Recannulation of Distal Radial Artery for Staged Procedure After Successful Primary Percutaneous Coronary Intervention

J INVASIVE CARDIOL 2018;30(10):E105-E106.

Key words: acute coronary syndrome, cardiac imaging, myocardial infarction, radial artery 

A 76-year-old man presented with sudden-onset chest pain at rest and evidence of ST-segment elevation in the anterior electrocardiogram leads. After loading of aspirin 300 mg and ticagrelor 180 mg, urgent coronary angiography (CAG) was performed via left distal radial artery (the so-called snuffbox approach), which was successfully cannulated by 6 Fr sheath with administration of 3000 U unfractionated heparin via sheath. CAG demonstrated the severe stenosis in the proximal left anterior descending artery (LAD) with flow limitation (Figure 1A). Primary percutaneous coronary intervention (PCI) was successfully performed with a 2.5 x 18 mm everolimus-eluting stent (EES) after intracoronary bolus of abciximab (Figure 1B). Regarding the diffuse intermediate stenosis in mid-LAD and mid right coronary artery (RCA) (Figures 1B and 1C), we planned staged fractional flow reserve (FFR)-guided complete revascularization. Hemostasis was successfully obtained by compressive bandage with gauze for 3 hours (Figure 1E). 

Three days later, vascular ultrasonography demonstrated patent left distal radial artery (Figure 1F). Therefore, coronary catheterization was performed again via left snuffbox approach (Figure 1G). During hyperemia, the FFR measurement was 0.88 in the mid-RCA and 0.74 in the mid-LAD and it led to another 2.5 x 38 mm EES implantation in the mid-LAD. Final CAG showed good distal flow without residual stenosis (Figure 1D). There was no puncture-site bleeding after hemostasis for 3 hours (Figure 1H).

There are limited data regarding snuffbox approach, even though it has been interesting for the interventional cardiologists. Our experience highlights the feasibility of the snuffbox approach as the access route for primary PCI and recannulation of distal radial artery for staged PCI.

From the ¹Division of Cardiology, Chonnam National University Hospital, Gwangju, Korea; ²Division of Interventional Cardiology, City Clinical Hospital No 52, Moscow, Russia; ³Division of radiology, Sechenov First Moscow State Medical University, Moscow, Russia; ⁴Chungbuk Regional Cardiovascular Center, Chungbuk National University Hospital, Cheongju, Korea; and ⁵Division of Cardiology, Department of Internal Medicine, Chungbuk National University, College of Medicine, Cheongju, 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 accepted July 23, 2018. 

Address for correspondence: Myung Ho Jeong, MD, PhD, Cardiovascular Convergence Research Center of Chonnam National University Hospital, Gwangju 501-757, Republic of Korea. Email: myungho@chollian.net