Abstract
Compared to femoral access, radial access carries lower bleeding risk during diagnostic coronary angiography and percutaneous coronary intervention (PCI). Although, in experienced centers, PCI success rates are reported to be similar using radial or femoral access, radial PCI may be technically challenging due to poor catheter support. We report a case of radial PCI in a saphenous vein graft (SVG) lesion that failed, in spite of using multiple guide catheters and prolonged fluoroscopy time. After obtaining femoral access, PCI of the SVG lesion was easily accomplished. For selected PCI cases, early switching from radial to femoral access may be the optimum strategy.
1
Introduction
Higher use of radial artery access for diagnostic angiography and percutaneous coronary intervention (PCI) is encouraged because it carries lower bleeding risk and is more comfortable for the patients compared to femoral access. However, radial access also has limitations, such as poor catheter support and higher radiation doses to the operator . We report a case of saphenous vein graft (SVG) intervention that was unsuccessful through the radial approach but was easily completed through femoral access, suggesting that switching from radial to femoral access should be considered early in selected PCI cases.
2
Case report
A 64-year-old diabetic man presented with progressive exertional angina and was found to have significant inferolateral ischemia on nuclear stress testing. Ten years prior to presentation, he had undergone coronary bypass graft surgery, and 7 months prior, he had undergone stenting of a lesion in a SVG to the first obtuse marginal branch (OM1) with a bare metal stent. Nine years prior, he had aorto-bifemoral bypass surgery, and 4 months prior, he had undergone balloon angioplasty of the left common femoral artery. He was morbidly obese (body mass index, 38.7) and had no palpable femoral or lower extremity pulses.
Diagnostic coronary angiography performed via the left radial artery demonstrated chronic total occlusions of the right coronary and the proximal circumflex artery and severe mid-left anterior descending artery disease with competitive flow via a patent left internal mammary graft. The first obtuse marginal branch was filling by the previously stented SVG that had developed significant in-stent restenosis ( Fig. 1 A ). We encountered severe difficulty in engaging the SVG to OM1 in spite of using multiple guide catheters, such as AL1, AL1 short tip, Champ 2, ALR1-2, Champ 1 and LCB. The vessel was finally engaged using a diagnostic AL1 catheter through which a 300-cm Ironman wire (Abbott Vascular, Santa Clara, CA) was inserted into the graft ( Fig. 1 B), allowing for exchange for an AL1 guide. However, the guide offered poor support; a Filterwire (Boston Scientific, Natick, MA) could not be advanced through the lesion and the guide position was lost. The process was repeated, and the SVG was engaged after multiple efforts using a Jacky catheter (Terumo, Somerset, NJ). An attempt to exchange for an AL1 guide over a Spartacore 300-cm wire (Abbott Vascular) failed.
In view of the severe difficulty engaging the SVG to OM1, after 55 min of fluoroscopy, right femoral access was attempted, in spite of the lack of a femoral pulse. We were unable to advance a J-tipped wire through the tortuous and calcified femoral and iliac artery, but we were able to advance a Jindo wire (Cordis, Warren, NJ) to the abdominal aorta. The SVG was easily engaged with a 6 French LCB guide ( Fig. 1 C) that provided excellent support, and two everolimus-eluting stents (Xience V, Abbott Vascular) were delivered and deployed using Filterwire (Boston Scientific) distal embolic protection, providing an excellent final angiographic result ( Fig. 1 D). Total fluoroscopy time was 61 min. The patient tolerated the procedure well and was discharged the following day.
2
Case report
A 64-year-old diabetic man presented with progressive exertional angina and was found to have significant inferolateral ischemia on nuclear stress testing. Ten years prior to presentation, he had undergone coronary bypass graft surgery, and 7 months prior, he had undergone stenting of a lesion in a SVG to the first obtuse marginal branch (OM1) with a bare metal stent. Nine years prior, he had aorto-bifemoral bypass surgery, and 4 months prior, he had undergone balloon angioplasty of the left common femoral artery. He was morbidly obese (body mass index, 38.7) and had no palpable femoral or lower extremity pulses.
