Abstract
In a patient with a small-calibre radial artery and a 360° radio-ulnar loop, we combined the balloon-assisted tracking (BAT) technique (used to track a catheter trough the loop) with the use of a 6.5 F PB sheathless guiding catheter, in order to allow the extensive catheter manipulations needed for PCI despite the ongoing artery spasm.
Highlights
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Complex anatomical variations impact on the effectiveness of trans-radial approach.
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We combined the balloon-assisted tracking technique with a sheathless guiding catheter.
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We were able to perform a PCI in a case of severe spasm complicating a loop.
1
Introduction
Randomized clinical studies and large observational registries consistently show that trans-radial approach (TRA) reduces access site-related major bleeding compared to femoral access, and may even improve survival . In addition, smaller and thinner devices have made TRA increasingly practical . Among the few limitations of this approach, technical failure has been reported in the range of 1–5%, depending on operator and center experience . Even in experienced hands, however, complex anatomical variations such as small-radius radial loops may impact on the effectiveness of TRA .
2
Case report
A 76-year-old male patient with history of ischemic heart disease, hypercholesterolemia and hypertension was admitted with recurring effort angina. Six years before, he had undergone coronary artery bypass grafting (CABG) with left internal mammary artery to left anterior descending coronary artery and a saphenous vein graft to second obtuse marginal branch. A stress test performed one week before the admission had shown significant ST-segment depression in the inferior and lateral leads. Transthoracic echocardiography had revealed mild left ventricular dilation with regional hypokinesia of medio-basal segments of the inferior septum and akinesia of medio-basal segments of inferior wall.
Left radial artery access for coronary angiography, as it is standard practice in our center for CABG patients, was easily obtained. However, after insertion of a 6 F radial sheath (24-cm Radifocus, Terumo, Japan), some resistance was felt at the end of the insertion, and initial blood backflow through the sheath side port was poor. An increase in blood flow was seen after gentle pullback of the sheath, and contrast injection in multiple views revealed a small-caliber radial artery, with the co-presence of a complex radio-ulnar loop of 360° and of a recurrent radial artery branch at the top of the loop ( Fig. 1 A–C ). The loop was eventually crossed with a 0.014˝ Choice PT Extra Support (Boston Scientific, USA) guidewire supported by a JR4 4 F diagnostic catheter. The catheter, however, would not cross the first half of the loop, as resistance was felt and the patient complained of arm pain ( Fig. 1 A–C).
Balloon-assisted tracking (BAT) was planned. A 5 F JR4 diagnostic catheter was placed over the coronary wire distal to the loop. At the tip of the catheter, and over the coronary guidewire, we positioned the distal half of a 2.0 × 15 mm Ryujin Plus PTCA balloon catheter (Terumo), which was then inflated at 4 atm. The catheter was pushed gently with clockwise rotation, and the loop was successfully crossed ( Fig. 1 D). Before further advancing the catheter, the balloon/catheter system was gently pulled back with torque to straighten the loop. Coronary angiography was then performed in the usual manner, although the patient complained of severe arm discomfort (according to the Patel’s classification (8)) requiring injection of 2 doses of spasmolytic cocktail and sedation with i.v. morphine. Spasm limiting the catheter movements was clearly felt. With careful catheter exchanges over a 300 cm 0.035” wire, only 4 F diagnostic catheters were passed through the loop with difficulty and using cork-screw movements. Evidence of significant stenosis of the posterior interventricular artery arising from the left circumflex was found.
To perform the angioplasty, the 6 F radial sheath was easily replaced with a Sheathless PB 3.5 6.5 F (Sheathless Eaucath, Asahi Intecc, Japan), and the stenosis was treated by direct stenting ( Fig. 1 E–G) with an Orsiro 2.75 × 18 mm drug eluting stent (Biotronik). A “drive-by” brachial angiography was performed while the guiding catheter was pulled back at the end of the procedure, showing absence of perforation and the straightening of the loop ( Fig. 1 H).
2
Case report
A 76-year-old male patient with history of ischemic heart disease, hypercholesterolemia and hypertension was admitted with recurring effort angina. Six years before, he had undergone coronary artery bypass grafting (CABG) with left internal mammary artery to left anterior descending coronary artery and a saphenous vein graft to second obtuse marginal branch. A stress test performed one week before the admission had shown significant ST-segment depression in the inferior and lateral leads. Transthoracic echocardiography had revealed mild left ventricular dilation with regional hypokinesia of medio-basal segments of the inferior septum and akinesia of medio-basal segments of inferior wall.
Left radial artery access for coronary angiography, as it is standard practice in our center for CABG patients, was easily obtained. However, after insertion of a 6 F radial sheath (24-cm Radifocus, Terumo, Japan), some resistance was felt at the end of the insertion, and initial blood backflow through the sheath side port was poor. An increase in blood flow was seen after gentle pullback of the sheath, and contrast injection in multiple views revealed a small-caliber radial artery, with the co-presence of a complex radio-ulnar loop of 360° and of a recurrent radial artery branch at the top of the loop ( Fig. 1 A–C ). The loop was eventually crossed with a 0.014˝ Choice PT Extra Support (Boston Scientific, USA) guidewire supported by a JR4 4 F diagnostic catheter. The catheter, however, would not cross the first half of the loop, as resistance was felt and the patient complained of arm pain ( Fig. 1 A–C).
