Combined Brachial and Femoral Approach to BalloonAngioplasty in Coarctation of Aorta

George Joseph, * MD, DM, Dibya K. Baruah, MD, DM,and Shanker Krishnaswami, MD, DM, FACC

Transfemoral balloon angioplasty of native aortic coarctation was initially not feasible intwo patients, because of inability to cannulate the femoral artery percutaneously in one,and to cross the coarctation in the other. The percutaneous brachial approach helpedovercome both these problems, after which utilization of intravascular snares allowedsuccessful transfemoral completion of angioplasty. Cathet. Cardiovasc. Diagn. 42:196–200, 1997. r 1997 Wiley-Liss, Inc.

Key words: catheterization; peripheral; balloon dilatation; brachial artery; femoral artery

INTRODUCTION

Balloon angioplasty is an effective alternative methodof treatment of native aortic coarctation [1–4]. Mostauthors use a percutaneous femoral artery approach forthis procedure, crossing the coarctation in a retrogrademanner [5]. We report two patients in whom the usualretrograde femoral approach was not possible for differ-ent reasons. The percutaneous brachial approach wasused to surmount these problems, after which utilizationof intravascular snares allowed successful completion ofthe procedures in the usual transfemoral manner.

CASE REPORTS

Case 1

A 30-year-old male presented with 1-yr history offrontal headache and exertional fatigue of the lowerextremities. Systemic hypertension had been detected ayear earlier and despite antihypertensive medications, hisblood pressure at admission was 200/104 mm Hg and190/100 mm Hg in the right and left upper limbs,respectively. The femoral pulses were absent. Chestradiography and echocardiography were consistent with adiagnosis of coarctation of aorta. At our center, balloonangioplasty is offered to all patients with native aorticcoarctation, provided there are no coexisting conditionsrequiring surgical correction. Diagnostic angiographyprecedes the angioplasty procedure, both of which aredone in the same sitting using the femoral approach. Afterinformed consent and mild sedation, the patient wasbrought to the cardiac catheterization laboratory. At-tempts at percutaneous cannulation of the right femoralartery by two operators over 15 min were unsuccessful.Transcutaneous Doppler guidance was not available in

the catheterization laboratory. At this point, we decided toperform diagnostic angiography using the brachial ap-proach, rather than persist with efforts to cannulate theright femoral artery or to try the left femoral artery. Thedecision was based on two considerations: (1) before theadvent of balloon angioplasty at our center, diagnosticangiography in adults with coarctation of aorta wasroutinely performed using the brachial approach withgood results; (2) in addition to the need to confirm thediagnosis and exclude associated abnormalities, the pa-tient’s age and short duration of symptoms made exclu-sion of pulseless disease (Takayasu’s arteritis) imperativebefore proceeding with angioplasty.

Our technique of percutaneous brachial artery cannula-tion is similar to that described elsewhere [6]. The leftarm is rested on a sideboard with the cubital fossa facingupward. The brachial artery runs superficially along themedial edge of the biceps and brachialis muscles in thelower arm, and medial to the biceps tendon in the cubitalfossa (Fig. 1). Using sterile technique, the brachial arteryis stabilized between the index and middle fingers of onehand and the anterior wall is punctured 1–2 cm above thecubital crease using a 21-gauge needle held by the otherhand at an angle of 45 degrees to the skin. The Micropunc-tureTM introducer set (Cook, Bloomington, IN) allowsinitial placement of an atraumatic 0.018-inch wire withinthe artery through the needle and subsequent exchange to

Department of Cardiology, Christian Medical College Hospital,Vellore, India

*Correspondence to: Dr. George Joseph, Department of Cardiology,Christian Medical College Hospital, Vellore 632 004, South India.

Received 25 November 1996; Revision accepted 2 April 1997

Catheterization and Cardiovascular Diagnosis 42:196–200 (1997)

r 1997 Wiley-Liss, Inc.

a 0.038-inch wire using a coaxial dilator system. Finally,an arterial sheath is introduced over the 0.038-inch wire.

