Do a radial artery angiogram with diluted contrast to outline the anatomy

When radial or brachial artery loop is confirmed, downside the guidewire to a 0.014 in. coronary angioplasty guidewire to negotiate through

Once the diagnostic catheter has been advanced through the radial loop straightened by the coronary guidewire, one can switch to a polymer-jacket Terumo guidewire for further advancement

Use of second buddy guidewire in situations when a single coronary 0.014 in. guidewire delivers insufficient support to the catheter for crossing the loop

Upon difficulty in advancing into the loop: while keeping the tip of the catheter high, attempt to push as far as possible. And then pull back slightly (i.e., the catheter and the guidewire) which usually will be followed with straightening of the loop.

Balloon Assisted Tracking (BAT). This is a technique where an inflated PTCA balloon is slightly projected out of the distal end of the guide/diagnostic catheter and inflated at a pressure of 3–6 atmospheres. When 5 Fr diagnostic/guide catheters are used, balloon diameter of 1.5 mm is recommended. For 6 Fr guide catheters, balloon diameter of 2.0 mm is recommended. Balloon length of 15 mm or 20 mm will be sufficient. Once the partially protruded balloon is inflated in deployment, the entire structure is advanced over a soft-tipped 0.014 in. PTCA guidewire through the difficult vascular anatomy. This technique provides smooth and non traumatic passage and is useful not only in tortuous radial or brachial artery, complex radial artery loop, severe subclavian tortuosity, but also atherosclerotic lesions in the upper limb arteries (Fig. 6.3).