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Coronary Catheter Course Via the Left Radial Approach Is Diametrically Opposed to the Course Via the Femoral Approach: A Stroke Paradox

CJC Open(2023)

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The apriori assumption that the left radial and the femoral approaches are quite similar maybe farfetched. The course taken by catheters being advanced from the left arm to the heart as compared to the femoral artery may be different in the arch of aorta. Since the bulk of the atheroma resides preferentially along the lesser curvature of the aortic arch, we hypothesize that this approach dissonance might explain the difference in stroke rates with either approach. The apriori assumption that the left radial and the femoral approaches are quite similar maybe farfetched. The course taken by catheters being advanced from the left arm to the heart as compared to the femoral artery may be different in the arch of aorta. Since the bulk of the atheroma resides preferentially along the lesser curvature of the aortic arch, we hypothesize that this approach dissonance might explain the difference in stroke rates with either approach. Overview:The trans-radial approach (TRA) is being employed more frequently for catheter based coronary procedures, however the difference in the incidence of peri-procedural stroke via transfemoral approach (TFA) versus TRA has been a matter of debate. Data from real world registries have associated TRA with reduced risk of periprocedural stroke, however randomized controlled trials have failed to prove this difference (1Valgimigli M. Gagnor A. Calabró P. Frigoli E. Leonardi S. Zaro T. et al.Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial.Lancet (London, England). 2015 Jun; 385: 2465-2476Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,2Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet [Internet]. 2011;377(9775):1409–20. Available from: https://www.sciencedirect.com/science/article/pii/S0140673611604042Google Scholar). The risk of stroke through either TFA, LRA or RRA has been hypothesized to be due to catheter related athero-embolic phenomena (3Rashid M, Lawson C, Potts J, Kontopantelis E, Kwok CS, Bertrand OF, et al. Incidence, Determinants, and Outcomes of Left and Right Radial Access Use in Patients Undergoing Percutaneous Coronary Intervention in the United Kingdom: A National Perspective Using the BCIS Dataset. JACC Cardiovasc Interv [Internet]. 2018;11(11):1021–1033. Available from: https://www.sciencedirect.com/science/article/pii/S1936879818304199Google Scholar). Some studies suggest that during RRA, catheters while traversing right brachiocephalic artery may theoretically increase risk of embolization into the right vertebral or the right carotid artery in all patients and into the left carotid artery as well in patients with bovine arch (25% of the population). It has been postulated that not only does the LRA offer an approach similar to TFA but by bypassing the descending thoraco-abdominal aortic source of atherosclerotic plaque, LRA may lead to decreased descending aortic and iliofemoral embolization events (3Rashid M, Lawson C, Potts J, Kontopantelis E, Kwok CS, Bertrand OF, et al. Incidence, Determinants, and Outcomes of Left and Right Radial Access Use in Patients Undergoing Percutaneous Coronary Intervention in the United Kingdom: A National Perspective Using the BCIS Dataset. JACC Cardiovasc Interv [Internet]. 2018;11(11):1021–1033. Available from: https://www.sciencedirect.com/science/article/pii/S1936879818304199Google Scholar). We hypothesized that contrary to popular belief based on trajectories of catheter approach dictated by the two different anatomies, catheters being advanced to the heart from TFA and LRA take a widely diverging course along the arch of the aorta (Figure 1). Here in this paper, through real-life angiographic images we describe the different course of these two respective catheter approaches and describe how these courses may theoretically impact stroke outcomes.Description of catheter courses as they relate to aortic arch plaque distribution:The divergent courses taken by the catheters from LRA and TFA were seen during an intervention being undertaken for right coronary artery chronic total occlusion (CTO). A 7F JR4 catheter was used for TFA whereas a 6 Fr JL3.5 catheter was used for LRA to engage right and left coronary arteries respectively for simultaneous injections during CTO percutaneous coronary intervention. Coronary angiogram was performed in the left anterior oblique 35’ view at 