In this patient, a 6 French sheath was placed in the leftbrachial artery, after which 5,000 units of heparin wereadministered. Angiography revealed severe aortic coarc-tation (Fig. 2) and no associated abnormalities. Wetherefore decided to proceed with angioplasty, makinguse of the available brachial arterial access to guidefemoral artery cannulation. The coarctation was crossedusing a 0.035-inch RoadrunnerTM guidewire (Cook), afterwhich a 5 French, 125-cm-long multipurpose catheterwas advanced into the right external iliac artery. Injectionof radiographic contrast through this catheter allowedvisualization and percutaneous cannulation of the rightfemoral artery under fluoroscopy and insertion of a 9French sheath. A 6 French Amplatz ‘‘Goose Neck’’ snare(Microvena, White Bear Lake, MN) was used to exterior-ize a 0.035-inch wire passed through the brachial catheter(Fig. 3) over which the tip of the brachial catheter itselfwas exteriorized. The 0.035-inch wire was replaced by a0.035-inch Amplatz Super-stiffTM guidewire (Meditech,Watertown, MA) passed retrograde from the right femo-ral artery through the brachial catheter and positioned inthe left subclavian artery. The brachial catheter was thenremoved. A gradient of 60 mm Hg was recorded acrossthe aortic coarctation (Table I). Dilation of the coarctationusing 8- and 15-mm diameter angioplasty balloons,introduced via the femoral artery in succession, abolishedthis gradient, with satisfactory angiographic result (Fig.4). There were no complications. At discharge 24 hr later,lower extremity pulses were normal and the right upperlimb blood pressure was 130/80 mm Hg off medications.

Case 2

A 7-year-old male child presented with a 2-yr historyof systemic hypertension and exertional claudication ofboth lower extremities. Lower extremity arterial pulseswere feeble. Upper limb blood pressure was 160/110 mmHg bilaterally. A continuous murmur was audible over thefourth to sixth thoracic spines. Plain chest radiographyrevealed classic findings of coarctation of aorta, with ribnotching and the distinctive ‘‘figure 3’’ silhouette present[7]. Coarctation could not be clearly demonstrated byechocardiography. After parental informed consent andpremedication, the right femoral artery was cannulatedpercutaneously and a 6 French sheath inserted. Heparin100 units/kg body weight was administered. Angiographybelow the coarctation showed severe narrowing with nosignificant retrograde passage of contrast through thecoarctation. The aorta measured 10 mm in diameter at thelevel of the diaphragm. Attempts to cross the coarctationwith various catheters and guidewires were unsuccessful.In view of the lack of adequate visualization of thepassage through the coarctation and above, and to avoidpossible perforation or subintimal passage of guidewire, abrachial approach was utilized. The left brachial arterywas cannulated percutaneously (using identical techniqueas in case 1), and a 5 French sheath was inserted.Angiography revealed severe aortic coarctation with afairly long, obliquely angled, irregular passage through it(Fig. 5). A gradient of 42 mm Hg was present onsimultaneous pressure recording above and below thecoarctation (Table I). Antegrade crossing of the coarcta-tion was achieved fairly easily using a 0.016-inch Hiper-flexTM guidewire (USCI division, C.R. Bard, Billerica,MA) after which the wire was advanced into the rightiliac artery. A 3 French catheter (Cook) was used toreplace the 0.016-inch wire with a 0.025-inch Amplatzextra-stiff guidewire (Cook), which was then exteriorizedthrough the right femoral sheath using a 6 French

Fig. 1. Anatomic landmarks and technique of percutaneousleft brachial artery cannulation (see text for details).

TABLE I. Pressure Data *

Case 1 Case 2

Baseline dataProximal aortic pressure (S/D/M mm Hg) 161/105/120 136/91/106Distal aortic pressure (S/D/M mm Hg) 101/82/88 94/82/86Systolic gradient (mm Hg) 60 42Cardiac index (L/min/m2) 3.2 3.9Right arm pressure (noninvasive, 24 hr

before) (S/D mm Hg) 200/104 160/110

Postangioplasty dataProximal aortic pressure (S/D/M mm Hg) 156/102/117 136/100/112Distal aortic pressure (S/D/M mm Hg) 153/95/114 117/98/104Systolic gradient (mm Hg) 3 19Right arm pressure (noninvasive, 24 hr

after) (S/D mm Hg) 130/80 120/80

*S, systolic; D, diastolic; M, mean.

