120 Letters to the Editor A new operative classification of both anatomic vascular variants and physiopathologic conditions affecting transradial cardiovascular procedures Francesco Burzotta a, ⁎, Carlo Trani a , Maria De Vita a,b , Filippo Crea a a Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy b Cardiology Department “Morgagni-Pierantoni” Hospital, Forlì, Italy article info Article history: Received 12 June 2009 Accepted 15 June 2009 Available online 17 July 2009 Keywords: Radial approach Anatomy Classification Transradial approach (TRA) for coronary diagnostic and interven- tional procedures is known to shorten hospitalization and dramatically reduce access-site complications [1,2] On such bases, TRA has been successfully adopted not only for coronary interventions and in selected patients, but also for coronary interventions in complex patients [3,4] and for peripheral interventions [5–7]. Nevertheless, the average technical failure of transradial approach (TRA) in coronary procedures is 5.8% [2] and is significantly higher than that reported in transfemoral approach. Such higher failure rate of TRA is due to a series of factors including radial artery spasm and anatomical variants of the arteries which should be navigated to reach the ascending aorta. In particular, a wide range of anatomic variants either of the brachioradial and of the axillo-subclavian-anonymous arterial axis or of the aortic arch may be present in patients undergoing TRA procedures hindering procedural success. The relevance of anatomic variants of brachioradial arterial axis has been well recognized in a series of studies on populations under- going coronary procedures by radial access [8–12]. These angiographic studies tried to partially incorporate in their classification the definitions of anatomic variants of the upper limb arteries emerging from postmortem studies [13,14], but no homogeneous classification has been proposed. Thus, data are not easy to compare and to apply in the clinical practice. Moreover, anatomic classifications derived from postmortem studies describe many variants which do not have any influence on TRA procedures, like the anomalous course of radial and brachial arteries in relation to muscles and nerves which are not affecting TRA. Conversely, the postmortem studies do not even report radial or brachial artery tortuosities which are frequently detected by angiography and may influence the TRA procedures. Finally, both atherosclerotic disease of the arm arteries and anatomic variants of the axillary-subclavian-anonymous arterial axis and of the aortic arch, regardless of their obvious relevance for TRA procedures, are not classified and usually not reported. Since the knowledge and recognition of the different anatomic variants is the key to successfully complete transradial coronary procedures, we reviewed the most comprehensive autopsy-based classification of arterial variants in the upper limb by Rodríguez- ⁎ Corresponding author. Via Prati Fiscali 158, 00141 Rome, Italy. Tel.: +39 3494295290; fax: +39 06 3055535. E-mail address: f.burzotta@rm.unicatt.it (F. Burzotta). Niedenführ et al. [14] and the categories identified in the angiographic studies on TRA coronary procedures. Then, we propose a simplified “operative” classification which is not limited to the radial–brachial axis but also includes the variants of the axillary-subclavian-anonymous axis and of the aortic arch [15–17], possibly affecting TRA procedures. In this new classification we add to the anatomic variants some physiopatho- logic conditions, potentially altering the arterial lumen and course, like arm arteries atherosclerotic disease and the age-related aortic arch elongation which in our experience are relevant for TRA. The proposed operative classification is reported in Table 1 (left column) and compared with the postmortem anatomical classification (if available, right column) [14]. However, the incidence of such variants assessed by postmortem studies or by systematic angiography does not reflect their impact on procedures. Thus, we estimated the frequency of each variant in a series of 2680 consecutive TRA coronary procedures (by two expert operators, CT and FB, from January 2006 to April 2009) in which angiography was performed anytime difficulty was encountered during catheter or wire advancement/manipulation (338 cases, 12.6%). This simplified but comprehensive classification, incorporating all the angiographic variants which need to be overcame for successful TRA, may provide practical insights to interventional cardiologists performing transradial procedures. The authors of this manuscript certify that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [18]. References [1] Agostoni P, Biondi-Zoccai GG, de Benedictis ML, Rigattieri S, Turri M, Anselmi M, Vassanelli C, Zardini P, Louvard Y, Hamon M. 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