Percutaneous coronary intervention via transulnar sheathless approach

Diagnostic and interventional coronary procedures via cannulation of the radial artery have proven to be useful in patients with acute coronary syndrome (ACS) ST-segment elevation myocardial infarction, non-ST-segment elevation ACS, and non-ACS clinical syndromes. In many patients, vascular access and catheter advancement can be difficult due to vessel size, vasospasm, anatomical branching variations, and catheter manipulation. The ulnar artery may prove to be a preferred alternative in many cases where the radial artery is unable to be utilized. Furthermore, the use of large caliber catheters through these smaller caliber vessels also limits the use of some devices for treatment of bifurcation lesions. We report the use of a sheathless percutaneous coronary intervention through the ulnar artery. In this case a sheathless technique was shown. The sheathless catheter has already been shown as safe in small case series and in a multicenter registry. With a smaller luminal diameter than that of traditional sheath systems, the risk of vasospasm, vascular damage, radial artery occlusion, and bleeding complications, even in maximal platelet inhibition, is theoretically reduced.     

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.     

Percutaneous transradial approach for coronary angiography.

A percutaneous radial artery approach for coronary angiography was performed in 40 patients using a 5-F catheter. The patients, in whom the femoral artery approach was difficult or contraindicated because of advanced arteriosclerosis, were selected on the basis of easily palpable radial and ulnar arteries and a normal Allen test. In 1 patient the catheter could not be advanced to the brachial artery, and subsequently this patient underwent the brachial approach. In all 39 patients, selective left coronary angiography was accomplished using a left Judkins catheter, and the right coronary artery and the saphenous vein graft were entered successfully using a right Judkins or Amplatz catheter. All patients had excellent quality of images of coronaries and vein grafts. In 5 patients (13%), the pulse remained acutely diminished, but there were no evidences or complaints of pain. Bleeding at the puncture site occurred in 1 patient (3%), and 5 patients (13%) had subcutaneous bleeding around the puncture site. Pseudoaneurysm, nerve injury and arteriovenous fistula were not detected at the time of discharge.     

A late complication of percutaneous radial artery cannulation

Radial artery pseudoaneurysms occurring as a late complication of percutaneous radial artery cannulation are rare, while those which are infected are exceptional. Known risk factors are age-related with patients being in their seventies and onwards, the duration of the radial artery catheter and staphylococcal catheter-related infections. We report the case of an 82-year-old patient who developed a mycotic radial artery pseudoaneurysm as a late complication of arterial catheterization.     

Selection of hardware and cathlab preparation for transradial approach

The percutaneous transradial approach for cardiac catheterization has been shown to be a safe alternative to femoral artery approach, owing to the favorable anatomical relation of the radial artery to surrounding structures and the dual blood supply to the hand. Selection of guide catheter is elementary but an issue of extreme importance in performance of percutaneous coronary interventions (PCI) and depends on the size of aorta, location of ostia on the aorta, the kind of back-up required and whether the artery arises from a normal origin or anomalously. Currently a variety of guiding catheters are available, each with a unique design and construction, which has vastly improved the technique of transradial PCI. However, much of the cause for procedural failure of the radial approach is associated with the need for higher technical skills and the difficulty in using femoral catheters in the smaller radial artery. There is a learning curve, and many interventionists are uncomfortable attempting a more technically challenging procedure. Nevertheless, it is a procedure that can be taught, and with the innovation of new catheters and devices made specifically for radial approach, it may become easier to adopt for interventionists with a sound knowledge of the anatomical considerations and skill on guiding catheters and hardwares. The current article provides a vivid insight on the various aspects of the learning curve for Transradial approach including proper patient selection, radial access assessment, troubleshooting arm vessel anomalies, guide catheter selection and engagement, augmentation of guide support, and adjunctive device selection.     

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.     

Percutaneous retrieval of a fractured guide catheter using contralateral snaring

Guide catheter kinking and fracture is an uncommon complication of percutaneous coronary intervention and may require emergency surgical intervention if percutaneous retrieval fails. We present a case of guide catheter kinking and fracture during attempts to engage the left main coronary artery in a patient with marked iliac tortuosity. The retained guide catheter fragment was retrieved percutaneously by using a snare from the contralateral femoral artery and removing the "folded-over" catheter fragment through the contralateral arteriotomy.     