17X magnification to allow panoramic view of the aortic arch and view the course of the two catheters along the calcified arch outline. The TFA mediated catheter while being advanced to the heart coursed along the greater curvature of aortic arch while the LRA mediated catheter was found to hug the lesser curvature of the aortic arch (Figure 1 and Figure 2). The widely diverging course taken by these catheters may not impact the technical aspect of the procedure much, but their relation to the distribution of the atherosclerotic plaque in the arch of aorta may at least theoretically impact the peri-procedural stroke rates.Figure 2Angiographic images of arch of aorta with catheter from left radial access (blue arrow) hugging the lesser curvature and catheter from femoral access (red arrow) hugging the greater curvature.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Atheroma distribution in the arch has been shown to affect the stroke risk. In a topographic analysis of the aorta, plaque location along the lesser curvature of aortic arch carried a 5-fold higher risk of stroke during coronary surgeries (4van der Linden J. Bergman P. Hadjinikolaou L. The Topography of Aortic Atherosclerosis Enhances Its Precision as a Predictor of Stroke.Ann Thorac Surg [Internet]. 2007; 83 (–92. Available from:): 2087https://www.sciencedirect.com/science/article/pii/S0003497507003700Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). The preponderance of atherosclerotic plaque deposition along the lesser curvature can be explained by the association between wall stress and plaque formation. The phenomenon of shear stress being atheroprotective is not a new concept and has been studied widely (5Cunningham K.S. Gotlieb A.I. The role of shear stress in the pathogenesis of atherosclerosis.Lab Investig [Internet]. 2005; 85 (Available from:): 9-23https://doi.org/10.1038/labinvest.3700215Crossref PubMed Scopus (806) Google Scholar). To study this relation between shear stress and location of atherosclerotic plaque in the arch of aorta, Soulis and colleagues measured the wall stress along the arch and found lower values along the lesser curvature of the aorta. In this study they also found the levels of low-density lipid (LDL) to be elevated along the lesser curvature of the aorta (6Soulis J. Giannoglou G. Dimitrakopoulou M. Papaioannou V. Logothetides S. Mikhailidis D. Influence of oscillating flow on LDL transport and wall shear stress in the normal aortic arch.Open Cardiovasc Med J [Internet]. 2009 Sep 17; (3:128–42. Available from:)https://pubmed.ncbi.nlm.nih.gov/19834577Crossref Scopus (16) Google Scholar). The combination of decreased wall stress and higher LDL clustering may explain the higher rate of atherosclerotic plaque formation along the lesser curvature of aorta thus theoretically contributing to elevated stroke risk during manipulation along this aspect of the aortic arch.Therefore, even though the major source of atherosclerotic plaque in the abdominal and descending thoracic aorta encountered during TFA is obviously averted in the LRA, the course taken by catheters during LRA may however be preferentially along the lesser curvature of aorta, which is the region of high atherosclerotic burden in the arch. This may explain the counterintuitively comparable stroke rates via TFA and TRA during coronary procedures as well as a surprisingly higher than expected stroke rate during percutaneous axillary access for transcatheter aortic valve replacement (TAVR) which is preferentially undertaken from left arm (1Valgimigli M. Gagnor A. Calabró P. Frigoli E. Leonardi S. Zaro T. et al.Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial.Lancet (London, England). 2015 Jun; 385: 2465-2476Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,2Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet [Internet]. 2011;377(9775):1409–20. Available from: https://www.sciencedirect.com/science/article/pii/S0140673611604042Google Scholar,7DT G. Tsuyoshi K. MJ M. Outcomes Following Subclavian and Axillary Artery Access for Transcatheter Aortic Valve Replacement.JACC Cardiovasc Interv [Internet]. 