A side-hole catheter for catheterization of a difficult internal mammary artery

Abstract

Background

The internal mammary artery (IMA) can be a source of hemoptysis in patients with chronic lung disease. Intervention via the IMA can be a challenge due to anatomic variations and lead to excessive contrast use and radiation exposure.

Purpose

To evaluate safety and efficiency of a new side-hole catheter for the catheterization of the IMA in patients with hemoptysis.

Material and Methods

From January 2011 to August 2014, a total of 96 transarterial embolization procedures required exact evaluation of the IMA due to chronic lung disease involving the anterior thorax. In 17 cases (18%) of these 96 procedures, the conventional selective IMA angiography failed and instead a novel side-hole catheter as a modification of a cobra-type curved catheter was used. The side hole allowed passage of a micro-wire and catheter.

Results

Failed catheterizations were due to severe vascular tortuosity, acutely angulated subclavian artery, or abnormal takeoff of the IMA. The Cobra shaped catheter with the microcatheter through the side-hole catheter yielded a technical success rate of 100%. Longer time was required to catheterize the IMA with the Cobra shaped catheter than with the side-hole catheter (17 vs. 2 min, P < 0.05). There were no procedure-related complications.

Conclusion

Side-hole catheter technique is useful in patients whose internal mammary artery is difficult to access. Further design revisions are needed to improve the ease and speed of IMA catheterization and angiography.

Keywords

Arterial catheterization pulmonary hemoptysis internal mammary artery

Introduction

Massive and untreated hemoptysis has a high mortality rate. Although the source of massive hemoptysis is the bronchial circulation in the majority of cases, non-bronchial systemic arteries can also be a significant source of massive hemoptysis and a cause of recurrent hemoptysis after successful transarterial embolization (TAE) (1).

Chronic lung diseases involving both the lung parenchyma and pleura in the anterior thorax are likely to have blood supply from the internal mammary artery (IMA) (2). Intervention via the IMA is a challenge due to anatomic variations (3). Selective catheterization can occasionally fail, leading to excessive contrast use and radiation exposure (4), patient discomfort, and rarely to complications, such as dissection of the subclavian artery (4 –6). The aim of the study was to describe the side-hole catheter technique for IMA.

Material and Methods

Patients

Institutional review board approval was obtained for this retrospective study. From January 2011 to August 2014, a total of 374 TAE procedures were performed for hemoptysis. Of the 374 embolization procedures, 96 (25.7%) required exact evaluation of the IMA due to chronic lung disease involving the anterior thorax; of these 96 procedures, 17 (17.7%) failed in selective IMA angiography using the conventional catheter and thus underwent catheterization using a modified side-hole catheter.

The patients’ ages were in the range of 34–90 years (mean ± SD, 61 ± 17 years). Ten were men and seven were women. Table 1 shows the clinical characteristics of the patients. The amount of hemoptysis at the time of TAE < 300 mL/day in five patients and >300 mL/day (massive hemoptysis) in 12 patients. On chest radiographs and computed tomographic (CT) scans obtained within 1 week before embolization, the underlying causes of hemoptysis were found in the upper lobe (n = 9), middle lobe (n = 3), and in other locations (n = 5).

Table 1.

Characteristics of the patients.

	Patients (n)
Underlying disease
Inactive (chronic) tuberculosis	8
Bronchiectasis	6
Pneumoconiosis	2
Lung malignancy	1
Amount of hemoptysis
Mild to moderate (<300 mL/day)	5
Massive (≥300 mL/day)	12
Distribution
Upper lobe	9
Middle lobe	3
Multifocal	5

Catheterization using a side-hole catheter

The side-hole catheter was developed as a modification of a cobra-type curved catheter (bronchial catheter, made by Jungsung Medical). The catheter is 100 cm in length, 5 Fr in diameter, and modified by the creation of a side hole to allow passage of a microcatheter (less than 2.6 Fr in diameter) and to perform IMA arteriography superselective (Fig. 1a).

Fig. 1.

(a) The side-hole catheter has a side hole (arrow) as a modification of a cobra-type curved catheter. (b) Stable position of a side-hole catheter supporting the concavity of the subclavian artery and superselection with a microcatheter via the side hole.

Procedures

TAE for hemoptysis was carried out in a dedicated vascular interventional suite equipped with digital subtraction technology by three experienced interventional radiologists. Patients underwent angiography via the femoral route using the standard Seldinger technique, and descending thoracic aortograms were initially obtained to identify the bleeding point. For the embolization of the pathologic arteries, a 5 Fr angiographic catheter (Bronchial catheter; Jungsung Medical) was placed in pathologic arteries, and a microcatheter was advanced as close as possible to the distal embolization site. Polyvinyl alcohol (PVA) particles of 355–500 µm diameter (Contour, Boston Scientific, Watertown, MA, USA) were used as an embolic agent.

