Left anterior descending artery percutaneous coronary intervention from the right radial access via the left internal mammary artery: a case report

Abstract

Background

Trans-radial access in coronary intervention has gained popularity as it grants advantages in patients with higher risk of haemorrhage, especially those with non-cardiac conditions and those treated with oral anticoagulant therapy.

Case report

We report a case of percutaneous coronary intervention (PCI) of the left anterior descending (LAD) artery distal to left internal mammary artery (LIMA) anastomosis from the usually contraindicated right radial approach, in an actively bleeding patient affected by gastric cancer and chronic atrial fibrillation, and with no other available low-risk route.

Conclusion

LAD trans-LIMA PCI via right radial access can be attempted in selected cases with suitable anatomy.

1 Introduction

In the last years, trans-radial intervention (TRI), first reported in 1993 , has gained large acceptance among operators and patients due to the evident reduction in adverse events compared to trans-femoral intervention (TFI) , including both access-site (as severe as retroperitoneal bleeding) and non–access-site complications such as cholesterol embolism, lumbar pain, and urologic problems . Moreover, TRI permits immediate patient mobilization after the procedure, making it the procedure of choice for day-case percutaneous coronary intervention (PCI) and clearly improving patient comfort . The success rate of right TRI for either the left or the right coronary artery, in any case, is extremely high , and left TRI is increasingly considered a good alternative for native vessel interventions as well as the access of choice for trans-left internal mammary artery (LIMA) graft PCI in post-coronary artery bypass graft (CABG) patients , due to the anatomical acute angle between the proximal left subclavian artery and the LIMA origin, making TFI challenging and right TRI difficult. However, although LIMA graft angiography from the right radial artery is often limited by the tortuosity of brachiocephalic trunk and by the severe calcified and tortuous left subclavian artery, in some cases this can be considered the only possible approach .

Here we present a case with lack of viable alternatives, in which suitable anatomy allowed trans-LIMA left anterior descending (LAD) artery angiography and PCI from the right radial access. This option might thus be considered, in experienced hands, when the left radial artery is not available and femoral access is contraindicated.

2 Case report

An 82-year-old man with history of previous myocardial infarction and known three-vessel coronary artery disease treated with triple CABG presented to our catheterization laboratory for urgent catheterization.

One year before, chronic atrial fibrillation had been diagnosed and the patient had undergone a single, ineffective, attempt at electrical cardioversion and was subsequently placed on oral anticoagulation. In September 2009, he was admitted to our hospital because of fatigue associated with severe anaemia (6 mg/dl on admission) and evidence of gastrointestinal bleeding requiring repeat blood transfusions. A gastric ulcer sustained by stomach adenocarcinoma was diagnosed, with an indication for palliative surgery. Oral anticoagulation was stopped and the patient began treatment with low-dose enoxaparin (2000 IU bid), later withdrawn because of several bleeding episodes. While waiting for surgery, the patient experienced sudden cardiac arrest caused by ventricular fibrillation treated by single direct current cardioversion shock at 200 J. The echocardiogram performed after the episode showed severe left ventricular dysfunction (ejection fraction ∼30%), moderate mitral and severe aortic regurgitations, and moderate increase in pulmonary artery systolic pressure. Ischemic changes in the anterior leads and mild troponin I elevation led to the diagnosis of non–ST-elevation myocardial infarction. Regarding angiographic access, we elected to try the right radial artery approach first due to (1) occlusion of the left radial artery (as revealed by the absence of radial pulse at palpatory exam and negative “reverse” Allen’s test) possibly due to intraoperatory radial artery cannulation at the time of CABG, (2) severe peripheral atherosclerosis with minimal bilateral femoral pulses and known abdominal aortic aneurysm of more than 5 mm in diameter, and (3) elevated international normalized ratio (INR) of 2.3 indicating liver failure and/or incomplete correction of the anticoagulation. Moreover, the patient himself denied the presence of arterial grafts. After positioning a 25-cm, 6-Fr hydrophilic-coated radial sheath (Radifocus Introducer II, Terumo Corporation), without the need for administration of anti-spasm drugs, we performed the coronary angiogram, showing severe native three-vessel disease with chronic total occlusion of the posterior descending artery (PDA) and of the LAD, total occlusion of the first obtuse marginal (OM1), and sub-occlusion of the circumflex artery after the marginal branch. The venous grafts to PDA and OM1 were patent, without significant stenoses and no venous graft to the LAD was seen, even after aortic angiography. The presence of clips clearly suggested a LIMA graft. LIMA selective angiography was then attempted using a standard 6-F Judkins Right (JR) 4 diagnostic catheter (Cordis, Miami, FL, USA) and a hydrophilic-coated 0.035-in. guidewire (Glidewire, Terumo, Japan) to engage the left subclavian artery and reach the axillary artery ( Fig. 1 ). From non-selective dye injections, the LIMA ostium appeared suitable to be intubated with this catheter, which was then manipulated and advanced into position with slow push and pull motion and gentle torque ( Fig. 2 ). Selective LIMA angiography showed a significant stenosis of LAD after LIMA distal anastomosis and PCI was decided ( Fig. 3 ). Considering the relative ease of LIMA cannulation from the right radial artery, we decided to try and perform the angioplasty from the same route. Two “buddy” Choice 0.014-in. Extra Support (Boston Scientific, Maple Grove, MN, USA) 300-cm wires were thus placed in the LAD through the diagnostic catheter, which was exchanged over the two wires for a 6-F JR guide (Vista Brite Tip 0.071-in. inner lumen, Cordis) ( Fig. 4 ). Pre-dilation was then performed using a semi-compliant balloon (Maverick 2.0×12 mm, Boston Scientific) up to 12 atm ( Figs. 5 and 6 ), followed by partial removal of one guidewire to avoid “jailing” and by stenting with Titan 2 (2.5×13 mm up to 12 atm), a bio-active stent coated with titanium-nitric oxide (Hexacath, Rueil-Malmaison, France) ( Fig. 7 ). The final angiographic result was optimal, without complications ( Fig. 8 ). The total procedure time was 57 min, while total contrast used was 128 ml and amount of radiation dose was 137,432 cGy cmq. The patient later successfully underwent implantable cardioverter defibrillator (ICD) positioning and could undergo palliative surgery by distal gastrectomy and partial resection of the tumor-laden colon. After surgery, the patient experienced two episodes of ventricular tachycardia correctly recognized and treated by the ICD. Considering the high bleeding risk of the patient and the type of stent implanted, double anti-platelet therapy was stopped before discharge without events. At 1 year follow-up, the patient is still alive, without further episodes of life-threatening ventricular arrhythmias or need of blood transfusions.