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A Q&A for Cath Labs With Physicians Performing Radial Access
Question #1: Can you do an acute coronary syndrome (ACS) with the transradial approach?
Case performed by Zaheed Tai, DO, Winter Haven Hospital, Winter Haven, Florida.
An 84-year-old female was admitted to the emergency department and diagnosed with an ST-elevation myocardial infarction (STEMI). She was brought immediately to the cardiac 
catheterization laboratory and a left heart catheterization was performed via the right radial artery approach through a 5 French (F) Glidesheath (Terumo Corporation, Somerset, New Jersey). The ejection fraction was estimated to be 20-25% with severe anterior wall hypokinesis based on the left ventricular (LV) angiogram performed at the start of the procedure.
Based on the LV angiogram and the electrocardiogram, a 5F EBU guide catheter (Medtronic, Minneapolis, Minn.) was inserted for the diagnostic angiography of the left coronary artery, which showed a calcified left main artery and a 100% mid occlusion in the left anterior 
descending (LAD) artery. A Runthrough wire (Terumo) was inserted and advanced to the distal portion of the LAD. A 2.0 x 12 mm Apex balloon (Boston Scientific, Natick, Mass.) was then inserted, resulting in reperfusion prior to inflation, and deployed in the mid portion of the vessel at the site of the 100% occlusion. The angiogram performed immediately after removal of the balloon showed diffuse disease throughout the vessel. A 3.0 x 30 mm Integrity stent (Medtronic) was inserted, but was unable to be advanced past the blockage in the proximal portion of the vessel. It was removed, undeployed. A second Runthrough wire was inserted as a buddy wire and another unsuccessful attempt was made to advance the 30mm stent, which 
was again removed, undeployed. A 2.5 x 18 mm Integrity was inserted, but, similarly, it was not able to cross the proximal lesion in the vessel, and so was removed, undeployed. A 2.5 x 15 mm Quantum Maverick balloon (Boston Scientific) was inserted and deployed in the proximal and mid portions of the vessel. Another unsuccessful attempt was made to advance the 18 mm stent, which was again removed, undeployed. The second Runthrough wire was removed and reinserted as a single unit with a 1.25 x 10 mm over-the-wire Sprinter balloon.
Both the balloon and wire were advanced distal to the mid lesion, at which time the Runthrough was exchanged for a 300cm Wiggle wire (Abbott Vascular, Redwood City, Calif.) and the balloon was removed, undeployed. A 2.5 x 15 mm Apex was inserted and deployed in the proximal/mid segment. The 2.5 x 18 mm Integrity stent was again inserted and this time, advanced to the mid/distal portion of the vessel. After pulling the Wiggle wire back, the stent was deployed and the Wiggle wire was readvanced to support the next stent to be delivered. A 3.0 x 18 mm Integrity stent was then inserted and advanced to the proximal/mid portion of the vessel, and deployed after the Wiggle wire was removed. Post stent angiography showed slow flow in the vessel, which was resolved with the administration of approximately 50mcg of nipride, given intra-coronary by the physician, and a possible gap between the stents.
ST-segment elevations persisted. A 2.5 x 15 mm Quantum Maverick balloon was inserted and inflated at the point of the possible gap between the stents, and the wire and balloon were removed for angiography, which showed a definite gap. The Runthrough wire was reinserted and a 2.5 x 14 mm Integrity stent was advanced to the area in the mid vessel between the stents and deployed. Another 200mcg of nipride was administered by the physician. Post procedure angiography showed the return of normal TIMI-3 flow to the entire vessel. The patient was hemodynamically stable, with only mild residual ST-segment elevations. Door-to-reperfusion time on this complex ACS, performed through a 5F system, was 45 minutes.
Question #2: Has your cath lab ever done a carotid stent via the transradial approach?
Case performed by Byron C. Sizemore, MD, Winter Haven Hospital, Winter Haven, Florida.
A patient with a history of right carotid endarterectomy surgery, diagnosed with restenosis by computed tomography (CT) angiogram of 80-90% and by duplex ultrasound of greater than 90%, was admitted for diagnostic carotid angiography with the possibility of stenting. The 
patient was assessed by a neurologist prior to arrival to the cardiac catheterization laboratory. The diagnostic procedure was performed from the right femoral artery approach and confirmed the diagnosis of right internal carotid artery restenosis with a type 3 arch. Due to the type of arch noted, it was decided to perform the intervention through the right radial artery. The vessel was accessed and a 5 French (F) Glidesheath (Terumo Corporation, Somerset, New Jersey) was inserted and then exchanged for a 6F, 90cm 
sheath that was advanced to the subclavian artery just beyond the internal carotid artery. A 5F IM diagnostic catheter (Cordis Corporation, Miami, Fl.) was inserted and advanced over a 0.035” J-wire, which was then exchanged for a 0.035” stiff-angled Glidewire (Terumo), allowing manipulation of both the wire and catheter into the mid common carotid artery. As stenosis was also noted in the right external carotid artery, the wire could not be safely advanced any further than the mid portion of the common. A 6F sheath was advanced over the IM catheter, using telescopic technique to obtain the desired position. After removing the IM catheter and the Glidewire, the system was de-aired 
and bivalirudin (Angiomax, The Medicines Company, Parsippany, New Jersey) was started for anticoagulation. A 6mm Angioguard distal protection device (Cordis) was inserted and deployed distal to the lesion in the right common carotid artery. The vessel was then predilated with a 4 x 30 mm Aviator balloon (Cordis). A 8 x 40 mm Precise self-expanding carotid stent (Cordis) was deployed, after which angiography showed a 20-30% residual stenosis. The stent was postdilated with a 6 mm x 30 mm Aviator balloon and the filter was successfully retrieved. Final angiography showed a 0% residual stenosis, with TIMI-3 flow in the vessel. 