Brachial Approach in Coarctation Angioplasty 197

Fig. 2. A: Transbrachial angiogram (LAO projection) in case 1 showing severe aortic coarcta-tion with a tiny amount of contrast (arrows) flowing antegrade through it. B: Opacification ofdistal aorta (arrows) mainly through extensive collaterals.

Fig. 3. A 6 French Amplatz ‘‘Goose Neck’’ snare introducedthrough the femoral artery approaching a guidewire placed inthe iliac artery via the left brachial artery.

Fig. 4. Postangioplasty angiogram (LAO projection) in case 1showing satisfactory result.

198 Joseph et al.

Amplatz ‘‘Goose Neck’’ snare. A 5 French catheter, intro-duced via the right femoral artery, was used to replace the0.025-inch wire with a similar 0.035-inch wire, and itsdistal tip was positioned in the left subclavian artery. Theaortic coarctation was dilated using 6-, 8-, and 10-mm-diameter angioplasty balloons, introduced via the femoralartery in succession, at 3 atm of pressure. Descendingaortograms and pressure gradient assessment followedeach balloon dilatation. The final angiogram showedgood result with minor dissection (Fig. 6). The finalpressure gradient was 19 mm Hg. The postprocedureperiod was unremarkable. The patient was discharged 48hours later with normal lower extremity pulses and anupper limb blood pressure of 120/80 mm Hg off antihyper-tensive medications.

DISCUSSION

The percutaneous brachial approach is an importantadjunctive option to have available during interventionsin coarctation of aorta for two reasons: first, it may not bepossible to cannulate the femoral arteries percutaneouslybecause of feeble/absent femoral pulse, as in our firstcase. In this situation, femoral artery cut-down [8,9] orleft axillary artery cut-down [8] have been used to obtainvascular access. The antegrade transseptal approach usedin aortic valvuloplasty [10] could potentially be extendedto coarctation angioplasty in such situations. Comparedwith these options, the technique of fluoroscopic guid-ance for femoral artery cannulation using a catheterintroduced percutaneously via the brachial artery forcontrast injection is less invasive and causes less patientdiscomfort after the procedure. In addition, it is safe and

Fig. 5. A: Transbrachial angiogram (PA projection) in case 2 showing severe coarctation of theaorta with an oblique, irregular passage through it (arrows). B: Aortic arch angiogram (LAOprojection) in the same patient.

Fig. 6. Postangioplasty angiogram (PA projection) in case 2showing good result with minor dissection.

Brachial Approach in Coarctation Angioplasty 199

can be quickly performed. Brachial arteries in patientswith aortic coarctation are usually well felt, because ofthe accompanying systemic hypertension, allowing easypercutaneous cannulation. An alternative approach wouldbe to puncture the femoral artery using the Dopplerguided Smart needleTM (Peripheral Systems Group, Moun-tain View, CA) or to locate the femoral artery using asterile transcutaneous Doppler probe. However this op-tion may not be available in all centers. Also, brachialaccess offers additional benefits such as angiographicvisualization of the lesion before crossing it, ease ofgradient measurement, and arterial pressure monitoringduring balloon dilation.

Second, clear visualization of the passage through andthe distal end of an obliquely angled, severely stenoticlesion is necessary to maximize chances of crossing thelesion successfully and minimize possibility of perfora-tion or subintimal passage of the guidewire used to probethe lesion. Coarctation of aorta is best visualized by anaortogram just above the lesion, as antegrade flowthrough the coarctation and flow through collaterals willhelp delineate the stenosis and distal aorta. Also, crossinga stenotic lesion is often easier from one side comparedwith the other. This finding often happens in situations inwhich severely stenotic/occluded lesions have to becrossed in arteries such as the subclavian [11] andsuperficial femoral artery [12], necessitating a two-sidedapproach to angioplasty.