2019 Apr 8; 12 (Available from:): 662-669https://doi.org/10.1016/j.jcin.2019.01.219Crossref PubMed Scopus (85) Google Scholar).Conclusion:Our case demonstrated that catheters when advanced from the LRA to the heart may traverse along the lesser aortic curvature whereas catheters being advanced from the TFA to the heart may traverse along the greater aortic curvature. Since the bulk of the aortic arch atheroma resides preferentially along the lesser curvature of the aortic arch, this approach dissonance might explain the counterintuitive comparable stroke rates through either approach and also the surprisingly higher stroke rate during percutaneous axillary access for TAVR. Close observation, prior arch imaging, cautious tip control and use of guidewire to avoid catheter contact of the lesser aortic curve may be utilized while using LRA approach to prevent stroke. This observation is hypothesis generating and larger studies inclusive of patients with different arch types need to be undertaken to shed further light on this approach dissonance in a variety of clinical scenarios.Novel teaching points:•The course of catheters along the arch of aorta when accessed through the left radial approach may be diametrically opposed to the femoral approach.•Atherosclerotic plaque is differentially distributed along the arch of aorta.•Relationship of catheter course along the differentially distributed plaque in the arch of aorta may explain surprisingly comparable stroke rates through transfemoral and left radial access. Overview:The trans-radial approach (TRA) is being employed more frequently for catheter based coronary procedures, however the difference in the incidence of peri-procedural stroke via transfemoral approach (TFA) versus TRA has been a matter of debate. Data from real world registries have associated TRA with reduced risk of periprocedural stroke, however randomized controlled trials have failed to prove this difference (1Valgimigli M. Gagnor A. Calabró P. Frigoli E. Leonardi S. Zaro T. et al.Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial.Lancet (London, England). 2015 Jun; 385: 2465-2476Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,2Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet [Internet]. 2011;377(9775):1409–20. Available from: https://www.sciencedirect.com/science/article/pii/S0140673611604042Google Scholar). The risk of stroke through either TFA, LRA or RRA has been hypothesized to be due to catheter related athero-embolic phenomena (3Rashid M, Lawson C, Potts J, Kontopantelis E, Kwok CS, Bertrand OF, et al. Incidence, Determinants, and Outcomes of Left and Right Radial Access Use in Patients Undergoing Percutaneous Coronary Intervention in the United Kingdom: A National Perspective Using the BCIS Dataset. JACC Cardiovasc Interv [Internet]. 2018;11(11):1021–1033. Available from: https://www.sciencedirect.com/science/article/pii/S1936879818304199Google Scholar). Some studies suggest that during RRA, catheters while traversing right brachiocephalic artery may theoretically increase risk of embolization into the right vertebral or the right carotid artery in all patients and into the left carotid artery as well in patients with bovine arch (25% of the population). It has been postulated that not only does the LRA offer an approach similar to TFA but by bypassing the descending thoraco-abdominal aortic source of atherosclerotic plaque, LRA may lead to decreased descending aortic and iliofemoral embolization events (3Rashid M, Lawson C, Potts J, Kontopantelis E, Kwok CS, Bertrand OF, et al. Incidence, Determinants, and Outcomes of Left and Right Radial Access Use in Patients Undergoing Percutaneous Coronary Intervention in the United Kingdom: A National Perspective Using the BCIS Dataset. JACC Cardiovasc Interv [Internet]. 2018;11(11):1021–1033. Available from: https://www.sciencedirect.com/science/article/pii/S1936879818304199Google Scholar). We hypothesized that contrary to popular belief based on trajectories of catheter approach dictated by the two different anatomies, catheters being advanced to the heart from TFA and LRA take a widely diverging course along the arch of the aorta (Figure 1). Here in this paper, through real-life angiographic images we describe the different course of these two respective catheter approaches and describe how these courses may theoretically impact stroke outcomes.Description of catheter courses as they relate to aortic arch plaque distribution:The divergent courses taken by the catheters from LRA and TFA were seen during an intervention being undertaken for right coronary artery chronic total occlusion (CTO). A 7F JR4 catheter was used for TFA whereas a 6 Fr JL3.5 catheter was used for LRA to engage right and left coronary arteries respectively for simultaneous injections during CTO percutaneous coronary intervention. Coronary angiogram was performed in the left anterior oblique 35’ view at 17X magnification to allow panoramic view of the aortic arch and view the course of the two catheters along the calcified arch