The following case is part of a series of transradial-focused reports directed by section editor Dr. Samir Pancholy. This case series is supported by an educational grant from Medtronic.

History

A 67-year-old male with diabetes, hypertension, chronic kidney disease, and known coronary artery disease presents with progressive exertional dyspnea, peripheral edema, and intermittent chest discomfort. He had prior coronary stenting of the right coronary artery (RCA) and coronary artery bypass grafting with in situ left internal mammary artery (LIMA) bypass graft to the first diagonal, saphenous vein graft (SVG) to ramus intermedius, and SVG to the second obtuse marginal artery (OM2). Upon evaluation in the emergency department, he was found to have pulmonary and peripheral edema with B-type natriuretic peptide (BNP) of 727pg/ml, peak troponin I of 0.43ng/ml and a glomerular filtration rate (GFR) of 43ml/min. Cardiac catheterization performed via right radial artery (RRA) access revealed moderate calcific tortuosity of innominate artery. Ninety percent (90%) proximal and 80% mid disease of the RCA, as well as a 95% proximal anastomotic lesion of the SVG to OM2, and the LIMA to the left anterior descending coronary artery (LAD) was widely patent. The LAD was diffusely diseased, with a small-caliber lumen beyond the LIMA graft. Staged multivessel percutaneous coronary intervention (PCI) of the RCA and SVG to OM2 were recommended. 

In view of the tortuous innominate artery and the associated difficulty with the diagnostic catheterization procedure, a transfemoral option was strongly considered. The left radial artery was not available. Rotational atherectomy was deemed optimal for lesion preparation for the RCA PCI. The patient was brought back to the catheterization laboratory 48 hours after the diagnostic procedure, and a 6 French introducer sheath was placed in the RRA.  A 6 French multiaortic (MAC) 4.0 guide catheter (Medtronic) was used to engage the SVG ostium (Figure 1) and primary stenting of proximal SVG was performed using a 3.5 x 12mm Resolute Integrity stent (Medtronic) (Figure 2). At this point in the procedure, <20ml of contrast was administered. The same guide catheter was then used to engage RCA ostium. An .014-inch Rotawire (Boston Scientific) was placed in the distal RCA and a 1.5mm Rotablator burr (Boston Scientific) was used to perform 6 passes at 180,000 rpm, each for <5 seconds. Both stenoses in RCA were crossed with the burr (Figures 3-4). 

In view of severe calcification and some tortuosity of the RCA, the Rotawire was exchanged for a .014-inch Hi-Torque Wiggle guide wire (Abbott Vascular). A .014-inch Runthrough NS guide wire (Terumo) was placed alongside the Wiggle wire in anticipation of difficult advancement of hardware through the proximal and mid RCA. After predilatation with a 3.0 x 12mm Sprinter Legend balloon (Medtronic), the mid stenosis was stented using 3.0 x 18mm Resolute Integrity stent, and the proximal stenosis was stented using a 3.0 x 15mm Resolute Integrity stent, respectively (Figures 5-7). Rapid injection, short-duration cineangiographic acquisitions were used. Before each catheter exchange, the contrast column from the guide catheter and the extension tubing was aspirated using the manifold, and replaced with saline. 

The entire procedure was completed using 80ml of contrast and 11 minutes of fluoroscopy time. After local band compression, the patient was transferred to the ward. 

Discussion 

Transradial intervention (TRI) has typically been considered a handicap compared to the transfemoral approach, with concerns about less guide support¹ and more procedural adversities inherent to the access site. The case described above highlights several important aspects of PCI strategy, including preprocedural planning of steps, and hardware selection to eliminate the potential concerns in TRI regarding guide support and other procedural attributes. Planning and equipment selection in this case led to certain advantages. In a patient with subclavian tortuosity and a larger than usual aortic root, a guide catheter with a longer distal curve will have a higher probability of providing optimal guide support. Hence a larger curve multiaortic (MAC) shape catheter was selected. This catheter shape was also expected to provide acceptable engagement for both the SVG and RCA. Using the MAC catheter eliminated one catheter exchange, and likely reduced radiation and contrast use. The RCA had several adverse angiographic characteristics, predicting a difficult procedural course. In anticipation, rotational atheterectomy was chosen as the initial modality for lesion preparation, as is frequently done in this type of lesion subset. After rotablation, a priori use of a “buddy” guide wire with a working wire (Wiggle wire) well suited for non-conforming, calcified segments improved the ease of advancing stents through potentially unfriendly arterial segments. 

Frequently, in the spirit of limiting utilization of disposables, interventionalists escalate their hardware choices after initial failure. As in this instance, proactive and anticipatory posturing with upfront use of specialty hardware and techniques led to a decrease in overall resource utilization, contrast, and radiation burden, and improved the ease of the procedure, positively reinforcing the initial choice of radial access and giving the patient the advantage of an ideal access site. 

In this patient, where azotemia limited the safety of contrast use, using previously described techniques² paying special attention to the duration of cineangiographic acquisitions, minimizing the number of “puffs”, and using fluorosave with each contrast injection, led to significant decrease in contrast volume. The technique of rapid and short contrast injections, with incorporation of 1-2 cardiac cycles before initiation of contrast injection in the cineangiographic loop, led to a significant reduction in dye load. 

This case demonstrates the importance of proper planning in the performance of PCI, where in a high complexity coronary and co-morbid substrate, TRI could be utilized, with its accompanying safety³ and patient comfort advantages⁴, without adversely affecting the procedural attributes. Modification of contrast injection routines with the above-mentioned cineangiographic technique may decrease contrast and radiation burden. 

References

1. Dehghani P, Mohammad A, Bajaj R, Hong T, Suen CM, Sharieff W, Chisholm RJ, Kutryk MJ, Fam NP, Cheema AN. Mechanism and predictors of failed transradial approach for percutaneous coronary interventions. JACC Cardiovasc Interv. 2009; 2(11): 1057-1064.
2. Nayak KR, Mehta HS, Price MJ, Russo RJ, Stinis CT, Moses JW, Mehran R, Leon MB, Kandzari DE, Teirstein PS. A novel technique for ultra-low contrast administration during angiography or intervention. Catheter Cardiovasc Interv. 2010; 75(7): 1076-1083.
3. Bertrand OF, Bélisle P, Joyal D, Costerousse O, Rao SV, Jolly SS, Meerkin D, Joseph L. Comparison of transradial and femoral approaches for percutaneous coronary interventions: a systematic review and hierarchical Bayesian meta-analysis. Am Heart J. 2012; 163(4): 632-648.
4. Cooper CJ, El-Shiekh RA, Cohen DJ, Blaesing L, Burket MW, Basu A, Moore JA. Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison. Am Heart J. 1999; 138(3 Pt 1): 430-436.

Disclosure: Dr. Ierovante reports no conflicts of interest regarding the content herein. Dr. Pancholy reports he is a technical consultant for the transradial product line for Terumo and a speaker for Pfizer.

The authors can be contacted via Dr. Samir Pancholy at pancholy8@gmail.com.