Complex Coronary Intervention Via Right Distal Transradial Access With Lusoria Subclavian Artery Under Refractory Electrical Storm: A Really Challenging Case

J INVASIVE CARDIOL 2021;33(1):E65-E66. doi:10.25270/jic/20.00056

Key words: distal transradial access, electrical storm, lusoria subclavian artery

The adoption of distal transradial access (dTRA) as default approach for coronary angiography and interventions was recently published. As a refinement of conventional (proximal) TRA, this technique has advantages in terms of patient and operator comfort and risk of radial artery occlusion. We report herein a very challenging case of coronary angiography (CAG) followed by complex percutaneous coronary intervention (PCI) via right dTRA (rdTRA), with aberrant (lusoria) subclavian artery, in the setting of non-ST segment elevation acute myocardial infarction complicated by refractory electrical storm.

A 78-year-old woman, former smoker with known hypertension, diabetes, and obesity presented to an outside hospital with prolonged and persistent rest chest pain and positive troponin raising, with complex persistent polymorphic ventricular arrhythmias alternating with periods of advanced second-degree atrioventricular block. She was then referred to our catheterization laboratory for urgent CAG. Immediately after lying on the cath lab table, she developed episodes of polymorphic, re-entrant, and incessant complex ventricular tachyarrhythmias, with periods of torsades de pointes (despite parenteral infusions of magnesium sulfate, metoprolol, amiodarone, and lidocaine), followed by ventricular fibrillation (reversed with prompt defibrillation) and unstable (syncope) sustained polymorphic ventricular tachycardia, requiring immediate synchronized electrical cardioversion (Video 1). After relative stabilization, the intended CAG was then performed via rdTRA (Figure 1), showing (1) aberrant (lusoria) right subclavian artery, with huge tortuosities and angulations up to the ascending aorta, making the selective catheterization of the coronary arteries extremely difficult; (2) complex, multiarterial obstructive coronary artery disease with highly calcified, tortuous, and severe long lesions at proximal and mid portions of the dominant right coronary artery (RCA) (Figure 2); and (3) calcified and severe lesion at the mid left anterior descending artery (LAD) involving the bifurcation with a large bifurcated diagonal branch (Figure 3). Due to refractory electrical storm presumably secondary to myocardial ischemia, the complex RCA and LAD lesions were all fixed by very complex ad hoc PCI with 3 drug-eluting stents (Figures 2 and 3), with multiple balloon pre- and postdilations via rdTRA, complicated by the presence of the aberrant (lusoria) subclavian artery, under refractory electrical storm, but with hemodynamic, neurological, and ventilatory stability. Transthoracic echocardiogram after PCI showed preserved global left ventricular contractility, without significant structural abnormalities. During the recovery period at the intensive care unit, the patient developed persistent and symptomatic (syncope) total atrioventricular block, requiring immediate temporary transvenous and posterior (14 days) permanent pacemakers. The patient was then discharged home without any neurological or cardiovascular complaints, under optimal medical therapy (aspirin, prasugrel, rosuvastatin, metoprolol, ramipril, metformin, and empagliflozin). Sixteen months later, she continues asymptomatic, under regular follow-up.

From the ¹Department of Interventional Cardiology, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil; ²Department of Interventional Cardiology, Hospital Regional do Vale do Paraíba, Taubaté, São Paulo, Brazil; ³Faculty of Medicine, Universidade de Taubaté (UNITAU), Taubaté, São Paulo, Brazil.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted February 7, 2020.

Address for correspondence: Marcos Danillo Peixoto Oliveira, Street: Napoleão de Barros, nº 715 -Vila Clementino, Sao Paulo-SP, Brazil, postal code 04024-002. Email: mdmarcosdanillo@gmail.com