Subclavian arterial angiography was performed with the catheter tip placed near the ostium of the IMA on the affected side with an injection of 3 mL/s for 4 s of a contrast medium (Visipaque 320, GE Healthcare, Waukesha, WI, USA). When good image quality of the IMA was not identified on subclavian angiograms taken with the conventional catheter, a selective IMA angiography with the conventional catheter with a 0.035-inch guidewire and/or a microcatheter with a microwire were performed. In failed cases, angiography was performed with the novel side-hole catheter. Selective IMA angiography was performed through microcatheter catheterization. In cases with pathologic findings, the IMA, an end artery, was embolized using PVA particles following coil embolization of the distal IMA to prevent unintended skin damage.

Study parameters

The following parameters were retrospectively assessed: (i) Time 1, interval between initial subclavian arteriography with the conventional catheter and subclavian arteriography with the side-hole catheter (procedure with the conventional catheter to select the IMA); (ii) Time 2, time required to place the microcatheter in the IMA with the side-hole catheter after subclavian arteriography (procedure with the side-hole catheter to select the IMA) (Times 1 and 2 were calculate from acquisition time recorded on angiograms); and (iii) image quality defined as follows: (A) excellent, full opacification of the IMA and its branches; (B) good, full opacification of the IMA, but insufficient opacification of branches; (C) poor, not full opacification of the IMA. Image improvement was defined as the upgrade of image quality after catheterization using the side-hole catheter. Image quality was evaluated by two independent interventional radiologists. Disagreements were resolved through a consensus conference.

Results

The side-hole catheter was applied in 17 (17.7%) of the 96 procedures that failed to catheterize the IMA selectively due to severely tortuous subclavian or innominate arteries and failed to obtain the sufficient image quality of the IMA. All the 17 cases were unilateral (11 cases on the right side, 6 cases on the left side). In failed cases with the conventional catheter, superselection with the microcatheter through the side hole yielded a technical success rate of 100%. The mean time required to catheterize the IMA with the side-hole catheter was 4 ± 1.3 min. There were significant differences in Times 1 and 2 between the conventional and side-hole catheters, favoring the side-hole catheter (17 ± 8.7 min vs. 4 ± 1.3 min, P < 0.05). More time (longer than 5 min) was required to catheterize the IMA with the conventional than with the side-hole catheter (17 vs. 2 procedures, P < 0.05).

In non-selective subclavian arteriography with the two different catheters, image quality of diagnostic angiograms was more improved when the side-hole catheter was used. For the conventional catheter, the image quality of the angiograms was excellent in five cases, good in seven cases, and poor in five cases; for the side-hole catheter, they were excellent in 11 cases, good in four cases, and poor in two cases (Table 2). The image quality was improved in 13 cases (76%) by the use of the side-hole catheter. Pathological findings in the IMA were noted in 11 cases with excellent image quality, which were successfully embolized through superselection with the microcatheter through the side hole. In six cases with insufficient image quality with the side-hole catheter, superselection with the microcatheter via side hole was performed. Four showed pathologic findings in the IMA and were embolized, while two did not undergo embolization. There were no procedure-related complications, such as cerebrovascular events, arterial dissection, or thromboembolism after catheterization with the side-hole catheter.

Table 2.

Comparison between cobra-shaped and side-hole catheters.

	Cobra-shaped catheter	Side-hole catheter	P
Procedure (effort) time (min)	17 ± 8.7	4 ± 1.3	<0.05
Number with prolonged effort (>5 min) to catheterize the IMA	17	2	<0.05
Image quality
Excellent	5	11
Good	7	4
Poor	5	2
Complications	0	0

Discussion

This study compared the conventional catheter with a side-hole catheter in terms of catheterization time and image quality of the IMA.

The side-hole catheter markedly reduced catheterization time and increased success rate. It also improved the image quality in non-selective subclavian arteriography. The reasons for failure to catheterize the IMA were severe vascular tortuosity, an ulcerative plaque in the IMA ostium, and an acutely angulated subclavian artery. In general, the transradial or transbrachial approach can be a second option in order for successful access to the branches of the subclavian artery that are difficult to catheterize. The transradial or transbrachial approach is popular for IMA imaging and catheterization in interventional cardiology (7 –10). In patients with hemoptysis, however, the transfemoral approach is widely used because the evaluation and embolization of the bronchial artery are essential. In these cases, the additional puncture through the brachial approach for the selection of a difficult IMA increases the risk of puncture-induced complications, such as bleeding and infection.

The side-hole catheter has several advantages over the conventional catheter. First, if the side hole is advanced the expected origin of IMA while small amounts of contrast material are manually injected, a certain portion of the injected contrast material drains through the side hole, and thus more accurate IMA angiography is feasible. Second, in a tortuous subclavian artery, IMA selection with the conventional catheter has difficulty in assuming a stable position of the catheter due to insufficient supporting force. In IMA selection with our side-hole catheter, however, its tip is placed well beyond the origin of the IMA, and thus superselection of the IMA with the microcatheter through the side hole is feasible with the stable supporting force against the concavity of the subclavian artery (Fig. 1b).

In conclusion, it is suggested that the side-hole catheter technique may have safety, efficiency, and short procedural time in patients where IMA is difficult to access. Further design revisions are needed to improve the ease and speed of IMA catheterization and angiography.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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