Balloon assessment of patent foramen ovale morphology and the modification of tunnels using a balloon detunnelisation technique

Background: Percutaneous coronary intervention (PCI) using a guiding catheter with small diameters may have a favorable impact on vascular access complications and patient morbidity. Here, we report the initial results of PCI using a 4‐Fr coronary accessor. Methods: A total of 31 patients underwent 4‐Fr PCI. Exclusion criteria for 4‐Fr PCI were (1) lesions associated with large side branches requiring wire protection or kissing balloon technique and (2) planned use of angioplasty devices which were not compatible with 4‐Fr catheter. Results: A total of 36 lesions, including 4 chronic total occlusions (CTO), were treated. Access sites included radial artery in 19 patients (61%), brachial artery in 8 (26%), and femoral artery in 4 (13%). Four‐Fr PCI was successful in 34 of 36 lesions (94%) in 29 of 31 patients (94%). One of the two unsuccessful patients was a case of CTO, and the other a case of tortuous right coronary artery. In both, crossover to a 6‐Fr PCI was necessary. Among successfully treated 34 lesions of the 29 patients, coronary stents were deployed in 30 lesions (88%). There were no stent dislodgements or inadequate contrast opacification. No access‐site related complications including radial artery occlusion were observed. Conclusions: PCI with a 4‐Fr coronary accessor is a viable alternative to the use of larger guide catheters. The advent of 4‐Fr stent delivery system may afford a less invasive approach for the treatment of patients with coronary artery disease. © 2008 Wiley‐Liss, Inc.     

Percutaneous coronary intervention using a virtual 3‐Fr guiding catheter

Background : We have recently reported a novel percutaneous coronary intervention (PCI) system using a hydrophilic‐coated sheathless guiding catheter (Virtual 3‐Fr, Medikit, Tokyo, Japan), which provides us with less invasive angioplasty and a puncture site injury equivalent to a conventional 3‐Fr introducer sheath. Here, we report the initial results of PCI using this novel system. Methods : A total of 36 coronary artery lesions of 27 patients were treated by using a virtual 3‐Fr PCI system. Procedural outcomes of virtual 3‐Fr PCI were retrospectively evaluated. Results : The mean age was 73.0 ± 8.7 years (range, 46–84 years), and 15 were men (56%). Access sites included the radial artery in 18 patients (67%), the brachial artery in eight patients (30%), and the femoral artery in 1 patients (4%). Among 36 lesions, seven were chronic total occlusions, and a virtual 3‐Fr PCI was successful in 33 lesions (92%). Among the successfully treated 33 lesions, coronary stents were deployed in 32 (97%), and intravascular ultrasound examination was performed in 19 (58%). Hemostasis was achieved immediately after PCIs in all cases. No access‐site related complications including radial artery occlusion were observed. Conclusions : The performance of a virtual 3‐Fr PCI system appears to be comparable to one using a regular 5‐Fr guiding catheter while the puncture‐site damage remains equivalent to that of a 3‐Fr introducer sheath. Virtual 3‐Fr PCI may have a potential to serve as a minimally invasive strategy for the treatment of coronary artery diseases. © 2010 Wiley‐Liss, Inc.     

Surgical retrieval of dislodged stent during transradial coronary intervention

Coronary stent dislodgment is a rare but serious complication during percutaneous coronary intervention. During transradial coronary intervention, retrieval of a dislodged and deformed stent into the guiding catheter is difficult or impossible, since a small 6 Fr guiding catheter and sheath system is commonly used. I describe a new method to retrieve a dislodged and damaged stent during transradial coronary intervention. When a dislodged and unexpanded stent is not pulled back completely into the guiding catheter, the damaged stent and guiding catheter can be withdrawn together into the radial artery and retrieved successfully by radial artery cutdown and repair method.     

