Clinical Images

Ambidextrous Angiography: Mother-and-Child Telescopic Catheter Technique to Evaluate LIMA and RIMA Grafts From the Radial Approach

Zaki Akhtar, MBBS;  Nikunj Shah, MBBS;  Richard Bogle, PhD, FRCP

Zaki Akhtar, MBBS;  Nikunj Shah, MBBS;  Richard Bogle, PhD, FRCP

J INVASIVE CARDIOL 2019;31(6):E157.

Key words: coronary angiography, internal mammary artery graft


A 72-year-old man with a history of ischemic heart disease (coronary artery bypass grafts), ischemic cardiomyopathy, severe aortic stenosis, and a cardiac resynchronization therapy defibrillator in situ for ventricular arrhythmias  underwent a coronary angiogram graft study via the right radial artery for stable angina in 2015. Four Fr diagnostic catheters (JR 4 and JL 3.5) were utilized for assessment of the native coronary arteries. Selective angiography of the right internal mammary artery-left anterior descending (RIMA-LAD) graft was performed using a 4 Fr internal mammary diagnostic catheter demonstrating a well-functioning graft. Selective angiography of the left internal mammary artery-obtuse marginal (LIMA-OM) graft was performed via a telescopic extension of a 6 Fr JL 3.5 guide catheter with a 5 Fr GuideLiner coaxial guide catheter (Teleflex) directed into the ostium of the graft with a Pilot50 guidewire (Abbott Vascular) (Figure 1). This graft was also functioning well.

Three years later, he underwent a repeat graft study as work-up for a transcatheter aortic valve implantation, via the left radial artery on this occasion. Following assessment of the native coronaries with 5 Fr diagnostic catheters (JR 4 and JL 3.5), the LIMA was evaluated with an internal mammary diagnostic catheter. Selective angiography of the RIMA was achieved with a repeat mother-and-child telescopic catheter technique using a 6 Fr extra backup 3.5 guide catheter extended by 5 Fr GuideLiner coaxial guide catheter directed into the vessel with a Sion blue guidewire (Asahi Intecc) (Figure 2). Both internal mammary grafts remained widely patent, as observed 3 years earlier.

Left heart catheterization graft study is commonly performed via the femoral approach to allow selective angiography of both internal mammary grafts, which originate from either subclavian artery. A straightforward mother-and-child catheter extension technique allows this procedure to be performed successfully via either radial approach, which is more comfortable for the patient and less likely to result in vascular complications.


From the Department of Cardiology, St. George’s University Hospital NHS Trust, London, United Kingdom.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted November 27, 2018.

Address for correspondence: Zaki Akhtar, MBBS, Department of Cardiology, St. George’s University Hospital NHS Trust, Cranmer Terrace. London SW17 0RE, United Kingdom. Email: zakiakhtar@doctors.org.uk

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