Transradial Unprotected Left Main PCI With Use of the Impella
Disclosure: Orlando Marrero reports no conflicts of interest regarding the content herein. Dr. Zaheed Tai reports the following: Terumo (proctor for transradial course), Spectranetics (proctor for laser course, speaker, advisory board), Medicines Company (speakers bureau).
Orlando Marrero can be contacted at orlm8597@yahoo.com. Dr. Zaheed Tai can be contacted at zaheedtai@gmail.com.
Q: What approach do you use when the case requires mechanical support?
A: We will still use the radial approach for the intervention with femoral access for the support device (Impella [Abiomed] or an intra-aortic balloon pump [IABP]), although there has been use of these devices via an upper extremity approach. Following is the case of an unprotected left main (LM) intervention via the radial approach with femoral access for an Impella device.
Case
This case features a 90-year-old gentleman with a history of coronary artery disease with previous heart catheterization in 2012 with a proximal left anterior descending (LAD) coronary artery chronic total occlusion (CTO) filling via right to left collaterals, pulmonary fibrosis, osteoarthritis, hyperlipidemia, gastroesophageal reflux disease, bladder cancer, and aortic insufficiency. He presented to the hospital with angina-type chest discomfort and underwent diagnostic angiography on 06/04/2014, which demonstrated the known CTO of the LAD as previously described, distal left main ostial circumflex disease that is progressive from 2012, and distal right coronary artery (RCA) disease proximal to the branch that supplies a functional collateral to the LAD via an epicardial. Given his anatomy, a brief discussion ensued with regards to potential options and limitations. The patient did not want surgical consideration (nor would he have been a good candidate, given his age and co-morbidities), therefore, he presented for percutaenous revascularization. Given the myocardium at risk and intended targets (distal RCA and LM), percutaneous coronary intervention (PCI) was performed with the Impella left ventricular assist device.
The right radial artery was prepped and draped and accessed with a Terumo Slender sheath (5 French [Fr] outer diameter, 6 Fr inner diameter). We upsized to a 7 French sheath and an
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Bivalirudin was administered and a Runthrough (Terumo) wire was passed distally into the right coronary artery and into the posterior left ventricular artery (PLV). The PLV bifurcates, and in the larger, more proximal branch, we placed a Fielder wire (Abbott Vascular/Asahi) and in the distal branch, we placed the Runthrough wire to try and preserve it (Figure 3). A 2.0 x 12 mm Emerge balloon (Boston Scientific) was easily advanced and we were able to predilate the lesion. We then tried to advance a 2.5 x 10 mm AngioSculpt scoring balloon catheter (AngioScore), but were
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Discussion
A major advantage of the transradial approach is significant reduction in vascular access complications compared with the femoral approach.1,2 Post procedure bleeding is most commonly related to the vascular access site and is an independent predictor of short- and long-term morbidity and mortality.3,4 Despite the benefits of transradial intervention, there has been apprehension about utilizing this approach in complex cases, although there are reports of its
References
- Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: A report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv. 2008; 1: 379–386.
- Jolly SS, Amlani S, Hamon M, et al. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischaemic events: A systematic review and meta-analysis of randomized trials. Am Heart J. 2009; 157: 132-140.
- Manoukian SV, Feit F, Mehran R, et al. Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes. J Am Coll Cardiol. 2007; 49: 1362-1388.
- Chase AJ, Fretz EB, Warburton WP, et al. Association of the arterial access site at angioplasty with transfusion and mortality: the M.O.R.T.A.L study (Mortality benefit Of Reduced Transfusion after percutaneous coronary intervention via the Arm or Leg). Heart. 2008;94:1019–1025.
- Yang YJ, Kandzari DE, Gao Z, et al. Transradial versus transfemoral method of percutaneous coronary revascularization for unprotected left main coronary artery disease: Comparison of procedural and late-term outcomes. JACC Cardiovasc Interv. 2010; 3: 1035-1042.
- Rathore S, Hakeem A, Pauriah M, et al. A comparison of the transradial and the transfemoral approach in chronic total occlusion percutaneous coronary intervention. Catheter Cardiovasc Interv. 2009; 73: 883-887.
- Lo TSN, Hall IR, Jaumdally R, et al. Transradial rescue angioplasty for failed thrombolysis in acute myocardial infarction: reperfusion with reduced vascular risk. Heart. 2006; 9: 1153-1154.
- Minden HH, Lehmann H, Meyhofer J, et al. Transradial unprotected left main coronary stenting supported by percutaneous Impella Recover LP 2.5 assist device. Clin Res Cardiol. 2006; 95: 301-306.
- Burzotta F, Trani C, Coroleu S. Retrograde recanalization of left main from saphenous vein graft supported by percutaneous Impella Recover LP 2.5 assist device. J Invasive Cardiol. 2009; 21: E147-E150.