Single Radial Access Simultaneous Left Ventricular and Ascending Aortic Pressure for the Evaluation of Aortic Stenosis: The “Double-Barrel” Technique

Abstract

The use of simultaneous left ventricular and ascending aortic pressure tracings by cardiac catheterization is the gold standard of care for accurate hemodynamic assessment of aortic stenosis severity in patients with equivocal echocardiogram. We describe the first-in-man single radial access “double-barrel” technique for the evaluation of aortic stenosis. A 7-Fr Glidesheath Slender hydrophilic-coated introducer sheath (Terumo) was placed in the right radial artery. Two 4-Fr pigtails, 1 in the left ventricle and 1 in the ascending aorta, were advanced through the single sheath. The single radial access “double-barrel” technique is a simple way to accurately evaluate patients with aortic stenosis, avoiding multiple access sites or femoral access.

Keywords: aortic stenosis, aortic valve stenosis, hemodynamics

The use of simultaneous left ventricular and ascending aortic pressure tracings by cardiac catheterization is the gold standard of care for the accurate hemodynamic assessment of aortic stenosis severity in patients with equivocal echocardiogram.¹ After the recall of the Langston dual-lumen pigtail catheter (Teleflex) in 2020, the use of 2 vascular access sites or a single large femoral arterial sheath was needed to acquire the same results.² We describe the first-in-man single radial access “double-barrel” technique for the evaluation of aortic stenosis.

Technique Description

A 7-Fr Glidesheath Slender hydrophilic-coated introducer sheath (Terumo) was placed in the right radial artery in the standard fashion. A 6-Fr AL-1 diagnostic catheter was used to cross the aortic valve with the use of a straight 0.035˝ guidewire. A J-tip 0.035˝ exchange wire was advanced in the left ventricle to assist with the introduction of a 4-Fr pigtail in the left ventricle. The J wire was then introduced next to the 4-Fr pigtail catheter through the slender sheath and advanced to the ascending aorta. A second 4-Fr pigtail catheter was positioned in the proximal ascending aorta. Hemodynamic assessment of the aortic stenosis was measured with the evaluation of the pressure waveforms from the two 4-Fr pigtail catheters simultaneously (Figure 1 and Figure 2).

Discussion

Echocardiography is currently the standard imaging technique for the evaluation of aortic stenosis. The 2020 American College of Cardiology/American Heart Association guidelines recommend cardiac catheterization for the determination of severity of aortic stenosis when data from noninvasive testing are either nondiagnostic or if there is a discrepancy between clinical and echocardiographic evaluation.¹

Optimal hemodynamic assessment requires simultaneous pressure tracings of the left ventricle and the proximal ascending aorta. Using a single vascular access, evaluation of the aortic stenosis severity can be performed with the comparison of the left ventricular waveform to the femoral or radial sheath waveform, which has often been inaccurate due to the pressure tracing shift. The use of longer sheaths (45 or 90 cm) may improve the accuracy of the technique.³ The traditional pigtail catheter “pull-back” technique does not allow simultaneous measurement and can be affected by premature ventricular contractions, atrial arrhythmias, or pressure changes associated with breathing.⁴ The “mother-child” technique involves the placement of a long, 4-Fr pigtail inside a 6- or 7-Fr guiding catheter. A different technique (fractional flow reserve) requires the introduction of a pressure wire to the left ventricle. This technique requires additional postprocedure measurements and calculations for the determination of the transaortic gradient and the aortic valve area (Figure 3).

The development of the dual-lumen pigtail produced excellent simultaneous real-time pressure tracings without timing delay or systemic pressure overshoot, requiring a single access. In March 2020, the Langston catheter was recalled due to reports of tip fracture.

The novel 7-Fr Glidesheath Slender, which has a smaller outer diameter of 2.79 mm, can be inserted in most radial arteries. Here, we report a novel technique with the use of two 4-Fr pigtail catheters through a single 7-Fr radial arterial sheath. This technique obviates the need for additional arterial access site, which may increase the risk of complications.

Study limitations. This is the first description of the single radial access “double-barrel” technique. It is unclear whether smaller radial arteries can accommodate the passage of two 4-Fr catheters. It is also unknown if this technique may affect the long-term patency of the radial artery. We have not attempted a different type of 4-Fr catheter or a Glidesheath instead of the second pigtail catheter.

Conclusion

The single radial access “double-barrel” technique is a simple way to accurately evaluate patients with aortic stenosis, avoiding multiple access sites or femoral access. This strategy avoids unnecessary vascular complications from multiple access sites.

Affiliations and Disclosures

From the ¹HCA Northside Hospital, St Petersburg, Florida; ²University of Texas, MD Anderson Cancer Center, Houston, Texas; ³University of California Irvine, Irvine, California; and ⁴School of Medicine, Bahcesehir University, Istanbul, Turkey.

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.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted September 30, 2021.

Address for correspondence: Konstantinos Marmagkiolis, MD, 29333 Picana Lane, Wesley Chapel, FL 33543. Email: c.marmagiolis@gmail.com

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