Successful Use of an Extra-Long Hydrophilic-Coated Sheath in Enlarged Aorta to Overcome Extreme Tortuosity of Right Subclavian Artery Via Transradial Approach During Coronary Angiography

Coronary angiography and revascularization procedures can be performed by the transradial approach (TRA) in most cases,^1–3 as this route is associated with lower rates of bleeding complications versus the transfemoral approach (TFA).^4,5 The main limitations of this approach are the learning curve, arterial spasm, anatomic abnormalities, tortuosity and loops of the radial artery itself or of the right subclavian artery (RSA).⁶ We describe the successful use of an extra-long hydrophilic-coated sheath for coronary angiography via the TRA in a case of severely dilated ascending aorta in a patient with severe tortuosity of the RSA.

Case Report. A 59-year-old woman had been previously admitted to another hospital with acute pulmonary edema. She had a history of severe enlargement of the ascending aorta with moderate aortic regurgitation. The most recently performed echocardiogram showed no evidence of left ventricular dilation. Left ventricular function was normal, with ejection fraction of 60%. A severe enlargement (measuring > 6 cm) of the ascending aorta with moderate aortic regurgitation was observed. A computed tomography scan confirmed the enlargement of the ascending aorta measuring 6.4 cm in greatest diameter. After treatment with intravenous diuretics, nitrates and continuous positive airway pressure ventilation achieving significant clinical improvement, cardiac surgery was scheduled and the patient was transferred to our cardiac center to undergo coronary angiography. We performed the procedure through the right radial artery approach. After insertion of a 6 French (Fr) hydrophilic 10 cm-long radial sheath (Glidesheath, Terumo, Tokyo, Japan), a very severe tortuosity of RSA was encountered (Figure 1) and we were unable to selectively cannulate the right and left coronary arteries with any of the conventional diagnostic and guide catheters of varying sizes and shapes, not even using a very stiff 0.035" guidewire (Hy-torque Supracore, Abbott, Santa Clara, California). An aortogram was then performed and confirmed the severe dilatation of the ascending aorta with moderate to severe aortic regurgitation (Figure 2). At this point, the short sheath was removed and a 6 Fr, 90 cm, hydrophilic-coated sheath (Pinnacle Destination, Terumo) was inserted and advanced to reach the ascending aorta (Figure 3). We thus were able to easily cannulate the right and left coronary arteries with a JR-4 catheter and an AL-3 catheter (Figure 4); the coronary arteries were noted to be free from disease. At the end of the procedure, the sheath was easily removed and no complications occurred. The patient was transferred the day after to the cardiac surgery department while asymptomatic with normal radial pulse and underwent a successful aortic root/ascending aorta/aortic valve replacement.

Discussion. In recent years, the TRA has gained widespread acceptance among interventional cardiologists after Campeau performed the first cardiac catheterization in 19897 and after the first successful transradial PCI performed by Kiemeneij in 1993.⁸ However, technical failure has been reported in up to 5% of cases even when procedures are performed by skilled operators.⁹ After a steep learning curve, the main reasons for failure are represented by anatomic abnormalities of upper limb arteries and of RSA.⁵ Valsecchi et al reported in a series of 2,211 consecutive patients undergoing PCI via TRA an anatomic abnormality rate of 22.8% with a significantly lower success rate in this group (93.1% versus 98.8% in patients not presenting with any abnormality; p 10 The incidence of vessel tortuosity usually rises with increasing age.^11–13 The use of hydrophilic-coated catheters or TRA via the left radial artery¹⁵ has been proposed to overcome these technical challenges. On the other hand, in the presence of a severely dilated ascending aorta, selective coronary cannulation is technically challenging and sometimes impossible even via the TFA. Telescopic techniques for selective coronary cannulation have been reported to successfully overcome these technical difficulties.^16,17 In the case discussed in this paper, we had to deal not only with a very enlarged ascending aorta, but also with the extreme tortuosity of the RSA, which made catheter advancement and manipulation quite impossible, even with the support of a very stiff guidewire. Only the insertion of a very long sheath enabled us to successfully select the coronary ostia. The Pinnacle Destination is an extra-long hydrophilic sheath designed for peripheral interventional procedures via the TFA. The use of this device via the TRA has been described in some cases of peripheral interventions,^18,19 but to our knowledge, this is the first report of its use for coronary angiography. In our opinion, it is a safe and easy-to-use device and we believe it may be profitably used in cases of extreme tortuosity of the RSA either for coronary angiography or to increase guide support in transradial PCI.

References

1. Kiemeneij F, Laarman GJ, de Melker E. Transradial artery coronary angioplasty. Am Heart J 1995;129:1–8.
2. Kiemeneij F, Laarman GJ. Percutaneous transradial artery approach foro coronary Palmatz-Schatz stent implantation. Am Heart J 1994;129:167–174.
3. Ochiai M, Isshiki T, Toyoizumi H, et al. Efficacy of transradial primary stenting in patients with acute myocardial infarction. Am J Cardiol 1999;83:966–968.
4. Mann T, Cubeddu G, Bowen J, et al. Stenting in acute coronary syndromes: A comparison of radial versus femoral access sites. J Am Coll Cardiol 1998;32:572–576.
5. Mann T, Cowper PA, Peterson ED, et al. Transradial coronary stenting: Comparison with femoral access closed with an arterial suture device. Cathet Cardiovasc Interv 2000;49:150–156.
6. Amoroso G, Laarman GJ, Kimeneij F. Overview of the transradial approach in percutaneous coronary intervention. J Cardiovasc Med 2007;8:230–237.
7. Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn 1989;16:3–7.
8. Kiemeneij F, Laarman GJ. Percutaneous transradial artery approach for coronary stent implantation. Cathet Cardiovasc Diagn 1993;30:173–178.
9. Kiemeneij F, Laarman GJ, Odekerken D, et al. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: The Access study. J Am Coll Cardiol 1997;29:1269–1275.
10. Valsecchi O, Vassileva A, Musumeci G, et al. Failure of transradial approach during coronary interventions: Anatomic considerations. Cathet Cardiovasc Interv 2006;67:870–878.
11. Dobrin PB, Schwarcz TH, Baker WH. Mechanism of arterial and aneurismal tortuosity. Surgery 1988;104:568–571.
12. Dobrin PB, Schwarcz TH, Mrkvicka R. Logitudinal retractive force in pressurized dog and human arteries. J Surg Res 1990;48:116–120.
13. Wenn CM, Newmann DL. Arterial tortuosity. Aus Phys Eng Sci Med 1990;13:67–70.
14. Barbeau GR. Radial loop and extreme vessel tortuosity in the transradial approach: Advantage of hydrophilic-coated guidewires and catheters. Cathet Cardiovasc Interv 2003;59:442–450.
15. Kawashima O, Endoh N, Masayoshi T, et al. Effectiveness of right or left radial approach for coronary angiography. Cathet Cardiovasc Interv 2004;61:333–337.
16. Geijer H, Kahari A. Coaxial technique for catheterization of the coronary arteries with a very dilated ascending aorta. Cathet Cardiovasc Interv 2004;62:32–34.
17. Rigatelli G, Giordan M, Mantovani R, et al. Telescopic technique for selective coronary angiography in severely dilated ascending aorta. Cathet Cardiovasc Interv 2007;69:1078–1079.
18. Sanghvi K, Kurian D, Coppola J. Transradial intervention of iliac and superficial femoral artery disease is feasible. J Interv Cardiol 2008;21:385–387.
19. Staniloae CS, Kurian DC, Coppola J. Transradial bilateral iliac stenting. J Invasive Cardiol 2006;18:E256–E257.