13 Sep 2018
Navigating a high take-off of the radial artery with spasm during trans-radial coronary intervention
Consult this Twitter case concerning a 70-year-old woman who presented with acute coronary syndrome (non-ST elevation myocardial infarction).
Radial artery spasm specially when encountered in a small caliber vessel could be a cause for radial access failure and cross-over to femoral access. Here is a technique on how to deal with this.
This case was originally published on Twitter by @Jedicathvia #CardioTwitterCase
Clinical presentation
This is the case of a 70-year-old woman who presented with acute coronary syndrome (non-ST elevation myocardial infarction). After a standard right radial artery access via a 6F Terumo sheath we noticed that the J-wire had resistance at the level of the elbow. An angiography revealed a high take-off of the radial artery from the proximal brachial artery and the vessel was both small in caliber and spastic. Even after intra-arterial verapamil and nitroglycerine the standard J-wire could not navigate it.
Case Management
We used a 0.014 BMW (Abbott Vascular) coronary guidewire to navigate it. Using 5F diagnostic catheters an Ultimate 2 (Merit Medical) diagnostic angiography was performed. This showed two severe culprit lesions in the right coronary artery.
As 5F guiding catheters were not available and a standard 6F JR4 guide would not cross the radial artery, instead we used a technique where a 2.5 / 20 mm coronary balloon was passed in the guide and was inflated at 12 ATM half way out of the distal end of the guide. The combined balloon and guide was then placed on the prior 0.014 BMW wire with the razor edge of the guide “protected” by the inflated balloon. We could then easily cross the radial artery into the subclavian artery and then proceed with standard PCI of the RCA.
Original tweet and Twitter discussion
First successful #RadialFirst BAT
— Jedicath (@jedicath) 6 septembre 2018
70 year old lady with high take off radial 5F dx cath passed but 6F guide wouldn't <5F guides not available> pic.twitter.com/n64Fm0KRC4
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1 comment
excellent