outline. The TFA mediated catheter while being advanced to the heart coursed along the greater curvature of aortic arch while the LRA mediated catheter was found to hug the lesser curvature of the aortic arch (Figure 1 and Figure 2). The widely diverging course taken by these catheters may not impact the technical aspect of the procedure much, but their relation to the distribution of the atherosclerotic plaque in the arch of aorta may at least theoretically impact the peri-procedural stroke rates.Atheroma distribution in the arch has been shown to affect the stroke risk. In a topographic analysis of the aorta, plaque location along the lesser curvature of aortic arch carried a 5-fold higher risk of stroke during coronary surgeries (4van der Linden J. Bergman P. Hadjinikolaou L. The Topography of Aortic Atherosclerosis Enhances Its Precision as a Predictor of Stroke.Ann Thorac Surg [Internet]. 2007; 83 (–92. Available from:): 2087https://www.sciencedirect.com/science/article/pii/S0003497507003700Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). The preponderance of atherosclerotic plaque deposition along the lesser curvature can be explained by the association between wall stress and plaque formation. The phenomenon of shear stress being atheroprotective is not a new concept and has been studied widely (5Cunningham K.S. Gotlieb A.I. The role of shear stress in the pathogenesis of atherosclerosis.Lab Investig [Internet]. 2005; 85 (Available from:): 9-23https://doi.org/10.1038/labinvest.3700215Crossref PubMed Scopus (806) Google Scholar). To study this relation between shear stress and location of atherosclerotic plaque in the arch of aorta, Soulis and colleagues measured the wall stress along the arch and found lower values along the lesser curvature of the aorta. In this study they also found the levels of low-density lipid (LDL) to be elevated along the lesser curvature of the aorta (6Soulis J. Giannoglou G. Dimitrakopoulou M. Papaioannou V. Logothetides S. Mikhailidis D. Influence of oscillating flow on LDL transport and wall shear stress in the normal aortic arch.Open Cardiovasc Med J [Internet]. 2009 Sep 17; (3:128–42. Available from:)https://pubmed.ncbi.nlm.nih.gov/19834577Crossref Scopus (16) Google Scholar). The combination of decreased wall stress and higher LDL clustering may explain the higher rate of atherosclerotic plaque formation along the lesser curvature of aorta thus theoretically contributing to elevated stroke risk during manipulation along this aspect of the aortic arch.Therefore, even though the major source of atherosclerotic plaque in the abdominal and descending thoracic aorta encountered during TFA is obviously averted in the LRA, the course taken by catheters during LRA may however be preferentially along the lesser curvature of aorta, which is the region of high atherosclerotic burden in the arch. This may explain the counterintuitively comparable stroke rates via TFA and TRA during coronary procedures as well as a surprisingly higher than expected stroke rate during percutaneous axillary access for transcatheter aortic valve replacement (TAVR) which is preferentially undertaken from left arm (1Valgimigli M. Gagnor A. Calabró P. Frigoli E. Leonardi S. Zaro T. et al.Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial.Lancet (London, England). 2015 Jun; 385: 2465-2476Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,2Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet [Internet]. 2011;377(9775):1409–20. Available from: https://www.sciencedirect.com/science/article/pii/S0140673611604042Google Scholar,7DT G. Tsuyoshi K. MJ M. Outcomes Following Subclavian and Axillary Artery Access for Transcatheter Aortic Valve Replacement.JACC Cardiovasc Interv [Internet]. 2019 Apr 8; 12 (Available from:): 662-669https://doi.org/10.1016/j.jcin.2019.01.219Crossref PubMed Scopus (85) Google Scholar). The trans-radial approach (TRA) is being employed more frequently for catheter based coronary procedures, however the difference in the incidence of peri-procedural stroke via transfemoral approach (TFA) versus TRA has been a matter of debate. Data from real world registries have associated TRA with reduced risk of periprocedural stroke, however randomized controlled trials have failed to prove this difference (1Valgimigli M. Gagnor A. Calabró P. Frigoli E. Leonardi S. Zaro T. et al.Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial.Lancet (London, England). 2015 Jun; 385: 2465-2476Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,2Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet [Internet]. 