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Radial tortuosity defined by the presence of a bend of more than 90° in the contour of the vessel occurs in around 2% of cases and is often associated with severe spasm [28]. With any resistance to wire passage, the vessel should be mapped using angiography. We prefer crossing these with a coronary wire as they provide greater feedback and safety than a hydrophilic 0.035" wire. After wiring, the operator may use balloon assisted tracking (BAT) or catheter assisted tracking (CAT) to avoid the “razor” effect of a sharp leading edge causing subintimal injury dissection and spasm (Figure 3.2). This technique can help to deliver larger guide catheters in challenging anatomical situations including severe tortuosity, resistant spasm, small caliber radial artery and complex loops [29].

Figure 3.2 Navigating challenging radial anatomy using “balloon assisted tracking”: 91‐year‐old with acute coronary syndrome undergoes coronary angiography via the right distal radial artery. Figure illustrates steps of balloon assisted tracking (BAT) up a tortuous “high take off” radial artery originating in the axillary artery. The BAT technique is also used to deliver a guide catheter extension into the LAD (h). (a) High takeoff radial (origin above antecubital fossa) with short loop. (b and c) Wiring the loop with an 0.014" coronary guidewire, in this case the first step of wiring and placing the wire as proximally as possible whilst applying gentle traction and clockwise/counterclockwise catheter torque did not straighten the loop. (d and e) PTCA balloon (2.5x15mm) is placed with half protruding out the distal end of catheter and deployed at around 10–12 ATM. (f) entire assembly is advanced over coronary wire tracking the loop. (g) Clockwise or counter‐clockwise torque is applied with gentle traction to straighten loop. (h) The balloon assisted tracking (BAT) technique can be used in the coronary artery to help deliver the guide extension (e.g. Guideliner®) into the distal LAD for stent delivery without dissecting the vessel proximally.