Stenting an Unprotected Left Main Coronary Artery Stenosis via Right Radial Access

 This case demonstrates that a high-risk procedure can be done with very minimal risk, especially if all the factors that would promote a successful procedure are favorable, and as long as the procedure is performed in a setting where the operator, team, and center have extensive experience with high-risk patients.

Mr. AM is 47-year-old gentleman who presented a month prior with exertional chest pain. He had an exercise stress echo that showed a severe decrease in myocardial contractility involving the anterior apical wall. He was advised to have a cardiac catheterization. After a great deal of hesitation, the patient agreed to move forward with the procedure, and was started on aspirin, clopidogrel, and statins. On the day of the catheterization, he expressed concern about having open-heart surgery, commenting that he only wanted a percutaneous coronary intervention, if needed.

The procedure was performed through right radial access. Using a 6 French sheath, coronary angiography revealed evidence of a severe ostial 90% left anterior descending coronary artery (LAD) stenosis as well as a 70-80% smooth, non-calcified left main stenosis. A 6 French Launcher left guiding EBU (extra backup) catheter (Medtronic) was inserted into the left main coronary artery and two separate wires were inserted into the LAD, as well as into the circumflex artery. The ostial LAD was dilated with a 3 mm balloon followed by a 3.5 x 8 mm Xience stent (Abbott Vascular).

At this point, performing coronary stenting of the left main coronary artery with a left ventricular assist device was considered. However, it was opted to perform the procedure without the backup device, especially in view of the fact that the patient had a normal left ventricular ejection fraction and in the absence of any significant calcification in the left main coronary artery, favorable for a rapid stenting procedure. Both groins were prepped and draped, with an intra-aortic balloon pump ready and on standby. 

A 4.0 mm x 8 mm Xience stent was deployed in the left main coronary artery at 18 atms. Adequate stent deployment was confirmed by intravascular ultrasound. The process of stent insertion, stent balloon dilatation, and balloon deflation took no more than 30 seconds. 

The patient tolerated the procedure very well, without any complications. The radial sheath was removed and a wristband was applied for hemostasis. The patient was monitored carefully in the stepdown unit and discharged home the next morning.

Dr. Samir Dabbous may be contacted at sdabbous7@icloud.com.