How to Avoid Sacrificing the Benefits of Transradial PCI in Complex Patient Subsets

This case is part of a series of transradial-focused reports directed by section editor Dr. Samir Pancholy. This case series is supported by an educational grant from Medtronic.

Introduction 

Guide support during transradial percutaneous coronary intervention (PCI) has been deemed less optimal compared to transfemoral access. Although there is no conclusive evidence to support this presumption, many operators triage patients to transfemoral access when embarking upon complex PCI. Here, we describe a case where transradial access was used in the setting of complex primary PCI of the right coronary artery (RCA), using appropriate escalation of techniques known to enhance guide support without sacrificing the usual metrics from a quality standpoint.

Case 

The patient was a 36-year-old white male with diabetes mellitus, hypertension, and obesity, who drives a truck for a living. While in New York City, he developed retrosternal chest burning when unloading his truck. The pain subsided after he rested. He drove back to Pennsylvania, and upon reaching home, ate dinner, and then, while resting, developed retrosternal chest burning. It was more intense this time, and he, accompanied by his wife, promptly presented to the emergency department. Upon arrival to the emergency department, he was found to have electrocardiographic evidence of acute inferior wall ST elevation myocardial infarction. P2-Y12 inhibition and uncoated aspirin were administered, in addition to 70 units per kilogram of unfractionated heparin, given intravenously. The patient was hypertensive and tachycardic, and an intravenous beta-blockade was administered as well. He was promptly transferred to a nearby PCI-capable facility.

Upon arrival to the cardiac catheterization laboratory, the patient had 7 out of 10 retrosternal chest heaviness, was mildly nauseous, and appeared diaphoretic. After the usual preparation and set up, a 6 French (Fr) hydrophilic introducer sheath was inserted in the right radial artery, and a 6 Fr multi-aortic curve (MAC) 3.0 guiding catheter (Medtronic) was placed in the ascending aorta. The right coronary artery ostium was engaged and angiography revealed a 99% mid right coronary artery (RCA) stenosis, with TIMI-1 flow in the distal RCA (Figure 1). Severe, ectatic, diffuse disease was noted in the RCA, which was extensively calcified. Distal and pre bifurcation 70-80% stenoses were noted. Activated clotting time was measured at 251 seconds.

An .014-inch x 180 cm Runthrough NS guidewire (Terumo) was placed in the distal RCA, and a 2.5 mm x 15 mm balloon was advanced to the distal RCA with mild difficulty due to calcification necessitating aggressive guide position. The balloon was inflated at 18 atmospheres (atm) at the bifurcation of the distal RCA (Figure 2). The same balloon was then inflated in the mid portion at the infarct lesion, at 20 atm for 15 seconds. As the flow improved, it became apparent that the RCA had extensive intimal and adventitial calcification with moderate tortuosity, as well as ectatic segments with large plaque burden, throughout its entire course. The difficulty in advancing a regular balloon was noticeable and navigation challenges were anticipated. A few members of the team suggested crossing over to a femoral access site, with a larger diameter guide catheter to improve support. The operators decided on a transradial PCI strategy using active support as well as other maneuvers to escalate guide support and tackle this very complex anatomy with need for multi-site long stenting. The first step was to exchange the guidewire for a better support guidewire. A Finecross catheter (Terumo) was placed over the Runthrough NS guidewire into the distal right posterior descending artery, the Runthrough NS guidewire was removed, and a 180 cm Hi-Torque Wiggle wire (Abbott Vascular) was placed in the right posterior descending artery. The Finecross catheter was removed using Nanto technique¹, where the microcatheter is connected to an inflation device filled with isotonic saline, and by applying forward pressure between 12 and 16 atm, the frictionless wire-catheter interface allows for smooth withdrawal of the microcatheter without moving the coronary wire. After the Wiggle wire was in place, a 2.5 mm x 18 mm drug-eluting stent was placed over the wire and carefully advanced into the proximal RCA. As expected, the stent failed to advance beyond the proximal RCA. At this point, a 6 Fr GuideLiner catheter (Vascular Solutions) was opened and a 2.5 mm balloon was preloaded in the GuideLiner catheter outside the body. The balloon and GuideLiner composite were advanced over the guidewire, and with the balloon leading the GuideLiner catheter, the system was advanced into the distal RCA. Once the GuideLiner was placed in the distal RCA, the balloon was removed, and the stent was advanced into the right posterior descending artery with its proximal end extending into the distal RCA and deployed at 20 atm. A 4.0 mm x 38 mm drug-eluting stent was advanced and successfully placed into the distal RCA, and deployed at 20 atm (Figure 3). A 4.0 mm x 14 mm drug-eluting stent was deployed in the mid-RCA at 20 atm. The distal right coronary and mid right coronary stents were post-dilated with 4.5 mm x 15 mm NC Trek balloon (Abbott Vascular), with 5 inflations at 20 atm. At the completion of the procedure, optimal stabilization of the lumen and TIMI-3 flow were noted (Figure 4).

