Left Radial Artery Access to a Descending Aortic Saphenous Vein Graft to Circumflex Coronary Artery for Angioplasty

Abstract: As data continue to show the benefits of radial artery access, the versatility and feasibility of this approach for complex coronary interventions is continually tested. We report successful angioplasty of a circumflex obtuse marginal coronary lesion crossed retrogradely via a saphenous vein graft arising from the descending aorta, accessed via the left radial artery.

J INVASIVE CARDIOL 2012;24(7):352-353

Key words: radial access, percutaneous intervention

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An 85-year-old male presented with progressive angina compromising his quality of life. Coronary bypass surgeries had been performed 13 years and 4 years previously. On the second occasion, a vein graft was anastomosed from the descending aorta to the circumflex coronary artery through a lateral thoracotomy (Figures 1 A and 1B). He has since required two percutaneous interventions to the left main coronary artery for refractory angina despite medical optimization.

On this occasion, diagnostic catheterization via the left radial artery demonstrated a new 90% stenosis in the grafted native circumflex obtuse marginal, proximal to the graft anastomosis (Figure 2). This threatened two other moderate-size obtuse marginal branches and was thought to be the only possible culprit. Through a 6 Fr Judkins right guide catheter (Medtronic), a Fielder wire (Abbott Vascular) was passed through the vein graft to the anastomosis and retrogradely up the circumflex obtuse marginal and across the stenosis (Figure 3). The lesion was angioplastied with a 2.5 x 15 mm Sprinter balloon (Medtronic) at 12 atm. A 2.5 x 18 mm bare-metal Driver stent (Medtronic) failed to negotiate the 135% angle into the coronary artery at the anastomosis, despite excellent guide catheter backup. Since the angioplasty result was excellent (<10% residual; Figure 4), further attempts to stent were abandoned. The patient was discharged later the same day. Routine coronary angiography 10 months later, prior to transcutaneous aortic valve implantation, showed a sustained good result (Figure 5).

The benefits of radial artery catheterization have been documented.^1-4 Specifically, shorter operator learning curves have been seen with left radial access with reduction in fluoroscopy times and a trend toward lower contrast dose.⁵ This may be in part due to the similarity of catheter use and manipulation between left radial and the femoral approach. An added benefit to left radial access, which proved useful in this case, was easier access to the descending aorta. This may also facilitate angiography of renal or peripheral arteries.⁶

Coronary intervention through a graft to a lesion in the native coronary artery proximal to the anastomosis has been previously reported,^7,8 but is seldom performed. In the case reported here, left radial artery access was selected to allow direct access to both the left internal mammary artery^9,10 and the descending aorta vein graft. In summary, radial access can be used to reach targets in unusual locations, and the limits of radial access have not yet been identified.

References

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2. Pristipino C, Trani C, Nazzaro MS, et al. Major improvement of percutaneous cardiovascular procedure outcomes with radial artery catheterisation: results from the PREVAIL study. Heart. 2009;95(6):476-482.
3. Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;23(9775):1409-1420. 
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5. Sciahbasi A, Romagnoli E, Trani C, et al. Evaluation of the “learning curve” for left and right radial approach during percutaneous coronary procedures. Am J Cardiol. 2011;108(2):185-188. 
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7. Brilakis ES, Banerjee S, Lombardi WL. Retrograde recanalization of native coronary artery chronic occlusions via acutely occluded vein grafts. Cathet Cardiovasc Interv. 2010;75(1):109-113. 
8. Burzotta F, Trani C, Coroleu S. Retrograde recanalization of left main from saphenous vein graft supported by percutaneous Impella Recover LP 2.5 assist device. J Invasive Cardiol. 2009;21(8):E147-E150. 
9. Mann T, Cubeddu G, Schneider J, Arrowood M. Left internal mammary artery intervention: the left radial approach with a new guide catheter. J Invasive Cardiol. 2000;12(6):298-302. 
10. Sciahbasi A, Romagnoli E, Burzotta F, et al. Transradial approach (left vs right) and procedural times during percutaneous coronary procedures: TALENT study. Am Heart J. 2011;161(1):172-179.

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From the ¹Department of Cardiology, Heart and Vascular Institute at Geisinger Medical Center, Danville, Pennsylvania and ²Interventional Cardiology, Sparks Health System, Fort Smith, Arkansas.
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.
Manuscript submitted December 22, 2011, provisional acceptance given January 5, 2012, final version accepted February 14, 2012.
Address for correspondence: Nevin C. Baker, DO, Department of Cardiology 27-75 Geisinger Medical Center, 100 North Academy Drive, Danville PA 17822. Email:  ncbaker@geisinger.edu