Abstract
Historically, multiple arterial access sites have been used for cerebral, peripheral or coronary angiography prior to the widespread utilization of the safer transbrachial and, more recently, transfemoral or transradial approaches. Additionally, alternative sites for arterial access such as the carotid artery are often used in complex pediatric invasive procedures. We describe a case of a patient with severe peripheral arterial occlusive disease with active ischemia who required coronary angiography. In collaboration with cardiothoracic surgery, carotid cutdown was successfully performed in the cardiac catheterization laboratory to allow performance of diagnostic coronary angiography and intravascular ultrasound.
1
Introduction
Historically, a multitude of alternative arterial access sites have been utilized for invasive angiography. Reports from the 1940s describe direct axillary, subclavian, vertebral and carotid artery access primarily for cerebral, as well as, peripheral angiography . Translumbar aortic access was also utilized around this time for peripheral angiography . As safer arterial access sites have become available (namely, transfemoral, transradial and transbrachial), these alternative sites have largely been abandoned. Currently, nearly all coronary angiography is performed via transfemoral, transradial or less commonly transbrachial access. However, in extreme cases of extensive peripheral vascular disease, alternative arterial access sites are necessary to obtain central aortic access. Nath et al. and Maxwell et al. have described cases in the early 1980s of coronary angiography via direct translumbar aortic access. Direct carotid arterial access was more commonly utilized in the 1970s for cerebral angiography and is occasionally utilized in the pediatric population for complex interventional cardiac procedures . However, there have been no published reports of direct carotid access in adults for cardiac catheterization. We describe a challenging case requiring left common carotid arterial access via a surgical cutdown technique to enable coronary angiography and intravascular ultrasound (IVUS).
2
Case report
Our patient is a 62-year-old Hispanic woman with a history of Type 2 diabetes mellitus, hypertension, hypercholesterolemia, bilateral lower extremity claudication and an extensive smoking history who presented with an acute coronary syndrome. A prior cardiac workup in 2007 revealed decreased left ventricular systolic function. She was placed on medical therapy and did reasonably well until presenting to our institution in June 2009 with a 2-week history of chest pain associated with shortness of breath and occasional nausea. Initially, the episodes occurred with exertion but progressed to multiple episodes at rest. Workup revealed mild elevation of cardiac biomarkers (troponin T 0.04–0.08), baseline left bundle branch block and severely depressed left ventricular systolic function with a left ventricular ejection fraction of less than 20%. Cardiac catheterization was attempted on two separate occasions by two separate operators. Bilateral transfemoral arterial access was obtained, but angiography revealed bilateral complete distal external iliac artery occlusions. Multiple attempts were made to access her radial and brachial arteries bilaterally without success. Attempts were made to cross the right and left iliac occlusions during the first and second catheterization attempts, respectively. Multiple attempts with an angled Glidewire (Terumo, Somerset, NJ) and a 0.035-in. (0.889-mm) Quick-Cross Catheter (Spectranetics, Colorado Springs, CO), as well as an angled Glidecath (Terumo), were unsuccessful crossing into the distal aortic true lumen. The wire and catheters were able to be advanced through the distal cap of the occlusion and proximally into the area of the distal aorta, but during all attempts, the wire was located in a subintimal dissection plane and was not able to be redirected into the true lumen of the distal aorta. At this point, coronary computed tomographic angiography (CTA) was performed to noninvasively evaluate the coronary circulation; revealing severe coronary artery calcification (Agatston score, 1129; volume score, 912) with significant left main involvement, which prohibited accurate assessment of the degree of left main obstruction. The patient continued to have episodes intermittent chest pain complicated by noninvasive systolic blood pressure measurements in the 70 mmHg range, which precluded use of typical antianginal medications. The patient was started on a morphine patient-controlled anesthesia (PCA) pump for comfort while further workup was performed. Right-sided heart catheterization was performed to evaluate the hemodynamic response during the chest pain episodes, revealing a low resting cardiac output of 3.3 L/min but relatively normal cardiac filling pressures (right atrium, mean 2 mmHg; right ventricle, 32/2 mmHg; pulmonary artery, 32/18 mmHg; mean, 23 mmHg; pulmonary capillary wedge pressure, mean 14 mmHg). The Swan–Ganz catheter was left in place and revealed significant elevation of the pulmonary artery pressures to 60/35 mmHg and pulmonary capillary wedge pressure to 28 mmHg with chest pain.
There was significant concern for obstructive left main coronary artery disease given the heavy calcifications seen on the coronary CTA as well as the hemodynamic changes during chest pain episodes. Chest and abdominal CTA was performed to help direct further attempts at obtaining central aortic access to perform coronary angiography. This revealed bilateral subclavian artery occlusions at their origins with long segments of occlusion and an infrarenal aortic occlusion ( Fig. 1 ). The presence of the distal aortic occlusion (extending from the level of the L3 vertebra well into the distal common iliac arteries bilaterally, as shown in Fig. 1 B) is the likely reason for the unsuccessful attempts at retrograde crossing of the iliac occlusions during the first two cardiac catheterization attempts. Given the extent of peripheral vascular disease with long segment occlusions in both subclavian and iliac arteries as well as the occluded distal aorta, an alternative arterial access site was needed. The patient’s bilateral carotid arteries appeared widely patent on CTA and were subsequently found on Doppler ultrasound to have mild nonobstructive plaque bilaterally (peak velocities 96 cm/s on right and 67 cm/s on the left). We therefore decided to proceed with obtaining left common carotid access for cardiac catheterization.