Discussion 

Increasingly complex patient subsets with adverse characteristics such as calcification and tortuosity as well as large plaque burden have led to an increase in procedural complexity. Transradial PCI has been shown to improve outcomes², including mortality outcomes in patients with acute coronary syndromes (ACS)^3,4. In time-bound situations such as ST elevation myocardial infarction (STEMI) with primary PCI, where “time is muscle”, having a clear strategy is of paramount importance. Although in some instances increasing passive support with large catheter size as well as the use of certain preformed shapes that are more aggressive might improve procedural access, other, more effective strategies can be used without sacrificing the benefits of transradial PCI, especially in the setting of STEMI.

In this instance, the use of a guide catheter such as the multi-aortic curve (MAC) allows the operator to have support from the right coronary sinus of Valsalva, as well as the ability to deeply intubate the RCA (by applying clockwise torque). After initial balloon inflation using a workhorse guidewire and awareness of the difficult terrain that the hardware will have to traverse, escalating to a guidewire more suitable for this type of anatomy is a logical next step.  The guidewire can be exchanged using a 300-cm long guidewire, a DOC guide wire extension (Abbott Vascular), or by “trapping” the wire using a balloon. In time-sensitive situations, the fastest method is what the operators chose in this case, the previously described Nanto method: using a 180 cm guidewire, and removing the microcatheter by successfully deploying hydraulic principles and eliminating friction. Using a guidewire that provides the ability to deflect the tip of the balloon or the stent catheter from luminal adversities such as calcific plaque was not effective. The next step in the strategy was to use guide extenders. The GuideLiner, available in 5 and 6 French-capable sizes, could be used to intubate the vessel deeply and hence provide more support. Several important issues need to be kept in mind while using these devices. Although quite flexible, the “overhang” of the catheter tip of the .014-inch guidewire creates a sizeable transition, causing a razor effect⁵ that may lead to intimal dissection while advancing the transition through difficult anatomy^6,7. In trying to lessen this mismatch and make the transition less traumatic to the vessel, the use of a balloon shaft may be of help. If the balloon shaft is not sufficient to reduce the razor effect, balloon inflation at the tip of the GuideLiner with balloon-assisted tracking may improve success rates further. 

In summary, transradial PCI can be used with success in the most complex subsets, without compromising procedure duration or efficacy, using contemporary techniques and technology, preferably combined with clearly outlined escalation strategies.

References 

1. Nanto S, Ohara T, Shimonagata T, Hori M, Kubori S. A technique for changing a PTCA balloon catheter over a regular-length guidewire. Cathet Cardiovasc Diagn. 1994; 32(3): 274-277.
2. Bertrand OF, Bélisle P, Joyal D, Costerousse O, Rao SV, Jolly SS, et al. Comparison of transradial and femoral approaches for percutaneous coronary interventions: a systematic review and hierarchical Bayesian meta-analysis. Am Heart J. 2012 Apr; 163(4): 632-648.
3. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, Politi L, Rigattieri S, Pendenza G, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol. 2012 Dec 18; 60(24): 2481-2489.
4. Mehta SR, Jolly SS, Cairns J, Niemela K, Rao SV, Cheema AN, et al; RIVAL Investigators. Effects of radial versus femoral artery access in patients with acute coronary syndromes with or without ST-segment elevation. J Am Coll Cardiol. 2012 Dec 18; 60(24): 2490-2499.
5. Patel T, Shah S, Pancholy S. Balloon-assisted tracking of a guide catheter through difficult radial anatomy: a technical report. Catheter Cardiovasc Interv. 2013 Apr; 81(5): E215-E218. 
6. Waterbury TM, Sorajja P, Bell MR, Lennon RJ, Mathew V, Singh M, et al. Experience and complications associated with use of guide extension catheters in percutaneous coronary intervention. Catheter Cardiovasc Interv. 2015 Dec 23. doi: 10.1002/ccd.26329. [Epub ahead of print].
7. Murphy JC, Spence MS. Guideliner catheter--friend or foe? Catheter Cardiovasc Interv. 2012; 80(3): 447-450.

Disclosures: Dr. Nanavaty and Dr. Kaushik have no conflicts of interest regarding the content herein. Dr. Pancholy reports he is currently serving as a speaker for Medtronic and Terumo, and has equity interest in Vasoinnovations, Inc.

The authors can be contacted via Dr. Samir Pancholy at pancholy8@gmail.com.

Dear Dr. Pancholy,

I am the cardiovascular lab manager in a facility that does 1,200 cardiac caths a year. We currently do about 90% radial access and try to use femoral closure devices as much as possible. Our telemetry and intensive care units are not being exposed enough to femoral access to stay competent in skills to safely remove these sheaths if patient do go to those units. What are other hospitals doing for education for the nursing staff on the floors? What competencies are required by your department and hospital floors? Thank you for your input.

Richard Joens RN, BSN
Cardiovascular and EP Lab Manager

Dear Richard,

With shrinking volumes of femoral access, competencies around the femoral space are becoming a real issue. In our lab, we have a very small percentage of use of vascular closure devices, so this has not been an issue, although it clearly requires volume to maintain competencies.

The two options that I envision are sending your staff to an adjoining facility where they do not close every groin, or “simulation”, which is even more difficult to get. Either way, they would need hands-on experience to maintain those competencies.

Maybe assign one or two people to get trained and they can cover the “sheath pull”, so to speak. It is a much bigger issue than training people how to handle the forearm after transradial cath.

Hope this helps.

Best regards,
Samir
Samir B. Pancholy, MD, FACP, FACC, FSCAI