Feasibility of complex coronary and peripheral interventions by trans‐radial approach using large sheaths

Background : Trans‐radial approach (TRA) reduces vascular access‐site complications but has some technical limitations. Usually, TRA procedures are performed using 5 Fr or 6 Fr sheaths, whereas complex interventions requiring larger sheaths are approached by trans‐femoral access. Methods : During 4 years, at two Institutions with high TRA use, we have attempted to perform selected complex coronary or peripheral interventions by TRA using sheaths larger than 6 Fr. Clinical and procedural data were prospectively collected. Attempt to place a 7 Fr or 8 Fr sheath (according to the planned strategy of the procedure) was performed after 5–6 Fr sheath insertion, administration of intra‐arterial nitrates and radial artery angiography. Late (>3 months) patency of the radial artery was checked (by angiography in the case of repeated procedures or by palpation + reverse Allen test). Results : We collected 60 patients in which TRA large sheath insertion was attempted. The large sheath (87% 7 Fr, 13% 8 Fr) was successfully placed in all cases. Most of the procedures were complex coronary interventions (bifurcated or highly thrombotic or calcific chronic total occlusive lesions), whereas 8.3% were carotid interventions. Procedural success rate was 98.3% (1 failure to reopen a chronic total occlusion). No access‐site related complication occurred. In 57 (95%) patients, late radial artery patency was assessed and showed patency in 90% of the cases, the remaining patients having asymptomatic collateralized occlusion. Conclusions : In selected patients, complex percutaneous interventions requiring 7–8 Fr sheaths can be successfully performed by RA approach without access‐site clinical consequences. © 2011 Wiley Periodicals, Inc.     

Entrapment of a kinked catheter in the radial artery during transradial coronary angiography

The transradial approach is currently popular for vascular access during percutaneous coronary angiography and intervention. Catheter kinking during catheter manipulation is not uncommon, but mostly the kinked catheter can be unraveled by gentle rotation of catheter in the opposite direction. We describe a case in which the diagnostic catheter was kinked and entrapped in the small radial artery during transradial angiography. Attempts to withdraw or to unravel the catheter with gentle rotation were unsuccessful. We were able to catch the catheter tip with a 6 Fr Amplatz goose-neck snare kit (ev3, Inc.) guided by an 8 Fr guiding catheter via right femoral approach. We pulled the kinked catheter up into the brachial artery with large diameter where successful unraveling was possible, allowing for its successful removal through the radial sheath.     

Anatomical consideration of the radial artery for transradial coronary procedures: arterial diameter, branching anomaly and vessel tortuosity

BACKGROUND: The radial artery is currently regarded as a useful vascular access site for coronary procedures. Adequate anatomical information of the radial artery should be helpful in performing the transradial coronary procedure. Therefore, we tried to evaluate the size of radial artery, the incidence and clinical significance of anomalous branching patterns and tortuosity of the radial artery related with transradial coronary procedure. MATERIALS AND METHOD: In 1191 cases, mean radial arterial diameter (RAD) was measured before and after the procedure using a two-dimensional ultrasound and retrograde radial artery angiography was performed before the transradial coronary procedure in all patients. Branching anomaly, tortuosity of the radial artery and procedural characteristics including procedure times and local vascular complications were analyzed. RESULTS: The mean RAD was 2.60 +/- 0.41 mm by two-dimensional ultrasound: 2.69 +/- 0.40 mm in men and 2.43 +/- 0.38 mm in women (p < 0.001). Radial artery occlusion occurred in 0.6% in coronary angiography and 1.4% in coronary intervention. In multivariate analysis, coronary intervention was significantly related to the radial artery occlusion (p = 0.048). Anomalous branching of upper extremity artery was found in 38 cases (3.2%); high origin of the radial artery was most frequent in 28 cases (2.4%). Tortuosity of radial and brachial artery was found in 67 of 50 cases (4.2%). Most common forms of tortuosity were S-shape in 21 cases (31.3%) and Omega-shape in 21 cases (31.3%). And most common site of radial artery tortuosity was proximal third of antecubital fossa (35 cases, 52.2%). Prolonged procedure times and cross-overs to other arteries were related with tortuosity of the radial artery, but not with anomalous branching. CONCLUSION: In our study, radial artery diameter was larger than the outer diameter of 5Fr sheath in 82.7% for transradial coronary procedure. Radial artery occlusion was associated with coronary intervention using larger size sheath than diagnostic angiography using 5Fr sheath. The incidence in branching anomaly and tortuosity of radial artery was not rare in our study. Radial artery tortuosity was associated with old age and prolonged procedure time.     