Diagnostic coronary angiography performed via the left radial artery demonstrated chronic total occlusions of the right coronary and the proximal circumflex artery and severe mid-left anterior descending artery disease with competitive flow via a patent left internal mammary graft. The first obtuse marginal branch was filling by the previously stented SVG that had developed significant in-stent restenosis ( Fig. 1 A ). We encountered severe difficulty in engaging the SVG to OM1 in spite of using multiple guide catheters, such as AL1, AL1 short tip, Champ 2, ALR1-2, Champ 1 and LCB. The vessel was finally engaged using a diagnostic AL1 catheter through which a 300-cm Ironman wire (Abbott Vascular, Santa Clara, CA) was inserted into the graft ( Fig. 1 B), allowing for exchange for an AL1 guide. However, the guide offered poor support; a Filterwire (Boston Scientific, Natick, MA) could not be advanced through the lesion and the guide position was lost. The process was repeated, and the SVG was engaged after multiple efforts using a Jacky catheter (Terumo, Somerset, NJ). An attempt to exchange for an AL1 guide over a Spartacore 300-cm wire (Abbott Vascular) failed.
In view of the severe difficulty engaging the SVG to OM1, after 55 min of fluoroscopy, right femoral access was attempted, in spite of the lack of a femoral pulse. We were unable to advance a J-tipped wire through the tortuous and calcified femoral and iliac artery, but we were able to advance a Jindo wire (Cordis, Warren, NJ) to the abdominal aorta. The SVG was easily engaged with a 6 French LCB guide ( Fig. 1 C) that provided excellent support, and two everolimus-eluting stents (Xience V, Abbott Vascular) were delivered and deployed using Filterwire (Boston Scientific) distal embolic protection, providing an excellent final angiographic result ( Fig. 1 D). Total fluoroscopy time was 61 min. The patient tolerated the procedure well and was discharged the following day.
3
Discussion
Our case illustrates that PCI via radial access may fail due to difficulty engaging the target vessel and poor guide catheter support. Early crossover to a femoral approach rather than repeated attempts through the radial access attempts may be the best strategy for such challenging cases.
Radial artery access for coronary angiography was first introduced by Campeau in 1989 , and its use for PCI was introduced by Kiemeneij and Laarman in 1993 . Compared to femoral access, radial access has been consistently associated with fewer access site complications , even in anticoagulated patients and with improved patient satisfaction due to earlier post-procedure ambulation and shorter hospital stays . However, radial artery angiography and PCI have limitations, such as a failure to engage or stent the target vessel necessitating an additional access site, as in our case , greater exposure to radiation and potentially prolonged procedural time. Although increasing operator experience with radial access can improve outcomes , radial artery PCI may not be feasible in some patients, as in our case.
The frequency of failure to perform PCI via radial access can be as high as 12.3% and may be due to inability to puncture or cannulate the radial artery , arterial spasm , inability to advance catheters or guidewires , inability to cannulate the target vessel , inability to cross a lesion and inability to provide adequate catheter support . In our patient, both SVG engagement and equipment delivery were challenging due to poor guide support. This was not due to lack of effort and equipment, as shown by the long fluoroscopy time and the multiple catheters used. The primary operator has performed >200 radial interventions. However, there are other techniques that could have been used in this case, such as use of a wiggle wire, injection of Rotaglide (Boston Scientific) or use of different guiding catheters, such as the AL 0.75, XB or EBU curves.
The decision to switch from radial to femoral access during PCI may be difficult for several reasons: (a) femoral artery puncture may carry increased risk in the setting of anticoagulation administered for PCI; (b) patients may be dissatisfied as they are expecting early ambulation post-procedure; (c) the operator may have difficulty admitting “failure” of radial PCI; and (d) challenging femoral access or obesity may have been the initial reason for selecting radial access, as in our patient. Yet, early crossover access may make the difference between success and failure; reduce contrast, fluoroscopy and equipment utilization; and potentially reduce complications associated with prolonged instrumentation of the target vessel.
The optimum timing for converting from radial to femoral access depends on several factors, such as (a) the complexity of the procedure (more complex cases, such as those including chronic total occlusions, multivessel interventions or interventions in bypass grafts as in our report, may be best converted earlier), (b) progress of the procedure (if significant progress has been achieved, then continuing radial PCI attempts may be justified), (c) availability of other access sites (e.g., our patient had significant lower extremity arterial disease, which is why repeat attempts for radial intervention were performed) and (d) radiation dose (in obese patients, the radiation exposure may be significant for both the patient and the operator after relatively short duration of fluoroscopy use, and in such patients, earlier conversion to a femoral approach may be preferable).
In summary, radial access PCI may be challenging or may fail due to poor catheter engagement of the target vessel and poor catheter support. Early crossover to the femoral approach may allow more rapid and safe completion of such interventions.
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