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Clinical Images

Recannulation of Distal Radial Artery for Staged Procedure After Successful Primary Percutaneous Coronary Intervention

Yongcheol Kim, MD1;  Myung Ho Jeong, MD, PhD1;  Kirill Berezhnoi, MD2,3;  Sang Yeub Lee, MD, PhD4,5;  Min Chul Kim, MD, PhD1;  Doo Sun Sim, MD, PhD1;  Young Joon Hong, MD, PhD1;  Ju Han Kim, MD, PhD1; Youngkeun Ahn, MD, PhD1

October 2018

J INVASIVE CARDIOL 2018;30(10):E105-E106.

Key words: acute coronary syndrome, cardiac imaging, myocardial infarction, radial artery 


A 76-year-old man presented with sudden-onset chest pain at rest and evidence of ST-segment elevation in the anterior electrocardiogram leads. After loading of aspirin 300 mg and ticagrelor 180 mg, urgent coronary angiography (CAG) was performed via left distal radial artery (the so-called snuffbox approach), which was successfully cannulated by 6 Fr sheath with administration of 3000 U unfractionated heparin via sheath. CAG demonstrated the severe stenosis in the proximal left anterior descending artery (LAD) with flow limitation (Figure 1A). Primary percutaneous coronary intervention (PCI) was successfully performed with a 2.5 x 18 mm everolimus-eluting stent (EES) after intracoronary bolus of abciximab (Figure 1B). Regarding the diffuse intermediate stenosis in mid-LAD and mid right coronary artery (RCA) (Figures 1B and 1C), we planned staged fractional flow reserve (FFR)-guided complete revascularization. Hemostasis was successfully obtained by compressive bandage with gauze for 3 hours (Figure 1E). 

FIGURE 1. (A) Urgent coronary angiography demonstrating the severe stenosis in the proximal left anterior descending artery (LAD) with TIMI 1 flow. (B) Coronary angiography on index procedure demonstrating successful percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation and intermediate stenosis in mid-LAD, fractional flow reserve (FFR) value of 0.74 on hyperemia. (C) Angiographic assessment of the right coronary artery (RCA) demonstrating diffuse intermediate stenosis in mid-RCA with the hyperemic FFR value of 0.88. (D) Successful FFR-guided PCI with DES implantation in the mid-LAD.

Three days later, vascular ultrasonography demonstrated patent left distal radial artery (Figure 1F). Therefore, coronary catheterization was performed again via left snuffbox approach (Figure 1G). During hyperemia, the FFR measurement was 0.88 in the mid-RCA and 0.74 in the mid-LAD and it led to another 2.5 x 38 mm EES implantation in the mid-LAD. Final CAG showed good distal flow without residual stenosis (Figure 1D). There was no puncture-site bleeding after hemostasis for 3 hours (Figure 1H).

FIGURE 1. (continued) (E) No puncture-site complication after primary PCI via left distal radial artery approach (white circle). (F) Vascular sonography demonstrating patent left distal radial artery before staged FFR-guided PCI (asterisk: first dorsal interosseous muscle). (G) Inserted 6 Fr sheath via left snuffbox approach on the staged PCI (arrow: first puncture site for primary PCI). (H) Two puncture sites (white circle, upper panel) on the day after staged PCI, first puncture site for primary PCI (arrow, lower panel), and second puncture site for staged PCI (arrowhead, lower panel).

There are limited data regarding snuffbox approach, even though it has been interesting for the interventional cardiologists. Our experience highlights the feasibility of the snuffbox approach as the access route for primary PCI and recannulation of distal radial artery for staged PCI.


From the 1Division of Cardiology, Chonnam National University Hospital, Gwangju, Korea; 2Division of Interventional Cardiology, City Clinical Hospital No 52, Moscow, Russia; 3Division of radiology, Sechenov First Moscow State Medical University, Moscow, Russia; 4Chungbuk Regional Cardiovascular Center, Chungbuk National University Hospital, Cheongju, Korea; and 5Division of Cardiology, Department of Internal Medicine, Chungbuk National University, College of Medicine, Cheongju, Korea

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted July 23, 2018. 

Address for correspondence: Myung Ho Jeong, MD, PhD, Cardiovascular Convergence Research Center of Chonnam National University Hospital, Gwangju 501-757, Republic of Korea. Email: myungho@chollian.net


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