Bleeding complications in patients with acute coronary syndrome undergoing early invasive management can be reduced with radial access, smaller sheath sizes, and timely sheath removal.

OBJECTIVES: Our objective was to analyze the impact of arterial access site, sheath size, timing of sheath removal, and use of access site closure devices on high-risk patients with acute coronary syndromes (ACS). BACKGROUND: In the SYNERGY trial, 9,978 patients with ACS were randomly assigned to receive enoxaparin or unfractionated heparin. METHODS: This analysis includes 9,404 patients for whom sheath access information was obtained for the first PCI procedure or diagnostic catheterization. Comparisons of baseline, angiographic, and procedural characteristics were carried out according to access site and sheath size. RESULTS: Overall, 9,404 (94%) patients underwent angiography at a median of 21 hr (25th and 75th percentiles: 5, 42) and 4,687 (50%) underwent PCI at a median of 23 hr (6,49) of enrollment. The access site was femoral for 94.9% of cases, radial for 4.4%, and brachial for 0.7%. Radial access was associated with fewer transfusions than femoral access (0.9% vs. 4.8%, P=0.007). For femoral access, the rates of noncoronary artery bypass grafting (CABG)-related TIMI major bleeding by sheath size was 1.5% for 4 or 5 French (Fr), 1.6% for 6 Fr, 3.3% for 7 Fr, and 3.8% for >or=8 Fr (P<0.0001). After adjustment for baseline characteristics, femoral access site, larger sheath size, and delayed sheath removal were independent predictors of need for transfusion. CONCLUSIONS: Smaller sheaths, radial access, and timely sheath removal may mitigate the bleeding risk associated with potent antithrombotic/platelet therapy and early catheterization.     

Successful retrieval of a coronary stent dislodged in the brachial artery by means of improvised snare and guiding catheter

This is a case report regarding the retrieval, by means of an improvised snare and guiding catheter, of a stent dislodged in the brachial artery during a transradial coronary intervention. A full-length guiding catheter could not be used to approach the lost stent, which was a mere 30 to 35 cm away from the sheath insertion site at the radial artery, and a commercial snare was not available at the time. Thus, we had to improvise a shortened guiding catheter and a snare, which was formed by folding an angioplasty Whisper guide wire (Abbott Laboratories, Abbott Park, IL) and was used successfully to snare the stent and retrieve it.     

经桡动脉普通导引导管7F无鞘技术治疗冠状动脉复杂病变

目的 评价经桡动脉普通导引导管7F无鞘技术治疗冠状动脉复杂病变的安全性、可行性.方法 纳入2013年11月至2014年4月,经桡/尺动脉置入6F桡动脉鞘造影后,需要用7F导引导管行介入治疗的患者31例.在桡动脉鞘内置入长260 cm,直径0.036 in（1 in=2.54 cm）非亲水涂层导丝至升主动脉;撤出桡动脉鞘,将6 F 110 cm猪尾管插入7 F 100 cm导引导管内,猪尾管头端突出于导引导管外;将猪尾管和导引导管呈一体,穿入长260 cm,直径0.036 in导引导丝,通过皮肤切口逐次进入桡动脉,导引导管到位后撤出猪尾管.结果 31例导引导管均成功通过桡动脉,到达靶冠状动脉开口,完成介入治疗后撤出导引导管.术后观察24 h,所有患者桡动脉穿刺处无出血,穿刺侧上肢未发生血肿、感觉障碍.术后1个月随访,未发生桡动脉闭塞.结论 经桡动脉普通导引导管7F无鞘技术是治疗冠状动脉复杂病变可选用的相对安全、有效的途径.     

Successful thrombus removal using 6Fr hydrolyser thrombectomy catheter in acute myocardial infarction via radial artery

The 6Fr Hydrolyser thrombectomy catheter for acute myocardial infarction (AMI) successfully removed a massive thrombus in the coronary artery in three patients. The 6Fr Hydrolyser catheter could be advanced into the right coronary artery with bare-wire methods via a 6Fr sheath at the radial artery. This approach suggests that the device can be an alternative method for thrombolysis in selected AMI patients with massive thrombus in the coronary artery.     

