Transradial Three-Vessel Coronary Angioplasty in a Patient with Bilateral Radial Artery Stenoses

The transradial approach as an access for percutaneous coronary intervention (PCI) has been widely adopted. However, anatomical variations and stenoses may pose significant challenges to the operator. We report a case of successful transradial PCI in a patient with triple-vessel disease and challenging bilateral radial artery anatomy. Case Report. A 74-year-old gentleman was referred to our center for transradial PCI. He had a history of hypertension and diabetes mellitus. A coronary angiogram, performed at another center for the patient’s exertion-induced angina, revealed triple-vessel disease. At that center, transfemoral PCI failed due to the patient’s bilateral tortuous iliac arteries that prevented the engagement of a suitable guiding catheter. Transradial PCI was then attempted at our center. The patient was already on aspirin 160 mg daily and clopidogrel 75 mg daily. A 6 French (Fr) arterial sheath was first placed in the right radial artery, and 6,000 units of heparin and 200 micrograms of glyceryl trinitrate (TNG) were administered through the radial sheath. However, a J-tip 0.035 inch Emerald guidewire (Cordis Corp., Miami, Florida) failed to pass through theproximal portion of radial artery. Contrast injection revealed a proximal radial artery loop with diffuse stenoses, which resolved subsequently upon administration of intra-arterial TNG. The disease-free radial artery loop (Figure 1A) was then successfully crossed with a J-tip 0.035 inch Radifocus hydrophilic wire (Terumo, Japan). The radial loop was successfully straightened with the hydrophilic wire, causing mild pain to the patient. A 5 Fr Zuma2 guiding catheter (Medtronic, Inc., Minneapolis, Minnesota) was passed, but it caused severe pain to the patient and could not be passed much beyond the radial loop. The procedure was stopped and another 6 Fr arterial sheath was placed in the left radial artery. Again, the J-tip Emerald 0.035 inch wire was unable to pass through the proximal radial artery. An angiogram was performed, revealing a tight proximal radial artery stenosis, which persisted after injecting 200 micrograms of TNG through the arterial sheath (Figure 1B). The lesion was then crossed with a 0.014 inch BMW coronary guidewire (Guidant Corp., Indianapolis, Indiana), and then dilated with a 3.0/20 Aqua coronary balloon (Cordis) at 8 atm (Figure 1C). Mild spasm with some residual stenosis was observed afterwards (Figure 1D). The lesion was then crossed with a J-tip Radifocus hydrophilic 0.035 inch guidewire, and a 6 Fr JL4 Zuma2 guiding catheter was successfully passed. Coronary angiography of the coronary arteries on the left side revealed, by visual estimation, a long, diffuse 90% left anterior descending artery (LAD) stenosis and a subtotal distal left circumflex artery, with a 85% left obtuse marginal artery stenosis (Figures 2A and B). PCI was successfully performed after predilatations with implantation of 3 Cordis sirolimus-eluting stents (2.25/33 mm, 3.0/33 mm and 3.0/8 mm) in the LAD, and one 2.5/28 mm Tetra stent (Guidant) at the left obtuse marginal artery (Figures 2C and D). A 6 Fr JR 3.0 Zuma2 guiding catheter was then exchanged for PCI of the right coronary artery (RCA), which on angiography, showed by visual estimation a 90% stenosis at the posterior descending artery (PDA) and 70% stenoses at the mid and proximal RCA (Figure 3A). Balloon angioplasty was successfully performed on the PDA with a 4.0/18 mm Tetra stent and another two 4.0/23 mm and 4.0/8 mm Tetra stents were implanted in the mid and proximal RCA, respectively (Figure 3B). The guiding catheter and the guidewire were withdrawn and a radial arteriogram after intra-arterial nitrate administration revealed minimal residual stenosis at the proximal radial artery (Figure 4). The patient was discharged uneventfully and was angina-free at 30 days. Discussion. Anatomical variations and stenoses are commonly encountered during transradial PCI and may cause access failure.¹ With proper technique, however, these access problems can often be overcome, and operators should not assume failure of the procedure too easily. Also, the initial pseudostenosis that resolved on intra-arterial TNG administration is not uncommon. Such spasm is occasionally induced during placement of the arterial sheath, and spasm should first be excluded with intra-arterial TNG before any stenosis in the radial artery is diagnosed. The complete loop of the proximal radial artery encountered in our patient is a common cause of access failure. Sometimes the loops may be crossed and straightened using hydrophilic wires with eventually successful PCI.² However, in our patient, severe pain was induced with straightening of the loop with wire and with passage of the guiding catheter. The procedure was stopped, as continuation of the manipulation can cause tearing and even rupture of the radial artery. Passage of guiding catheters, without pretreatment, through a tight stenosis such as that encountered in the left radial artery in our patient, may cause severe dissection. With careful pre-dilatation, access through the stenosis can often be allowed, as was done in our patient. Due to the proximity of the lesion to the elbow joint and the superficial location of the radial artery, stenting should be avoided if possible. If stenting is unavoidable, a self-expanding stent should be used to minimize the risk of stent deformation by external pressure. Although transradial PCI had successfully revascularized this diabetic patient with complex multivessel disease, the authors would like to point out that PCI has not been shown to be superior to bypass surgery in this patient subgroup. In studies like BARI and ARTS, patients with triple-vessel disease, particularly those with diabetes, who received PCI, had a higher rate of repeat revascularization when compared with those who underwent bypass surgery.^3,4 Despite the fact that drug-eluting stents may have narrowed the gap in repeat revascularization and mortality benefit between bypass surgery and PCI, further randomized trials are needed before we can advocate the routine use of PCI with DES in this subset of patients. Before the procedure, such information was discussed thoroughly with the patient, who ultimately opted for PCI. PCI of all three coronary arteries was performed in the same session because of the patient’s history of failed transfemoral approach and failed transradial access in the opposite radial artery. Conclusions Anatomical variations are common causes of access failure in the transradial approach. With careful technique, however, transradial access can often be achieved without local complications.

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