, a 5F Tiger (TIG) catheter was advanced over a 0.035” guidewire and retrograde angiography was undertaken when resistance was encountered during guidewire and catheter progression, which revealed the culprit lesion as a tortuous diseased subclavian artery with tight stenosis [Figure 1]a. Multiple attempts to navigate across the lesion with different available catheters such as MPA, IMA, JR, AR-1/2, and pigtail were made, along with usage of 0.032” hydrophilic guidewire, which were unsuccessful in view of eccentricity and severity of the lesion. After repeated failure of the conventional catheters, we decided to alter the shape of Tiger catheter to direct its end hole toward the lesion [Figure 2]a and [Figure 2]b, which enabled a more direct and smooth passage of guidewire [Figure 1]b. To prevent the razor effect of the sharp edges of the modified Tiger catheter from damaging the arterial intima, balloon-assisted tracking,[3] as described previously by our group, was used [Figure 2]c. Finally, we were able to negotiate the 0.032'' guidewire through the lesion and the modified Tiger catheter was then exchanged for another Tiger catheter and coronary angiography followed by revascularization was completed. According to our knowledge, this is the first case describing this innovative modification of a diagnostic catheter, which helped in surpassing the complex subclavian anatomy, allowing smooth entry in the ascending aorta. This technique should be used sparingly and by experienced operators and should always be accompanied by balloon-assisted tracking to prevent the intimal damage because of razor effect.
Figure 1: (a) Coronary angiographic view of subclavian tortuosity with stenosis. (b) Altered TIG catheter with wire across the lesion.

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Figure 2: (a) Unaltered Tiger catheter. (b) Altered Tiger catheter. (c) Altered Tiger catheter with BAT technique.

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Ethics clearance

As per institute's guidelines, ethical clearance not required for case/image reports. However the authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his/her consent for his/her images and other clinical information to be reported in the journal. The patient understand that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cha KS, Kim MH, Kim HJ. Prevalence and clinical predictors of severe tortuosity of right subclavian artery in patients undergoing transradial coronary angiography. Am J Cardiol 2003;92:1220-2.  Back to cited text no. 1
    
2.
Rigatelli G, Rigatelli G. Screening angiography of supraaortic vessels performed by invasive cardiologists at the time of cardiac catheterization: Indications and results. Int J Cardiovasc Imaging 2005;21:179-83.  Back to cited text no. 2
    
3.
Patel T, Shah S, Pancholy S. Balloon-assisted tracking of a guide catheter through difficult radial anatomy: A technical report. Catheter Cardiovasc Interv 2013;81:E215-8.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2]



 

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