Use of the sheathless guide catheter during routine transradial percutaneous coronary intervention: A feasibility study

Objective : The aim of this study is to investigate the feasibility of using a 6.5 Fr sheathless guide catheter as a default system in transradial (TRA) percutaneous coronary intervention (PCI). Background : TRA PCI has been shown to reduce mortality rates through a reduction in access site related bleeding complications compared with procedures performed though a femoral approach. Complications associated with the TRA route increase with the size of sheath used. These complications may be reduced by the use of a sheathless guide catheter system (Asahi Intecc, Japan) that is 1–2 Fr sizes smaller in diameter than the corresponding introducer sheath. Methods : We performed PCI in 100 consecutive cases using 6.5 Fr sheathless guides to determine the procedural success, rates of symptomatic radial spasm and radial occlusion. Results : Procedural success using the 6.5 Fr sheathless guide catheter system was 100% with no cases requiring conversion to a conventional guide and catheter system. There were no procedural complications recorded associated with the use of the catheter. Adjunctive devices used in this cohort included IVUS, stent delivery catheters, distal protection devices, and simple thrombectomy catheters. The rate of radial spasm was 5% and the rate of radial occlusion at 2 months was 2%. Conclusion : Use of the 6.5 Fr sheathless guide catheter system, which has an outer diameter <5 Fr sheath, as the default system in routine PCI is feasible with a high rate of procedural success via the radial artery. © 2009 Wiley‐Liss, Inc.     

Radial access - be prepared!

We present the case of a 46-year-old female patient that experienced recurrent stent thrombosis and underwent attempted primary PCI via the radial artery. Although radial artery cannulation with a 6 Fr sheath and the diagnostic angiography were successfully performed, the PCI could not be achieved because of failure to advance the 6 Fr guide through the radial artery, due to severe angulation of a high take-off radial artery, combined with a proximal radial artery stenosis.     

Management of Coronary Restenosis via the Radial Artery: An Elegant Approach to the AchillesÕ Heel of PTCA

In spite of many efforts, the most effective treatment for restenosis after coronary angioplasty remains repeat angioplasty. Although the second procedure is known to be at lower risk, it is usually performed by the same technique, thus requiring hospitalization. In such a group of patients, the feasibility of using the radial route for repeat coronary angiography and angioplasty when needed and the safety of early discharge were evaluated prospectively. Coronary angiography via the radial artery was attempted in 51 patients referred within 6 months of initial coronary angioplasty with the clinical suspicion of restenosis. Successful cannulation of the radial artery was possible in 48 (94%). Following placement of a 4 Fr arterial sheath, coronary angiography was completed successfully in all but one patient. Restenosis was confirmed angiographically in 25 patients (one via the femoral route) and a new lesion was observed in 3. Repeat angioplasty was attempted via the radial route (25 patients) or via the femoral route (one patient) using a fixed-wire balloon catheter through the 4 Fr diagnostic catheter (n=22). Angioplasty via the radial route including elective stent implantation (5 patients) was a technical success in 92% of the patients. Immediate arterial sheath withdrawal and mechanical compression of the radial artery provided satisfactory hemostasis after 186 +/- 126 minutes. The radial pulse was absent post-procedure without clinical consequence in 3 patients (6%). Of the 46 patients without a femoral artery puncture, 39 (85%) were discharged the same day without any cardiac or local complications. Thus, early discharge after repeat coronary angiography and angioplasty for restenosis is feasible and safe using the transradial route in the majority of patients.     

Supported percutaneous coronary intervention using a novel 6‐Fr intra‐aortic balloon pump catheter via the brachial artery in a nonagenarian patient with an abdominal aortic aneurysm

Intra‐aortic balloon pump (IABP) counterpulsation is a useful hemodynamic assist device during complex percutaneous coronary intervention (PCI) in patients with poor left ventricular function; however, the presence of an abdominal aortic aneurysm poses a problem, because insertion via the femoral artery may cause distal embolism and aneurysm rupture. A 92‐year‐old man with unstable angina was admitted to our hospital. Coronary angiography revealed chronic total occlusion of the proximal left anterior descending artery and severe stenosis of the left circumflex artery (LCX). The left ventricular ejection fraction was 36%. He also had an infrarenal abdominal aortic aneurysm with a diameter of 55 mm. Supported PCI was performed for the management of the LCX lesion. A novel 6‐Fr IABP catheter was inserted via the left brachial artery. The lesion was successfully dilated, and a 3.0 × 13 mm Cypher® stent was placed. After the PCI procedure, the IABP catheter was retrieved in the catheter laboratory, and the patient was discharged after 7 days. When a femoral approach is contraindicated in PCI, 6‐Fr IABP catheter insertion via the brachial artery is feasible and effective. © 2011 Wiley‐Liss, Inc.     

