Question: Do you use transradial access for STEMI patients with a history of CABG?

Case report

This is a 79-year-old gentleman with a history of coronary artery disease, status post bypass x 3 (left internal mammary artery to the left anterior descending coronary artery [LIMA->LAD]; saphenous vein graft to the right posterior descending artery [SVG->RPDA] and SVG to the lateral branch) in 2004. He had a heart catheterization done in South Carolina in 2011, at which time it was reported that he had high-grade stenosis of a graft. No intervention was performed, for unclear reasons. He presented to the emergency room approximately three hours after working out and developing chest discomfort. An electrocardiogram (EKG) on presentation demonstrated 1-mm ST elevations in the inferior leads and the patient was taken emergently to the cath lab.

The right radial artery was accessed with a Glidesheath Slender (5 French [Fr] outer diameter, 6 Fr inside diameter) (Terumo). An AL-1 guide (Boston Scientific) was used to engage the culprit lesion, followed by completion of the diagnostic angiogram (Figure 1). 

Given the patient’s clinical presentation and EKG findings, the AL-1 guide was used to cannulate the venous bypass grafts. Bivalirudin (Angiomax, The Medicines Company) was administered after engagement of the vein graft to the right coronary artery (RCA); a Runthrough wire (Terumo) was passed distally, restoring TIMI-1 flow. Due to time constraints, we took a QuickCat thrombectomy catheter (Kensey Nash) and performed manual aspiration of about 50 mL with retention of clot and restoration of TIMI-2 flow in the vessel (Figure 2). There remained a high-grade stenosis of about 95% in the mid body of the graft (Figure 3). At this point, we exchanged out the Runthrough wire (Terumo) for a 4.0 Spider filter (Coviden) placed in the distal vein graft (Figure 4), and then placed a 4.0 x 15 mm Integrity bare-metal stent (Medtronic) at 14 atmospheres. Following deployment (and filter retrieval), there was improved flow in the vessel; however, residual thrombus was noted at the proximal edge of the stent as well as in the proximal vein graft (Figures 5-6). We reoriented the guide angulation and aspirated the proximal clot. The vessel was rewired with a Runthrough wire and we advanced a 2.0 x 20 ClearWay balloon (Atrium Medical) to the residual thrombus and infused an eptifibatide (Integrilin, Millennium Pharmaceuticals) bolus. Angiography revealed brisk flow without any residual angiographic thrombus in the vessel (Figures 7-8). The patient’s ST segments resolved with minimal residual pain. The patient tolerated this part of the procedure well, and the diagnostic angiogram was then completed (Figures 9-10).

Discussion

Coronary artery bypass graft surgery (CABG) is among the most commonly performed surgical procedures in the United States, with approximately 400,000 performed annually.¹ Saphenous vein graft (SVG) occlusion and degeneration are a limitation in patients that have undergone CABG. SVG occlusion is approximately 15% in the first year, with a 60% patency at 10 years.¹ Various strategies have been utilized to treat SVG disease, including redo-CAB, percutaneous transluminal coronary angioplasty (PTCA), and stenting. The SAVED (Saphenous Vein De Novo) trial² demonstrated a benefit to stenting with a bare metal stent versus PTA. Observational studies and small-randomized trials have examined use of a bare metal versus drug-eluting stents. Some studies have demonstrated a benefit to DES and others have not.   

Transradial access is rapidly becoming a well-established technique for diagnostic and interventional coronary procedures. Despite its well-documented advantages, there is an associated learning curve and initially it may prove to be time consuming. Patients with a history of bypass are a unique population. A variety of catheters may be utilized from a femoral approach and cannulation may not be facile. This could potentially be compounded from a radial approach. Often the left radial is chosen because of concerns about cannulating the LIMA, although the ability to do this from the right radial has been demonstrated.^3,4 Sanmartin et al demonstrated similar success utilizing the radial and femoral approach without a significant use of contrast or increased procedure time.⁵

Interventions, particularly in venous bypass grafts, can prove to be more challenging, with a significant, increased risk of failure from the radial approach.⁶ This may be due in part to inability to seat the guide or inadequate guide support. The location of the grafts and the proximity of the innominate or subclavian, as well as access (left vs right radial) must be factored when approaching a lesion. From a right radial approach, part of the curve of the catheter may be compromised by the innominate and there may be no back up from the wall of the aorta. Pragmatic solutions to overcome support issues include use of a buddy wire, debulking (such as laser atherectomy) to facilitate delivery, and use of the Guideliner catheter⁷ (Vascular Solutions). Guides that often work well, especially if utilizing the right radial, include the Amplatz left (AL)-1 (Merit Medical), Amplatz right modified (AR mod) (Merit Medical), and Ikari Left 3.5 (Terumo).

Disclosure: Orlando Marrero reports no conflicts of interest regarding the content herein. Dr. Zaheed Tai reports the following: Terumo (proctor for transradial course), Spectranetics (proctor for laser course, speaker, advisory board), Medicines Company (speakers bureau).

Orlando Marrero can be contacted at orlm8597@yahoo.com. Dr. Zaheed Tai can be contacted at zaheedtai@gmail.com

References

1. Goldman S, Zadina K, Moritz T, Ovitt T, Sethi G, Copeland JG, Thottapurathu L, Krasnicka B, Ellis N, Anderson RJ, Henderson W; VA Cooperative Study Group #207/297/364. Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery: results from a Department of Veterans Affairs Cooperative Study. J Am Coll Cardiol. 2004 Dec 7; 44(11): 2149-2156.
2. Savage MP, Douglas JS Jr, Fischman DL, Pepine CJ, King SB 3rd, Werner JA, Bailey SR, Overlie PA, Fenton SH, Brinker JA, Leon MB, Goldberg S. Stent placement compared with balloon angioplasty for obstructed coronary bypass grafts. Saphenous Vein De Novo Trial Investigators. N Engl J Med. 1997; 337(11): 740-747.
3. Patel T, Shah S, Patel T. Cannulating LIMA graft using right transradial approach: two simple and innovative techniques. Catheter Cardiovasc Interv. 2012 Aug 1; 80(2): 316-320. doi: 10.1002/ccd.24321.
4. Tai Z. Selective LIMA injection via the right radial approach. Cardiac Interventions Today. January/February 2011. Available online at https://citoday.com/2011/02/selective-lima-injection-via-the-right-radial-approach. Accessed February 19, 2014.
5. Sanmartin M, Cuevas D, Moxica J, Valdes M, Esparza J, Baz JA, Mantilla R, Iñiguez A. Transradial cardiac catheterization in patients with coronary bypass grafts: feasibility analysis and comparison with transfemoral approach. Catheter Cardiovasc Interv. 2006 Apr; 67(4): 580-584.
6. Dehghani P, Mohammad A, Bajaj R, Hong T, Suen CM, Sharieff W, Chisholm RJ, Kutryk MJ, Fam NP, Cheema AN. Mechanism and predictors of failed transradial approach for percutaneous coronary interventions. JACC Cardiovasc Interv. 2009 Nov; 2(11): 1057-1064. doi: 10.1016/j.jcin.2009.07.014.
7. Farooq V, Mamas MA, Fath-Ordoubadi F, Fraser DG. The use of a guide catheter extension system as an aid during transradial percutaneous coronary intervention of coronary artery bypass grafts. Catheter Cardiovasc Interv. 2011 Nov 15; 78(6): 847-863. doi: 10.1002/ccd.22942.