Successful retrieval of a broken intravascular ultrasound catheter tip from a coronary artery

The fracture of IVUS catheter tip in the coronary artery is a very rare complication. It should be removed as soon as possible. Although it seems to be easy at first glance, percutaneous retrieval of broken IVUS catheter tip has some challenges. We hereby present a case report of successful percutaneous retrieval of broken IVUS catheter, probably caused by calcific left main stenosis, from the left circumflex artery using loop snare technique.     

Percutaneous closure of an aortic paravalvular leak via the transradial approach.

Percutaneous closure of aortic and mitral paraprosthetic leaks using the Amplatzer occluders (muscular ventricular septal defect occluder) is now a well recognized procedure although as "off label" use. Aortic paravalvular leak closure is usually carried out via transfemoral puncture, but problems with this approach include the need to stop warfarin and the inadequate length of standard delivery sheaths. We report the first case of percutaneous aortic paravalvular leak closure through the radial artery route.     

Successful transradial retrieval of broken catheter fragment during transradial coronary angiography

Intravascular fracture of angiographic catheters is very uncommon, but it happens. Removal of an intravascular foreign body may require surgical intervention or non-surgical retrieval necessitating additional vascular access (mostly via femoral artery). We describe a case in which the diagnostic catheter was broken. We were able to pass two guidewires (0.035-inch guidewire and 0.014-inch standard percutaneous transluminal coronary angioplasty guidewire) through the fragment. The 0.014-inch guidewire twirled, winding around the 0.035-inch wire, and the catheter fragment was retrieved successfully through the radial sheath.     

Successful percutaneous coronary intervention for complex bifurcated lesions with combination of “Reverse wire technique” and “Reverse bent wiring with the crusade catheter” novel wire manipulation technique

We encountered a case of percutaneous coronary intervention for complex bifurcated lesions in the mid portion of the left anterior descending (LAD) artery. The diagonal artery branched from the LAD artery with a markedly angulated pattern and there was severe stenosis from just proximal to this diagonal artery. The “reverse wire technique facilitated with the Crusade catheter” enabled us to cross a guidewire through to the markedly angulated diagonal side branch (SB). Next, we adopted a mini‐crushing stent strategy for this true bifurcated lesion. Thereafter, we adopted “reverse bent wiring with the Crusade catheter” for wire re‐crossing to the incarcerated side branch, and successfully completed all procedures. This technique for successful wire re‐crossing is simple but can be very effective in specific situations in practical percutaneous coronary intervention (PCI). Many PCI operators may empirically adopt this kind of wire manipulation technique. However, this case is the first report in the world describing the application of a “reverse bent wiring with the Crusade catheter” for wire re‐crossing through a double‐folded stent strut to a SB at the optimal point of the bifurcation. In this case, we made the most of the Crusade catheter. This catheter is a very useful device for multifactorial use in practical PCI. It can help us to perform complex PCI procedures successfully. © 2015 Wiley Periodicals, Inc.     

Coronary and bypass graft angiography via the right radial approach using a single catheter

Transradial cardiac catheterization in patients with previous coronary artery bypass graft surgery can be technically challenging. The presence of a left internal mammary artery (LIMA) graft was previously considered a relative contraindication for a right radial procedure, but there are several reports demonstrating the feasibility and safety of LIMA angiography from a right radial access. This case report demonstrates that transradial coronary and bypass graft angiography including LIMA angiography from the right radial approach is technically feasible with a single catheter. Catheter options for LIMA angiography from right radial access will also be discussed.     

Successful Percutaneous Coronary Intervention of an Anomalous Right Coronary Artery With High Anterior Takeoff Using a DIO Thrombus Aspiration Catheter

Selecting an appropriate guiding catheter is the most important determinant of procedural percutaneous coronary intervention success, especially with an anomalous right coronary artery with high anterior takeoff, which is rather complicated. We present a case of successful stent implantation in an anomalous right coronary artery with high anterior takeoff using DIO thrombus aspiration catheter. This method is useful when selection of the guiding catheter is rather complicated such as in the case of congenital coronary anomalies.     

Successful retrieval of transradially delivered unexpanded coronary stent from the left main coronary artery

Stent dislodgment during percutaneous coronary intervention is a rare complication. We report a case of successful retrieval of a dislodged stent from the left main coronary artery. It was retrieved via the transradial route using a 6 F coronary guiding catheter supported by an inflated percutaneous transluminal coronary angioplasty balloon distal to the stent.     

Entrapment of a Partially Degloved Stent in the Radial Artery: is there Any Way Out?

