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 Amplatz left (AL)1 guide was used to engage the right coronary system and an Extra Back Up (EBU) 3.5 guide was used to engage the left coronary system during the intervention. Following radial access, the right groin was accessed with a micropuncture kit. A 4 French sheath was inserted, then upsized to a 6 French, and eventually, an 8 French sheath, prior to insertion of the Impella device and sheath. The multipurpose catheter and 0.035-inch wire were used to get into the left ventricle and then exchanged out for the Impella device, which was positioned (Figure 1). Once the Impella was positioned and flow was started, intervention was begun (Figure 2).

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 unsuccessful. We predilated with a 2.5 x 15 Emerge balloon, advanced the 2.5 x 10 mm AngioSculpt, and predilated the distal lesion. We then were able to advance a 2.5 x 26 mm Integrity bare-metal stent (Medtronic). The wire was removed from the distal PLV branch, and the stent was deployed and overlapped more proximally with a 2.75 x 12 mm Integrity stent, post-dilated with high pressure at the overlap. Final angiography revealed TIMI-3 flow without dissection, perforation, or embolization (Figure 4). Intracoronary nitroglycerin was administered. The wire was removed and orthogonal views were obtained. The patient still had some mild, diffuse disease in the mid-RCA (Figure 5), but given his advanced age, the plan was to treat the most critical lesion, as well as the area that had progressed the most from 2012; therefore, we focused on the distal RCA bed (Figure 5). Angiography demonstrated TIMI-3 flow without dissection, perforation, or embolization, and brisk filling of epicardial collaterals to the LAD (Figure 6). We exchanged out for a 7 French EBU 3.5 guide to engage the left main system (Figure 7). Using an over-the-wire balloon and Runthrough wire, we were able to cross distally and change for a Rotowire (Boston Scientific). Rotational atherectomy was performed with a 1.25 mm burr, with a final polishing run (Figure 8). We advanced the Runthrough wire distally, and removed the burr and Rotowire (Figure 9). We then predilated with a 2.5 x 10 mm AngioSculpt at 20 atmospheres. Intravascular ultrasound (IVUS) was performed and demonstrated that the ostial circumflex was about 3.5 mm and the distal left main was about 4.0 mm. A 3.5 x 10 mm AngioSculpt was used to predilate that lesion as well and then a 3.5 x 15 mm Integrity bare-metal stent (Medtronic) was placed, crossing from the distal left main and the circumflex (Figure 10). We post-dilated with a 4.0 x 8 mm Quantum at high pressure. Final IVUS demonstrated good stent appostition and sizing. When we pulled the wire back, there was a lesion in the circumflex that was about 60% or so. We had assessed it to some degree in 2012 and since then, it had not progressed significantly by angiographic appearance. The fractional flow reserve 2 years ago was above 0.80 when we had evaluated the left main to circumflex into the obtuse marginal, therefore, again, given the patient’s advanced age, the plan was to stick to the most critical lesions. The patient tolerated the procedure well. The wire was removed and orthogonal views were obtained, revealing TIMI-3 flow without dissection, perforation, or embolization. The guide was removed and a TR Band (Terumo) placed over the radial artery. The Impella was weaned down and removed.  Given the patient’s advanced age, bare-metal stents were utilized despite the anatomy. He was placed on dual antiplatelet therapy for a minimum of 30 days, ideally longer if feasible.

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 utility in this subset.^5,6 There is also a sense that there is very little utility or benefit to the radial approach in a patient that will require lower extremity access. Avoiding bilateral femoral access does reduce the potential risk for access site bleeding and complications. Lo et al have demonstrated the safety and efficacy of this approach in conjunction with transfemoral IABP in patients with failed thrombolysis.⁷ In addition, there are case reports of using the Impella with radial access in complex lesion subsets.^8,9 The ability to combine the radial access with mechanical support may expand operators’ treatment options. Patients may have peripheral arterial disease, limiting bilateral access, as well as other issues. In addition, complex lesion PCI may result in intra-procedural decompensation, requiring additional support. Utilization of dual access (radial and the femoral) avoids concerns about increased bleeding risk with dual femoral access. 

References

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.