Working through challenges of subclavian, innominate, and aortic arch regions during transradial approach

Objectives The aim of this review is to discuss different methods of working through subclavian, innominate, and aortic arch anatomical challenges to increase the success rate of transradial approach (TRA). Background Anatomical challenges in the subclavian, innominate, and aortic arch regions are important reasons for failure of TRA. There is limited modern literature describing methods to overcome these challenges and reduce TRA failure. Methods A number of primary subclavian, innominate, and aortic arch anatomical challenges are identified and management techniques to overcome them are discussed. Results Subclavian, innominate, and aortic arch anatomical challenges can be divided into five subsets, including (1) tortuosity, (2) loop, (3) stenosis, (4) congenital aberrancy, and (5) combined challenges. In depth discussion with supportive examples for the identification and management of these challenges are provided. Conclusions Despite lower rates of bleeding and vascular complications as compared to transfemoral approach, the adoption of TRA has been relatively slow in part due to frustration from operator failure during the learning curve. Anatomical challenges of subclavian, innominate, and aortic arch regions play an important role in TRA procedural failure. Using a simple, conceptual, framework to classify the anatomical or functional problem and then applying a logical approach to these challenges can facilitate management and augment operator success rates for TRA.