Prone Position Coronary Angiography Due to Intractable Back Pain: Another Merit of Transradial Approach Compared to Transfemoral Approach

Abstract: We report a case of prone position coronary angiography due to intractable back pain via left transradial approach. When a patient cannot lie down in a supine position, prone position coronary angiography can be performed alternatively. This may be another merit of transradial approach compared to transfemoral approach on the evaluation of patients with suspected coronary artery disease.

J INVASIVE CARDIOL 2012;24(11):605-607

Key words: transradial coronary angiography, prone position

________________________________________________________

Case Report

A 60-year-old man with past medical history of diabetes and hypertension was referred to cardiology for the evaluation of peri-operative cardiovascular risk assessment. He had been admitted to the orthopedic department due to severe back pain that developed 1 month ago and was scheduled to undergo spine surgery. Seven years prior, he had undergone posterior lumbar interbody fusion (PLIF) of L3-4-S1 level due to spinal stenosis. On admission, lumbar spine magnetic resonance imaging (MRI) revealed chronic discitis at the L1-2 level, suggestion of low-grade pyogenic discitis, screw fracture and dislocation at L4 vertebral body, and mild degenerative bulging residual disc at the L3-4 level.

Physical examination revealed blood pressure of 140/90 mm Hg and a pulse of 109 beats/min. Auscultation showed clear lung sounds, normal heart beats, and no murmur or gallop. Twelve-lead electrocardiography revealed sinus tachycardia, and pathologic Q-wave in leads II, III, aVF (Figure 1). Laboratory analysis revealed creatine kinase (CK), 520 U/L (normal values: 24-170 U/L); CK-MB, 5.3 µg/mL (normal values: 0-6.6 µg/mL), troponin I, 0.037 ng/mL (normal values: <0.028 ng/mL), and brain natriuretic peptide, 34.8 pg/mL (normal values: 0-100 pg/mL). Even after careful, repetitive history taking and physical examination, he denied symptoms of chest pain or discomfort, since his back pain was so severe and intractable. However, under the diagnosis of recent myocardial infarction, we performed transthoracic echocardiography (TTE). TTE showed left ventricular (LV) ejection fraction of 51% with regional wall motion abnormalities — akinesis on basal segment of inferoseptum, severe hypokinesis on basal and mid-LV segments of inferior wall — corresponding to RCA (right coronary artery) territory ischemia.

For further evaluation and proper perioperative risk assessment, we decided to undergo invasive coronary angiography. Since the patient suffered from intractable back pain, we gave him intravenous injection of meperidine hydrochloride, a potent opioid analgesic drug, prior to coronary angiography. However, the back pain was so severe, he could not lie down despite this treatment. Therefore, the position of the patient was changed from supine position into prone position, and consequently, he was able to undergo coronary angiography by left transradial approach (Figure 2). Coronary angiography with a 5 Fr Judkins right catheter revealed total occlusion of the proximal RCA (Figure 3). Coronary angiography with a 5 Fr Judkins left catheter revealed diffuse 50%-60% luminal narrowing of the proximal to distal left anterior descending coronary artery (LAD) and total occlusion of the proximal left circumflex coronary artery (LCX) with collateral flows from distal LAD and septal branches to posterior descending and posterolateral branches of the RCA (Figure 4).

Since complete revascularization by percutaneous coronary intervention was not feasible, we decided to perform coronary artery bypass graft surgery (CABG) prior to spine surgery. Thus, medial branch block was done to relieve the patient’s back pain. Afterward, he underwent CABG (left internal mammary artery to distal LAD, aorta to diagonal branch, and posterolateral branch with saphenous vein graft). He remained clinically and hemodynamically stable during the 7 days of hospitalization and was discharged home. After medial branch block, his back pain relieved to a tolerable range, so we decided to postpone the spine operation for a few months.

Discussion

Since the first report of successful coronary angiography via transradial approach in 1989,¹ the radial artery has been increasingly used as an alternative access site to the femoral artery. Although transradial approach has its disadvantage of longer learning curve and higher procedural failure, which may lead to a crossover to the transfemoral route,² it has advantages of similar major adverse cardiovascular event (MACE) rates, lower bleeding complication rates, and reduced length of hospitalization when compared to the transfemoral approach.^3,4

When performing the transradial approach, there is an issue of which access site (left radial approach or right radial approach) is more feasible. The left radial approach may have several advantages compared to right radial approach in terms of vascular anatomy (ie, tortuosity of the subclavian artery), similarity of vascular pathway that may lead to similar manipulation technique to that of the transfemoral approach, and allowance of selective catheterization of the left internal mammary artery, which is frequently used in CABG.^5,6 In concordance with this perspective, a recent study reported that left radial access was associated with reduction in fluoroscopy time and the number of catheters used.6 In contrast, several other recent studies demonstrated that left radial approach was not associated with a significant reduction in procedural times, fluoroscopy times, or success rates compared to the right radial approach.^7-9 Probably, further larger and randomized-controlled studies are warranted to clarify the advantages of left radial approach versus right radial approach.

In our case, prone position coronary angiography was performed without difficulty. In addition, interpretation of prone position coronary angiography was simply done since only the cranial and caudal views were opposite compared to conventional supine position angiography. These consequences may be due to the geometry of the heart as well as the coronary anatomy, which were neither parallel nor perpendicular to the patient’s position. Although we did not undergo percutaneous coronary intervention (PCI) since it was not feasible to achieve complete revascularization, performing prone position PCI would not be troublesome compared to conventional supine position PCI.

Our article illustrates a case of prone position coronary angiography via left transradial approach of a patient with intractable back pain. When a patient cannot lie down in a supine position, prone position coronary angiography can be performed alternatively. This may be another merit of the transradial approach compared to the transfemoral approach when evaluating patients with suspected coronary artery disease.

References

1. Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn. 1989;16(1):3-7.
2. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004;44(2):349-356.
3. Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J. 2009;157(1):132-140.
4. 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;377(9775):1409-1420.
5. Lo TS, Nolan J, Fountzopoulos E, et al. Radial artery anomaly and its influence on transradial coronary procedural outcome. Heart. 2009;95(5):410-415.
6. Dominici M, Diletti R, Milici C, et al. Left radial versus right radial approach for coronary artery catheterization: a prospective comparison. J Interv Cardiol. 2012;25(2):203-209.
7. Biondi-Zoccai G, Sciahbasi A, Bodí V, et al. Right versus left radial artery access for coronary procedures: An international collaborative systematic review and meta-analysis including 5 randomized trials and 3210 patients. Int J Cardiol. 2011 Dec 20 (Epub ahead of print).
8. Larsen P, Shah S, Waxman S, et al. Comparison of procedural times, success rates, and safety between left versus right radial arterial access in primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction. Catheter Cardiovasc Interv. 2011;78(1):38-44.
9. Freixa X, Trilla M, Feldman M, Jiménez M, Betriu A, Masotti M. Right versus left transradial approach for coronary catheterization in octogenarian patients. Catheter Cardiovasc Interv. 2012;80(2):267-272.

________________________________________________

From the ¹Division of Cardiology, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea, and ²the Department of Cardiology and Cardiovascular Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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 April 26, 2012 and accepted May 8, 2012.
Address for correspondence: Sung Woo Kwon, MD, Clinical Assistant Professor, Division of Cardiology, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, 225 Geumhak-no, Cheoin-gu, Yongin-si, Gyeonggi-do, 449-930, Republic of Korea. Email: mdsungwoo@yuhs.ac