Abstract
Some severe calcified coronary lesions may resist the advancement of the stent despite rotational atherectomy and balloon predilation, when used via the transradial approach due to a lack of support of the guiding catheter and may require switching to the femoral approach. The latter is known to have better support but with the increased risk of vascular access site complications. Deep engagement of the guiding catheter with preferring 5-French to 6-French to avoid coronary dissection provides an active support and may be a solution in such situations. We report two cases of patients with calcified coronary lesions, where rotational atherectomy and balloon predilation were not sufficient for the stent to cross the lesion and switching to 5-French guiding catheter allowing a safe deep engagement which was the solution using the transradial access.
1
Introduction
Transradial coronary angiography or intervention has been associated with a lower frequency of vascular access site complications and a trend toward reduction in the composite of death, myocardial infarction, or stroke compared to femoral access . Furthermore, transradial coronary stenting using 5-French (5F) guiding catheters has been associated with a higher procedural success rate and a lower frequency of vascular access complications particularly in patients with small radial artery diameters in comparison to 6 French (6F) transradial coronary interventions . Nonetheless, calcified lesions require preliminary debulking before stenting. For this purpose, rotational atherectomy which is usually used with 6F guiding catheter due to the bulky nature of the atherectomy devices is useful. We report two cases of patients with calcified lesions, where rotational atherectomy was not sufficient for the stent to cross the lesion and switch to (5F) guiding catheter allowing safe deep engagement was the solution using the transradial access.
2
Case 1
An 89-year-old woman, with a history of hypertension and hypercholesterolemia, was sent to the coronary care unit for exploration of a new onset of heart failure without troponin increase nor ischemic changes. She underwent coronary angiography to reveal ischemic process. The latter that was performed via the right radial artery using a 6F arterial sheath revealed a heavily calcified tight stenosis in the second segment of the left anterior descending (LAD) artery. We decided to perform an angioplasty of this lesion after a rotational atherectomy. We used a (6F) extra back up (EBU) 3.5 Launcher guiding catheter (Medtronic, USA). We performed rotational atherectomy using a 1.25 mm burr Rotablator device (Scimed, Boston Scientific Corp, Maple Grove, Minnesota, USA). Burring runs were performed for a total of 130 seconds, confirming the highly calcified status of the lesion. After that, we were unable to advance the Pro Kinetic 3.0 mm × 26 mm stent (Biotronik, USA) due to a lack of support with the (6F) guiding catheter moving back every time in the aorta, even after predilation with a Maverick 2 2.5 mm × 20 mm balloon (Boston Scientific Company, USA). Then, we exchanged using a long guidewire 300 cm with ICE Hydrophilic Coating (Luge, Boston Scientific), to a (5F) extra back up (EBU) 3.5 Launcher guiding catheter (Medtronic, USA) allowing deep intubation far in the left main (LM) and providing an active support, in our opinion, higher than the passive support insured by the (6F) extra back up (EBU) 3.5 Launcher guiding catheter (Medtronic, USA). Thus, we were able to advance our stent till the lesion and deploy it. The final angiographic result was good with no residual stenosis. Post procedural recovery was uneventful.
2
Case 1
An 89-year-old woman, with a history of hypertension and hypercholesterolemia, was sent to the coronary care unit for exploration of a new onset of heart failure without troponin increase nor ischemic changes. She underwent coronary angiography to reveal ischemic process. The latter that was performed via the right radial artery using a 6F arterial sheath revealed a heavily calcified tight stenosis in the second segment of the left anterior descending (LAD) artery. We decided to perform an angioplasty of this lesion after a rotational atherectomy. We used a (6F) extra back up (EBU) 3.5 Launcher guiding catheter (Medtronic, USA). We performed rotational atherectomy using a 1.25 mm burr Rotablator device (Scimed, Boston Scientific Corp, Maple Grove, Minnesota, USA). Burring runs were performed for a total of 130 seconds, confirming the highly calcified status of the lesion. After that, we were unable to advance the Pro Kinetic 3.0 mm × 26 mm stent (Biotronik, USA) due to a lack of support with the (6F) guiding catheter moving back every time in the aorta, even after predilation with a Maverick 2 2.5 mm × 20 mm balloon (Boston Scientific Company, USA). Then, we exchanged using a long guidewire 300 cm with ICE Hydrophilic Coating (Luge, Boston Scientific), to a (5F) extra back up (EBU) 3.5 Launcher guiding catheter (Medtronic, USA) allowing deep intubation far in the left main (LM) and providing an active support, in our opinion, higher than the passive support insured by the (6F) extra back up (EBU) 3.5 Launcher guiding catheter (Medtronic, USA). Thus, we were able to advance our stent till the lesion and deploy it. The final angiographic result was good with no residual stenosis. Post procedural recovery was uneventful.
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