Retrograde subintimal recanalization of a radial artery occlusion after coronary angiography using the palmar loop technique




Abstract


We report interventional management of critical hand ischemia after transradial coronary angiography. The radial artery occlusion was confirmed by Doppler ultrasound and digital subtraction angiography. The radial artery was opened using retrograde recanalization technics through the palmar arch. After guidewire passage the proximal occlusion site was stented with balloon expandable drug eluting stent, and the distal segment underwent balloon angioplasty. The report discusses the potential risks and advantages of angioplasty in the treatment of a symptomatic radial artery occlusion and the retrograde recanalization technique via the palmar arch.


1


Introduction


The rationale for the use of transradial (TR) approach is to reduce the incidence of bleeding complications at the vascular access site and the necessity for prolonged bed rest. With the increasing number of the TR procedures worldwide many vascular complications have been reported, such as radial artery occlusion (RAO), perforation, pseudo aneurysm formation , brachial and subclavian artery dissection . RAO is a rare complication (1–5%) after TR angioplasty , and it does not have any clinical consequence in case of patent hand collateral flow. Critical hand ischemia (CHI) is an infrequent entity , and it is usually treated by open surgery, while only limited data are available on treating this condition with balloon angioplasty (BA) .




2


Case report


A 41-year-old woman presented with right hand pain at rest, 2 weeks after transradial diagnostic coronary angiography performed using a 5F sheath and a TIG diagnostic catheter (Terumo Co., Japan). The patient’s history was notable for smoking, hypertension, thrombophilia and non-significant coronary artery disease. On physical examination, the right hand was considerably colder than the left, and all fingers showed cyanosis, which was most marked at the thumb. Duplex ultrasound (US) confirmed the right radial artery (RA) occlusion. A right brachial angiogram via a 5F femoral sheath, demonstrated the anterograde filling of the ulnar and interosseal arteries, however the radial artery was occluded proximally ( Fig. 1 a–b ). In an effort to prevent tissue necrosis and to relieve the symptoms, the intervention was carried out from anterograde brachial access with 5F 11 hydrophilic sheath (Cordis Corporation, Bridgewater, USA). After the administration of 5000 U intra-arterial NaHeparin, first an attempt of anterograde recanalization was made using a Progress 40 guidewire (GW) (Abbott Vascular, Santa Clara, CA) and a CX support catheter (Cook Medical, Bloomington, IN), but the penetration attempt was failed (picture 2a). Due to limited access options, a retrograde recanalization from the ulnar artery (UA) and deep palmar arch was attempted. The UA and the palmar arch was passed with a Pilot 150 guidewire (GW) (Abbott Vascular, Santa Clara, CA) and an angulated CX Support catheter (Cook Medical, Bloomington, IN) ( Fig. 2 a–b ), and after the support catheter removal, a balloon angioplasty was performed with an Amphirion Deep 2.5 × 150 mm balloon (Invatec-Medtronic, USA). The GW advancement was achieved at this point with loop formation until the distal end of the occlusion ( Fig. 3 c ), and the re-entry was attempted first with the Pilot 150 wire, than with a Progress 40 GW (Abbott Vascular, Santa Clara, CA). At this point the anterograde GW was used as a marker wire because the native occlusion stump was not visible. Finally the retrograde GW passed the occlusion successfully with penetration technique. After the deflation of the balloon the anterograde GW could be advanced passed the occlusion, and the procedure was completed from anterograde way after removal of the retrograde devices from the UA. Despite prolonged balloon dilatation the anterograde flow was not sufficient, therefore the proximal entry site had to be stented with a drug-eluting Promus 3.5 × 38 mm coronary stent from anterograde approach (Cordis Corporation, Bridgewater, USA) while the distal RA and the palmar arch was dilated with the 2.5 × 150 mm balloon. Final flow was patent, and no flow limiting dissection was visible ( Fig. 3 c–d.). The sheath was removed immediately from the BA, and conventional brachial pressure bandage was applied for 6 hours. Post procedural Duplex US confirmed the patent RA with good flow, and the patient was released from the hospital 3 days after the procedure with palpable RA and without symptoms. At 3 months FU the patient was still asymptomatic.




Fig. 1


Right brachial angiography shows RA occlusion without sufficient collateral flow from the ulnar artery (Fig. 1A, white arrow). Final angiography shows good palmar flow with typical subintimal pattern (Fig. 1B, white arrow).



Fig. 2


Anterograde radial artery recanalization attempt with CX support catheter and Progress 40 GW (White arrow, Figure A). Palmar loop technique: GW passage through the palmar arch with Pilot 150 GW and CX support catheter (White arrow, Fig. 2B–C). Retrograde GW passage with loop formation (white arrow, Fig. 2E) and failed re-entry at the proximal occlusion site (white arrow, Fig. 2D). Marker wire technique (white arrow, Fig. 2F).



Fig. 3


Anterograde GW passage beside the retrograde GW (white arrow, Fig. 3A) and dilatation of the RA with a 2.5 × 150 mm Amphirion Deep balloon (Fig. 3B, white arrow). Stenting of the proximal occlusion site with Promus stent 3.5 × 32 mm (Fig. 3D) due to occlusive dissection (Fig. 3C). Balloon dilatation of the RA and the proximal palmar artery (Fig. 3F) due to residual stenosis (Fig. 3F). Final angiography after BA shows nice filling of the palmar arch (Fig. 3G).

Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. Long-term safety and performance of the orbital atherectomy system for treating calcified coronary artery lesions: 5-Year follow-up in the ORBIT I trial
  2. Clinical presentation and outcome of patients with ST-segment elevation myocardial infarction without culprit angiographic lesions
  3. Composite outcomes in 2.25-mm drug eluting stents: a systematic review
  4. Coronary artery perforation in a patient with STEMI and a myocardial bridge: an increased risk for coronary artery perforation?

Stay updated, free articles. Join our Telegram channel
Tags:
Nov 14, 2017 | Posted by in CARDIOLOGY | Comments Off on Retrograde subintimal recanalization of a radial artery occlusion after coronary angiography using the palmar loop technique

Full access? Get Clinical Tree
Get Clinical Tree app for offline access