2011;377(9775):1409–20. Available from: https://www.sciencedirect.com/science/article/pii/S0140673611604042Google Scholar). The risk of stroke through either TFA, LRA or RRA has been hypothesized to be due to catheter related athero-embolic phenomena (3Rashid M, Lawson C, Potts J, Kontopantelis E, Kwok CS, Bertrand OF, et al. Incidence, Determinants, and Outcomes of Left and Right Radial Access Use in Patients Undergoing Percutaneous Coronary Intervention in the United Kingdom: A National Perspective Using the BCIS Dataset. JACC Cardiovasc Interv [Internet]. 2018;11(11):1021–1033. Available from: https://www.sciencedirect.com/science/article/pii/S1936879818304199Google Scholar). Some studies suggest that during RRA, catheters while traversing right brachiocephalic artery may theoretically increase risk of embolization into the right vertebral or the right carotid artery in all patients and into the left carotid artery as well in patients with bovine arch (25% of the population). It has been postulated that not only does the LRA offer an approach similar to TFA but by bypassing the descending thoraco-abdominal aortic source of atherosclerotic plaque, LRA may lead to decreased descending aortic and iliofemoral embolization events (3Rashid M, Lawson C, Potts J, Kontopantelis E, Kwok CS, Bertrand OF, et al. Incidence, Determinants, and Outcomes of Left and Right Radial Access Use in Patients Undergoing Percutaneous Coronary Intervention in the United Kingdom: A National Perspective Using the BCIS Dataset. JACC Cardiovasc Interv [Internet]. 2018;11(11):1021–1033. Available from: https://www.sciencedirect.com/science/article/pii/S1936879818304199Google Scholar). We hypothesized that contrary to popular belief based on trajectories of catheter approach dictated by the two different anatomies, catheters being advanced to the heart from TFA and LRA take a widely diverging course along the arch of the aorta (Figure 1). Here in this paper, through real-life angiographic images we describe the different course of these two respective catheter approaches and describe how these courses may theoretically impact stroke outcomes. Description of catheter courses as they relate to aortic arch plaque distribution: The divergent courses taken by the catheters from LRA and TFA were seen during an intervention being undertaken for right coronary artery chronic total occlusion (CTO). A 7F JR4 catheter was used for TFA whereas a 6 Fr JL3.5 catheter was used for LRA to engage right and left coronary arteries respectively for simultaneous injections during CTO percutaneous coronary intervention. Coronary angiogram was performed in the left anterior oblique 35’ view at 17X magnification to allow panoramic view of the aortic arch and view the course of the two catheters along the calcified arch outline. The TFA mediated catheter while being advanced to the heart coursed along the greater curvature of aortic arch while the LRA mediated catheter was found to hug the lesser curvature of the aortic arch (Figure 1 and Figure 2). The widely diverging course taken by these catheters may not impact the technical aspect of the procedure much, but their relation to the distribution of the atherosclerotic plaque in the arch of aorta may at least theoretically impact the peri-procedural stroke rates. Atheroma distribution in the arch has been shown to affect the stroke risk. In a topographic analysis of the aorta, plaque location along the lesser curvature of aortic arch carried a 5-fold higher risk of stroke during coronary surgeries (4van der Linden J. Bergman P. Hadjinikolaou L. The Topography of Aortic Atherosclerosis Enhances Its Precision as a Predictor of Stroke.Ann Thorac Surg [Internet]. 2007; 83 (–92. Available from:): 2087https://www.sciencedirect.com/science/article/pii/S0003497507003700Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). The preponderance of atherosclerotic plaque deposition along the lesser curvature can be explained by the association between wall stress and plaque formation. The phenomenon of shear stress being atheroprotective is not a new concept and has been studied widely (5Cunningham K.S. Gotlieb A.I. The role of shear stress in the pathogenesis of atherosclerosis.Lab Investig [Internet]. 