Diagnostic Brachial Coronary Arteriography Using a Power-Assisted Injector and 4 French Catheters with New Shapes

BACKGROUND: Right brachial access in diagnostic coronary arteriography (CAG) has demonstrated advantages over femoral approaches, including earlier ambulation and more predictable hemostasis, particularly when small diameter catheters were used. Poor results from some earlier reports of brachial CAG have been due partially to the need to use large diameter catheters for positional control. Technical advances in catheters and contrast injection may increase the utility of brachial access CAG. PURPOSE AND STUDY DESIGN: We evaluated three 4 French (Fr) catheters with new shapes and with a large internal to external diameter ratio that were designed to overcome previous limitations to brachial CAG. Contrast agent was delivered with a novel power injector (CAG-20) intended for arteriography using small catheters. Routine right brachial access CAG and left ventriculography (LVG) were evaluated in 2663 (69%) of 3880 consecutive patients admitted for examination from 1991 to 1995. The study population included 128 patients (5%) with left main trunk disease, 819 (21%) with old myocardial infarctions and 1747 (66%) with more than one vessel disease. For this trial, 1217 patients with valvular disease, ischemia associated with aortic or peripheral vascular disease, congenital cardiac disease and post-surgical and emergency catheterization were excluded because femoral access or a larger catheter (> 4 Fr) were required in those cases. RESULTS: A total of 2573 (97%) diagnostic quality CAG (> grade 3/5) were obtained solely with 4 Fr catheters placed via the right brachial artery. Of the other 66 examinations, 50 were completed through the brachial route but with alternate size or shape catheters and 16 cases required the femoral Judkin?s technique. Useful LVG (> grade 2/4) were obtained from 2604 patients (98%). Overall, 2536 (95%) of cases provided clinically valuable images for both CAG and LVG from brachial access. We experienced one semi-emergency bypass operation and one emergency stent implantation caused by coronary dissection. There were no deaths, acute myocardial infarctions, loss of pulse or nerve injuries. CONCLUSION: Power-injector assisted, brachial 4 Fr CAG and LVG proved to be safe and cost-effective. Brachial access has the potential to become a routine method for out-patient cardiac opacification.     

Balloon crush: treatment of bifurcation lesions using the crush stenting technique as adapted for transradial approach of percutaneous coronary intervention.

The recent advent of drug-eluting stents has allowed the crush stenting technique to be adopted, thus simplifying the treatment of bifurcation coronary artery lesions. However, this can only be achieved in 7 Fr or greater guiding catheters, hence precluding most transradial percutaneous coronary interventions that are usually undertaken using 6 Fr or less guiding catheters. We assessed the feasibility of balloon stent crush as a stepwise procedure in achieving bifurcation crush stenting in 6 Fr transradial percutaneous coronary interventions. Since it is not possible to place two stents through a 6 Fr guiding catheter, we have adapted the crush stenting technique by initially placing a stent in the side branch and a balloon in the main vessel. The side branch stent is then deployed against the main vessel balloon that is later inflated, crushing the side branch stent within the main vessel. The main vessel is then stented and the side branch recrossed for kissing inflations. Seven patients (five males; age range, 47-78 years) with bifurcation lesions were treated using the above-described technique without major complications. Balloon crush of the side branch stent were successfully achieved in all cases without balloon trapping. In six cases where side branch recrossing was attempted, all were successful and kissing balloon inflations were undertaken in five cases. We have demonstrated that the modified crush stenting technique is feasible and can be safely adapted for use in a 6 Fr transradial percutaneous coronary intervention approach.     