There was no evidence of distal embolization in the final intracranial angiogram and no neurological deficits were noted during or immediately following the procedure. The 6F sheath was removed and the access site was occluded by the use of the TR Band (Terumo). The patient was enrolled in the Cordis SAPPHIRE Worldwide Trial for carotid artery stenting.
(Case) #3: Treatment of a complex chronic total occlusion utilizing laser atherectomy
Case performed by Zaheed Tai, DO, Winter Haven Hospital, Winter Haven, Florida.
A patient who underwent a left heart catheterization and was found to have a chronic total occlusion (CTO) of the right coronary artery (RCA) and a focal high-grade stenosis in the 
proximal left anterior descending artery (LAD) was referred for percutaneous transluminal coronary angioplasty. The right radial artery was accessed and a 6 French (F) Glidesheath (Terumo Corporation, Somerset, New Jersey) was inserted. An Amplatz guide catheter was inserted over a 0.035” J-wire and advanced to the ascending aorta where the RCA was cannulated and initial angiography was performed. Bivalirudin (Angiomax, The Medicines Company, Parsippany, New Jersey) was started for anticoagulation. The lesion in the RCA was crossed 
with an Asahi Fielder wire (Abbott Vascular, Redwood City, Calif.) and a 1.25 x 6 mm over-the-wire balloon. The balloon and wire were then advanced, with some difficulty, into the posterior lateral ventricular (PLV) branch. The Fielder wire was exchanged through the over-the-wire balloon for a Asahi Prowater (Abbott Vascular), which was easily advanced into the PLV branch, at which time the balloon was removed. Laser atherectomy was performed with a 0.9mm excimer laser catheter (Spectranetics, Colorado Springs, Colorado) at the following settings*:
- Train 1: 45 watts at a fluency of 40 was unsuccessful.
- Train 2: 45 watts at a fluency of 60 was unsuccessful.
- Train 3: 60 watts at a fluency of 60 was unsuccessful.
- Train 4: 80 watts at a fluency of 80 was successful.
but a dissection in the distal portion of the RCA was seen. It extended to the bifurcation of the PLV and posterior descending artery (PDA) branches, resulting in suboptimal flow in both. Balloon angioplasty of the mid/distal RCA was performed with a 2.0 mm x 20 mm balloon. The PDA branch was then wired with a Runthrough 0.014” wire (Terumo). Balloon angioplasty of the distal RCA and proximal PDA was performed again, with the 2.0 x 20 mm balloon. An Endeavor 2.5 x 30 mm stent (Medtronic, Minneapolis, Minn.) was inserted into the PLV 
branch, as it appeared to be the larger of the vessels by angiography. The Runthrough wire was removed from the PDA branch and the Endeavor stent was deployed successfully. After removal of the stent delivery system, the Asahi Fielder wire was then reinserted and advanced into the PDA branch. Balloon angioplasty was once again performed in the ostial portion of the vessel, with the 2.0 x 20 mm balloon. Post angiography showed improved flow to both of the distal vessels, with a small dissection distal to the PLV stent. An Atom 2.25 x 8 mm balloon (Boston Scientific, Natick, Mass.) was inserted and deployed distal to the PLV stent to treat the dissection. Post dilation of all vessels was performed. A 2.5 x 15 mm Quantum Maverick balloon (Boston Scientific) was inflated to 20 atm in the mid and distal portions of the RCA. 
Kissing balloon angioplasty was performed, with 2.0 x 12 mm in the PDA and 2.5 x 15 mm in the PLV. Both Apex balloons (Boston Scientific) were inflated to 8 atm. Post procedural angiography showed TIMI flow to all vessels, with no evidence of dissection, perforation, embolization, or residual stenosis. The patient was noted to be in an atrial fibrillation rhythm that was not noted prior to the procedure.
Reference
- Bilodeau L, Fretz EB, Taeymans Y, et al. Novel use of a high-energy excimer laser catheter for calcified and complex coronary artery lesions. Catheter Cardiovasc Interv 2004 Jun;62(2):155-161.