Stent loss during percutaneous coronary intervention (PCI) is uncommon but may lead to serious adverse events. Here we describe a challenging case of stent loss in the radial artery during primary PCI. There, a long stent failed to cross the culprit lesion, and an attempt to pull back the undeployed stent into the guiding catheter resulted in eversion of the stent, partially stripping it off the stent balloon and rendering the stent irretrievable. Retrieval of the stent at all costs might have led to major complications; hence stent deployment in the radial artery bailed us out of this precarious situation.     

Successful endovascular renal artery aneurysm exclusion using the Venture catheter and covered stent implantation: a case report and review of the literature

Renal artery aneurysms are rare vascular anomalies in which rupture is associated with devastating consequences. Only a few reported cases involved percutaneous treatment. Recently, technological advances have expanded indications for percutaneous treatment of such complex peripheral lesions. Despite this, certain anatomical settings such as extreme vessel tortuosity or angulation of the afferent vessel continue to pose challenges. New steerable devices may play a crucial role in those cases where conventional techniques have failed. We report a case of successful percutaneous treatment of a renal artery aneurysm and stenosis in a young male using the Venture catheter.     

Management of a "saddle" embolus at the popliteal bifurcation by a variation of the "push and park" approach. A case report.

We present a modification of a previously reported endovascular technique where a large embolus was "pushed and parked" into a diseased artery. A saddle embolus at the bifurcation of the popliteal artery, which occurred as a complication after a percutaneous subintimal recanalization, was pushed and parked into the tibio-peroneal trunk. This was achieved using 2 balloon catheters, one to disengage the embolus from the anterior tibial artery, and the other to push the embolus into the tibio-peroneal trunk, thus establishing flow into the anterior tibial artery. Pushing and parking an embolus into a less useful vessel when all attempts at catheter embolectomy have failed is a simple and quick method which should be borne in mind by all vascular interventionalists.     

Left internal mammary artery intervention: the left radial approach with a new guide catheter

Coronary intervention involving left internal mammary bypass grafts is an increasingly common challenge for the interventionalist. Although successful in a high percentage of patients, the femoral approach may be technically challenging. The shorter, more direct approach from the left radial artery has potential advantages in these cases. The present study evaluated our experience using a new left transradial internal mammary guide catheter. Angiography alone was successfully performed with the catheter in 40 patients. In an additional 10 patients, internal mammary artery interventional procedures were performed. Angioplasty alone was performed in five patients. Five patients underwent coronary stenting within the internal mammary artery or native left anterior descending artery. Guide catheter backup was satisfactory and angioplasty catheters and/or stents could be advanced to the target lesion with minimal difficulty. No procedural complications occurred. The left radial artery access site is an excellent approach for left internal mammary intervention.     

Measurement of arterial pressure after cardiopulmonary bypass with long radial artery catheters

Radial arterial pressure can significantly underestimate central aortic pressure in the postcardiopulmonary bypass (post-CPB) period. At the study institution, routine monitoring of perioperative arterial pressure in adult patients undergoing cardiac surgery is performed with a long radial artery catheter with the distal end positioned in the subclavian artery. In 68 patients presenting for elective cardiac surgery, both a conventional short radial artery catheter and a contralateral long radial artery catheter were placed. Analysis of radial and subclavian arterial pressures post-CPS in the first 47 patients showed average maximum differences of 7 mm Hg systolic and 4 mm Hg mean. In 15% of patients, the differences were clinically significant 1>20 mm Hg systolic and/or >14 mm Hg mean). In 28 patients, central aortic pressure was measured post-CPB, and subclavian artery pressure was found to be an excellent estimator of central aortic pressure. There were no significant complications related to using long radial artery catheters in the 68 patients who were followed prospectively. Monitoring subclavian arterial pressure by percutaneous insertion of a long radial artery catheter provides a reliable estimation of central aortic pressure, even in patients with significant radial artery-to-central aortic pressure gradients post-CPB.     

Percutaneous brachial catheterization: the hidden hazard of high brachial artery bifurcation

We describe a patient in whom a brachial arterial cutdown done at the same site for percutaneous transluminal angioplasty immediately after uncomplicated percutaneous brachial coronary arteriography revealed the percutaneous sheath in a deeper, smaller, and more lateral artery than the brachial artery, complicating placement of the guiding catheter. This case illustrates the potential hidden hazard of normal brachial artery bifurcation variants, which may be responsible for some of the potential complications encountered in percutaneous brachial artery catheterization techniques.