Transradial Subclavian and Coronary Stenting in a Single Procedure

The transradial approach is a useful technique in patients undergoing percutaneous coronary intervention. As compared to femoral access, it is associated with reduced access site bleeding, lower patient morbidity, less post-procedure staff utilization and has been adopted at an increasing number of centers worldwide.^1–5 Although unusual, the presence of severe subclavian occlusive disease is an occasional cause for inability to access the coronaries from the radial artery. We describe two cases in which transradial coronary stenting of severe subclavian artery stenoses allowed successful coronary stenting as part of the procedure. Case Report 1. A 65-year-old white, diabetic female with no prior history of coronary artery disease was admitted for recurrent chest pain, an abnormal stress test and elective cardiac catheterization with possible intervention. A 6 French (Fr) MP guide catheter was inserted radially but could not be passed into the ascending aorta. Angiography revealed a 90% stenosis of the right subclavian artery (Figure 1A). The lesion was crossed with a 0.014 Luge guidewire and a 5.0/24 mm Wallstent which was post-dilated with a 5.0/22 mm Ranger (Boston Scientific Scimed, Maple Grove, Minn.) inflated to 16 atmospheres (Figures 1B, 1C). Subsequent angiography revealed incomplete lesion coverage. A second 5.0/24 mm Wallstent was thus deployed distal to the first stent and post-dilated with a 6.0/20 mm Speedy balloon inflated to 12 atmospheres. Angiography revealed full stent expansion of both subclavian stents with no residual subclavian artery stenosis (Figure 1D). A 6 Fr Kimny guide catheter was passed through the Wallstents and coronary angiography was performed. A 90% stenosis was demonstrated in the left circumflex. The patient was enrolled in the TAXUS IV stent trial (Boston Scientific Scimed, Maple Grove, Minn.) after informed consent had been obtained. Pre-dilation was performed with a 3.0/15 mm Crossail balloon (Guidant, Indianapolis, Indiana). A 3.0/16 mm Taxus stent was then deployed and post-dilated to 12 atmospheres with the Express delivery balloon (Boston Scientific Scimed). Post-procedure angiography revealed full coronary stent expansion. Total contrast used was 220 ml and fluoroscopy time was 34.8 min. The patient tolerated the procedure without complications. Pre-procedure serum creatinine was normal and remained normal following the procedure. Case Report 2. An 80-year-old black diabetic female with a history of successful two vessel coronary stenting of the right coronary and left anterior descending arteries with PTCA only of the left circumflex artery six months previously. She was admitted with recurrent chest pressure, non-specific EKG changes and negative cardiac enzymes. Catheterization via the femoral approach revealed a 90% stenosis of the right subclavian artery (Figure 2A) and a 99% stenosis in the first obtuse marginal artery. The procedure was described by the operator as extremely difficult due to iliofemoral disease. The patient was transferred for elective percutaneous intervention. A 6 Fr Kimny guide catheter (Boston Scientific Scimed) was inserted via the radial artery and positioned just proximal to the subclavian lesion. A 0.014 Trooper guidewire was positioned in the aorta and the subclavian lesion was directly crossed with a 5.5/23 mm Wallstent (Boston Scientific Scimed) (Figure 2B). The stent was deployed without difficulty, and post-delivery inflations were performed with a 5.5/20 mm Speedy balloon (Boston Scientific Scimed) inflated to 14 atmospheres (Figure 2C). Subsequent angiography revealed full stent expansion without residual narrowing (Figure 2D). The guide catheter was then passed through the Wallstent and positioned in the left main (Figure 2E). A 2.5/12 mm Pixel stent (Guidant Corp., Santa Clara, Calif.) was advanced across the obtuse marginal lesion and deployed with a 14 atmosphere inflation after predilatation with a 20/15 Maverick (Boston Scientific Scimed). A total of 320 ml contrast was used during the procedure and fluoroscopy time was 20.2 minutes. Pre-procedure serum creatinine was normal and remained normal following the procedure. The patient was subsequently discharged without complications. One month later, the patient was readmitted for chest pain. Angiography revealed a patent right subclavian artery and patent coronary arteries without restenosis. Discussion We describe two cases in which severe subclavian stenoses were successfully managed with balloon angioplasty and stenting through 6 Fr guide catheters from the transradial approach. Coronary interventions were subsequently performed through the stented segments as part of the same procedure. Subclavian disease is a rare cause of inability to perform a transradial coronary intervention, occurring in less than one percent of cases. The subclavian may be subtotally or totally occluded, thus preventing access to the ascending aorta from the radial artery. Subclavian disease may be treated successfully with angioplasty and stenting, although the procedure has traditionally been performed transfemorally because of the need for large bore catheters to deploy larger balloons and stents.^6–12 However, current miniaturization of angioplasty devices now allows even large stents to be deployed through smaller guide catheters. In both of the present cases, subclavian stenting was performed through 6 Fr catheters using 5.0 mm Wallstents. Direct stenting was performed in both cases and the stents were post-dilated using a 5.0–6.0 mm balloon. Subclavian stenting was performed expeditiously using a relatively small amount of contrast. Thus, coronary stenting could be performed as part of the same procedure through the stented segment. There are several controversial aspects to the present cases. Neither patient was symptomatic and the indication for the stent procedure was the need to complete the percutaneous intervention from the radial access site. Stent size was relatively small for the subclavian vessels, although both patients were relatively small women; more traditional larger subclavian stents would require large bore catheters. Additional contrast was required for the subclavian procedures although both patients’ renal function remained normal. Wallstents were used in both cases and stronger stent designs are more commonly used for contemporary subclavian procedures. Indeed, Wallstent fractures have been described in the shoulder vessels. In this regard, angioplasty alone may be a possible option if the goal is only to complete the transradial procedure.^13–16 The present cases illustrate the technical ease of management of subclavian disease using the ipsilateral radial artery access site. Furthermore, subclavian disease may not necessarily be the cause for failure of a transradial coronary procedure.

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