Impact of radial artery cannulation for coronary angiography and angioplasty on radial artery function

The radial artery is commonly used as a conduit in coronary artery bypass grafting. No data exist on the effects of radial sheath insertion on radial artery function. Because many patients considered for coronary artery bypass grafting have had previous radial procedures, it is important to understand any effects radial sheath insertion may have on radial artery function. Twenty-two patients who underwent elective coronary angiography or angioplasty with a 6Fr sheath through the right radial artery were studied. Radial artery function was assessed using ultrasound to measure flow-mediated dilation (FMD). Reactive hyperemia was produced by 5-minute cuff inflation on the arm to suprasystolic pressures. Radial artery diameter was measured at rest and 1 minute after cuff deflation. FMD was expressed as percent change in radial diameter compared with at rest. In all cases, the left radial artery was studied as a control. Patients were studied before sheath insertion, immediately after sheath insertion, and 6 weeks after sheath insertion. The FMD of the cannulated arm was 13.2% before sheath insertion versus 3.6% immediately after sheath insertion (p <0.01) and 0.2% (p <0.01) 9 weeks after sheath insertion. In contrast, there were no significant changes in the noncannulated arm at either time point. In conclusion, radial artery sheath insertion for coronary angiography or angioplasty results in immediate and persistent blunting of FMD, suggesting severe vasomotor dysfunction. Radial artery sheath insertion has important effects on radial artery function that must be considered when selecting radial conduits for coronary artery bypass grafting.     

Dual wire technique for aortic coarctation stent placement

A young adult presented for percutaneous treatment of a narrow aortic coarctation. A very large left subclavian artery originated immediately proximal to the coarctation. In order not to exclude or jail the left subclavian artery with a stent, a double wire technique was used. From a femoral approach, two guide wires were positioned, one in the aortic arch and another in the subclavian artery. A stent crimped over a 16‐mm balloon and a 4‐Fr catheter was advanced over the two wires within a 14‐Fr long introducer sheath. The stent was successfully deployed and molded within the bifurcation by a kissing balloon technique, relieving the obstruction and leaving a guaranteed passage to the subclavian artery. The double wire technique is an elegant way to deliver a stent safely across a narrowing with guaranteed access to important side branches. © 2011 Wiley‐Liss, Inc.     

Primary stent deployment in occlusive subclavian artery disease

Primary (without antecedent balloon dilation) Palmaz? stent implantation was successfully performed in 27 consecutive patients entering with 31 obstructed subclavian arteries. Stents (n = 50) were successfully deployed, using the brachial (n = 7), femoral (n = 16), or combined (n=8) approach, to revascularize 31 subclavian vessels [8 occluded (26%); 23 stenotic (74%)], using a 6 or 7.5 French delivery system. The indications for intervention were arm claudication in 8 patients (30%), subclavian steal syndrome in 11 patients (41%), angina pectoris secondary to impaired blood flow to the left internal mammary artery coronary bypass in 6 patients (22%), and recanalization of a left subclavian occlusion to permit central arterial access and performance of a second interventional procedure 2 patients (7%). The percent diameter stenosis improved from 85 f 12% to 6 f 7% (P<0.001); and, the peak and mean translesion gradients decreased, respectively, from 56 f 35 mm Hg to 3 f 4 mm Hg (P<0.01), and 29 f 18 mm Hg to 2 k 2 mm Hg (P<0.01). Procedural complications encountered were one stent dislodgement with migration into and uneventful deployment within the right external iliac artery, and two brachial artery repairs. No acute vessel closures, deaths, myocardial infarctions, cerebrovascular accidents, transient ischemic attacks, or need for transfusions occurred. Therefore, primary subclavian artery stent deployment can be performed using low-profile sheath systems with excellent success (100%), resulting in immediate restoration of pulsatile flow, and few complications. The incidence of lesion recurrence remains for follow-up studies.     

Brachial approach directional coronary atherectomy of a left coronary artery saphenous vein bypass graft

Directional coronary atherectomy (DCA) of a saphenous vein bypass graft to the left coronary artery was performed percutaneously from the brachial artery approach using a 7F endomyocardial biopsy sheath. Initial positioning was accomplished with a left bypass graft catheter inserted in the sheath. This technique permits use of smaller catheters than usual for DCA in patients in whom larger guides cannot be used. © 1993 Wiiey-Liss, Inc.