2005; 85 (Available from:): 9-23https://doi.org/10.1038/labinvest.3700215Crossref PubMed Scopus (806) Google Scholar). To study this relation between shear stress and location of atherosclerotic plaque in the arch of aorta, Soulis and colleagues measured the wall stress along the arch and found lower values along the lesser curvature of the aorta. In this study they also found the levels of low-density lipid (LDL) to be elevated along the lesser curvature of the aorta (6Soulis J. Giannoglou G. Dimitrakopoulou M. Papaioannou V. Logothetides S. Mikhailidis D. Influence of oscillating flow on LDL transport and wall shear stress in the normal aortic arch.Open Cardiovasc Med J [Internet]. 2009 Sep 17; (3:128–42. Available from:)https://pubmed.ncbi.nlm.nih.gov/19834577Crossref Scopus (16) Google Scholar). The combination of decreased wall stress and higher LDL clustering may explain the higher rate of atherosclerotic plaque formation along the lesser curvature of aorta thus theoretically contributing to elevated stroke risk during manipulation along this aspect of the aortic arch. Therefore, even though the major source of atherosclerotic plaque in the abdominal and descending thoracic aorta encountered during TFA is obviously averted in the LRA, the course taken by catheters during LRA may however be preferentially along the lesser curvature of aorta, which is the region of high atherosclerotic burden in the arch. This may explain the counterintuitively comparable stroke rates via TFA and TRA during coronary procedures as well as a surprisingly higher than expected stroke rate during percutaneous axillary access for transcatheter aortic valve replacement (TAVR) which is preferentially undertaken from left arm (1Valgimigli M. Gagnor A. Calabró P. Frigoli E. Leonardi S. Zaro T. et al.Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial.Lancet (London, England). 2015 Jun; 385: 2465-2476Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,2Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet [Internet]. 2011;377(9775):1409–20. Available from: https://www.sciencedirect.com/science/article/pii/S0140673611604042Google Scholar,7DT G. Tsuyoshi K. MJ M. Outcomes Following Subclavian and Axillary Artery Access for Transcatheter Aortic Valve Replacement.JACC Cardiovasc Interv [Internet]. 2019 Apr 8; 12 (Available from:): 662-669https://doi.org/10.1016/j.jcin.2019.01.219Crossref PubMed Scopus (85) Google Scholar). Conclusion:Our case demonstrated that catheters when advanced from the LRA to the heart may traverse along the lesser aortic curvature whereas catheters being advanced from the TFA to the heart may traverse along the greater aortic curvature. Since the bulk of the aortic arch atheroma resides preferentially along the lesser curvature of the aortic arch, this approach dissonance might explain the counterintuitive comparable stroke rates through either approach and also the surprisingly higher stroke rate during percutaneous axillary access for TAVR. Close observation, prior arch imaging, cautious tip control and use of guidewire to avoid catheter contact of the lesser aortic curve may be utilized while using LRA approach to prevent stroke. This observation is hypothesis generating and larger studies inclusive of patients with different arch types need to be undertaken to shed further light on this approach dissonance in a variety of clinical scenarios.Novel teaching points:•The course of catheters along the arch of aorta when accessed through the left radial approach may be diametrically opposed to the femoral approach.•Atherosclerotic plaque is differentially distributed along the arch of aorta.•Relationship of catheter course along the differentially distributed plaque in the arch of aorta may explain surprisingly comparable stroke rates through transfemoral and left radial access. Our case demonstrated that catheters when advanced from the LRA to the heart may traverse along the lesser aortic curvature whereas catheters being advanced from the TFA to the heart may traverse along the greater aortic curvature. Since the bulk of the aortic arch atheroma resides preferentially along the lesser curvature of the aortic arch, this approach dissonance might explain the counterintuitive comparable stroke rates through either approach and also the surprisingly higher stroke rate during percutaneous axillary access for TAVR. Close observation, prior arch imaging, cautious tip control and use of guidewire to avoid catheter contact of the lesser aortic curve may be utilized while using LRA approach to prevent stroke. This observation is hypothesis generating and larger studies inclusive of patients with different arch types need to be undertaken to shed further light on this approach dissonance in a variety of clinical scenarios.
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left radial approach,femoral approach
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