JACC: CARDIOVASCULAR INTERVENTIONS VOL. - ,NO.- ,2017

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PUBLISHED BY ELSEVIER http://dx.doi.org/10.1016/j.jcin.2017.02.026

IMAGES IN INTERVENTION

A Rare Radial Artery Anatomic Variant Look for the Pulse on the Dorsum of the Wrist!

Arjun Venkatesh, BSC, Erin Wagner, RT(R), Jodi Klebe, RN, Jessica Schmidt, CVT, RCIS, Laila Payvandi, MD, Wassef Karrowni, MD

everal radial artery anatomic variations have unusual course of a duplicate radial artery in the S been described (1,2). These are especially lateral forearm and the dorsum of the hand. important for the radialists in the catheteriza- A56-year-oldwomanpresentedtoourclinic tion laboratory for troubleshooting, especially with reporting exertional chest pain. A nuclear stress test the growing popularity of the radial artery as the was suggestive of ischemia in the inferior wall. This preferred access site for diagnostic and interventional was followed by cardiac catheterization, which was coronary angiographic procedures. Variation in the planned from the right radial approach. The patient origin of the radial artery is a common anomaly in had 1þ right radial pulse with normal results on Allen’s the upper limb. However, the distal part of its course test. Access was obtained in the right radial artery us- shows a constant pattern. Here, we report the ing the Seldinger approach. A 6-F Slender sheath

FIGURE 1 Angiography Through CannulatedHypoplasticRadialArteryRefluxing Into Large Anomalous Duplicate Radial Artery

Contrast injection through the small, hypoplastic radial artery (HRA) at the wrist, which refluxes at the brachial artery level into a large, laterally located duplicate radial artery (DRA) that crosses distally to the dorsum of the wrist.

From UnityPoint Clinic-St. Luke’s Hospital Cardiac Catheterization Laboratory, Cedar Rapids, Iowa. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Manuscript received January 31, 2017; accepted February 9, 2017. e2 Venkatesh et al. JACC: CARDIOVASCULAR INTERVENTIONS VOL. - ,NO.- ,2017 Radial Artery Anatomic Variant - 2017:e- – -

(Terumo, Tokyo, Japan) was placed, and intra-arterial FIGURE 2 Cannulation of a Duplicate Radial Artery at the Dorsum of the Wrist nitroglycerin was infused. Advancing a Tiger catheter (Terumo) over a 0.035-inch J-wire was challenging, as the wire could not be advanced past the midforearm level. Contrast injection was performed through the sheath and demonstrated a small radial artery with another larger anomalous vessel originating at the elbow level and migrating laterally (Figure 1). A 2þ pulse was palpated at the dorsum of the hand. Another 6-F Slender sheath was placed under ultrasound guidance in the duplicate vessel, and coronary angi- ography was completed with no difficulty (Figure 2).

ADDRESS FOR CORRESPONDENCE: Dr. Wassef Karrowni,

Large duplicate radial artery cannulated at the dorsum of the wrist for successful Interventional Cardiology, UnityPoint Clinic-St Luke’s angiography after inability to traverse the hypoplastic radial artery at the usual location. Hospital, 202 10th Street SE, Suite 225, Cedar Rapids, Iowa 52403. E-mail: [email protected].

REFERENCES

1. Thomas R, Newell R. Anomalous arteries in the 2. Chandni G, Vikram P, Murlimanju BV, Vaishali RS. upper limb. Clin Anat 1995;7:57. A morphological study of variations in the origin KEY WORDS anomaly, cardiac and course of radial artery. Res J Pharm Biol Chem catheterization, radial artery Sci 2012;3:333–40.