The brachial approach should be resorted to early in theprocedure if cannulation of the femoral artery is notquickly achieved or crossing the coarctation provesdifficult. Preparing the arm and cannulating the brachialartery takes approximately 10 min. Snaring a wire in theiliac artery and exchange of catheters/wires after thatrequires less than 5 min of extra fluoroscopy time. Hence,the total procedure time is not significantly changed if thisapproach is selected early in the procedure.

The percutaneous brachial approach cannot serve asthe sole vascular access route during interventions forcoarctation of aorta because of a major limitation: ballooncatheters required for coarctation angioplasty cannot beintroduced without risk of trauma to the brachial artery.The 9–12 French introducers needed for 13- to 20-mm-diameter balloons used in adults, and 6–7 French introduc-ers needed for 8- to 12-mm-diameter balloons used inchildren, are too large for the respective brachial arteries.Brachial introducers should be no larger than 6–7 Frenchin adults and 4–5 French in children. This technique

should not be used in neonates and very small children.After dilation, removal of unfurled balloons through thebrachial artery poses even greater risks. The femoralartery, with its larger diameter is a safer route forintroduction of balloon catheters. The use of intravascularsnares, as demonstrated here, makes it possible to com-bine the advantages of the two approaches while overcom-ing their individual limitations.

ACKNOWLEDGMENTS

We thank V. Sitapathy and S. Umakanth for photo-graphic assistance and Meenakshi M. for secretarial help.

REFERENCES

1. Cooper RS, Ritter SB, Rothe WB, Chen CK, Griepp R, GolinkoRJ: Angioplasty for coarctation of the aorta: Long-term results.Circulation 75:600–604, 1987.

2. Rao PS, Thapar MK, Galal O, Wilson AD: Follow-up results ofballoon angioplasty of native coarctation in neonates and infants.Am Heart J 120:1310–1314, 1990.

3. Shaddy RE, Boucek MM, Sturtevant JE, Ruttenberg HD, Jaffe RB,Tani LY, Judd VE, Veasy LG, McGough EC, Orsmond GS:Comparison of angioplasty and surgery for unoperated coarctationof the aorta. Circulation 87:793–799, 1993.

4. Schrader R, Bussmann WD, Jacobi V, Kadel C: Long-term effectsof balloon coarctation angioplasty on arterial blood pressure inadolescent and adult patients. Cathet Cardiovasc Diagn 36:220–225, 1995.

5. Rao PS: Balloon angioplasty of native aortic coarctation: Transcath-eter therapy in pediatric cardiology, 1st Edition. New York:Wiley-Liss, Inc., 1993.

6. Agrawal SK, Roubin GS: Percutaneous vascular access for cardiacinterventions. In Roubin GS, Califf RM, O’Neill WW, Phillips HR,Stack RS (eds): ‘‘Interventional Cardiovascular Medicine: Prin-ciples and Practice’’ 1st Edition. New York: Churchill Livingstone,1994.

7. Perloff JK (ed): ‘‘The Clinical Recognition of Congenital HeartDisease.’’ Philadelphia: WB Saunders Co., 1987.

8. Fontes VF, Esteves CA, Brago SLM, da Silva MVD, Sousa EMR,de Souza JAM: It is valid to dilate native aortic coarctation with aballoon catheter. Int J Cardiol 27:311–316, 1990.

9. Finley JP, Beaulieu RG, Nanton MA, Roy DL: Balloon catheterdilatation of coarctation of the aorta in young infants. Br Heart J50:411–415, 1983.

10. Block PC, Palacios IF: Comparison of hemodynamic results ofantegrade versus retrograde percutaneous balloon aortic valvulo-plasty. Am J Cardiol 60:659–662, 1987.

11. Kumar K, Dorros G, Bates M, Palmer L, Mathiak L, Dufek C:Primary stent deployment in occlusive subclavian artery disease.Cathet Cardiovasc Diagn 34:281–285, 1995.

12. Zaitoun R, Iyer SS, Lewin RF, Dorros G: Percutaneous poplitealapproach for angioplasty of superficial femoral artery occlusions.Cathet Cardiovasc Diagn 21:154–158, 1990.

200 Joseph et al.