15 Jul 2019
BAT technique to the rescue during primary PCI
#CardioTwitterCase originally published on Twitter
Consult this Twitter Case concerning a 61-year-old man with a diagnosis of anterior STEMI who was immediately transferred to the cath lab for primary percutaneous coronary intervention...
This case was originally published on Twitter by @crkiamco via #CardioTwitterCase
Clinical presentation
61-year-old man with history of type 2 diabetes, presented to the ER with chest pain that started 1 hour prior to his arrival.
A diagnosis of anterior STEMI was made and immediately transferred to the cath lab for primary percutaneous coronary intervention. The coronariography, accessing through distal right radial artery with 6F sheath and TIG 5F catheter, showed medial third occlusion of the left descending artery as culprit lesion (figure 1).
The circumflex obtuse artery and the right coronary artery both had intermediate lesions (40 and 45%, respectively).
Figure 1. Left anterior oblique caudal view, appreciating occlusion of the LAD.
Case management
At the time of advancing the guide catheter (EBU 3.5-6F) a resistance at elbow level is noted and an angiography of the arm is made, demonstrating a radial artery dissection with contrast extravasation (video 1). With a 0.014” Runthrough guidewire it was possible to negotiate the dissection via the true lumen. A 2.5/15mm Ryujin balloon was placed, one half inside the guide catheter and the other half outside de catheter (on the distal end of the catheter). The balloon was then insufflated at 4ATM and the catheter was then advanced and tracked without resistance up to ascending aorta (BAT-Balloon Assisted Tracking) (video 2).
An angioplasty was made using the same balloon and a DES Orsiro 2.75x18mm was implanted, obtaining TIMI 3 flow (figure 2). Once the guide catheter was removed from the arm, an angiography of the dissected region was made, visualizing a complete sealed lesion and without contrast extravasation (video 3).
Figure 2. Posterior anterior craneal view, showing the result of the stent implant, with TIMI 3 flow.
The sheath was removed and using a StatSeal a compressive bracelet was placed, obtaining a patent hemostasis. The patient was discharged 5 days after the event, with a satisfactory outcome and enrolled in a cardiac rehabilitation program.
Negotiating the dissection in the artery of the arm with care, and performing the “BAT” technique, did not take more than two minutes; the guide catheter worked as a cast or scaffold, sealing the dissection during the primary PCI. Both tips and tricks should always keep in mind in the armamentum of the radial operator.
Original tweet and Twitter discussion
Primary PCI 4 Anterior STEMI #RadialFirst#distal#snuffbox dissection with the guide + runthrough & BAT @dimitri_zappi@INC_CathLab@mmamas1973@RadialFirstBotpic.twitter.com/GBOztNnrNy
— crkiamco (@crkiamco) June 17, 2019
3 comments
This is nice approach because of the guide catheter assisted as sealing and balloon as a guide to pass the catheter...
In my experience, dissection or rupture of the radial artery never occurs until trying to force the guide/catheter/guiding catheter against a perceived resistance. This case presentation elegantly describes the optimal way of dealing with this kind of complication, however it sometimes is quite difficult(and very seldom impossible) to pass a PCI wire through. It is important to prevent such a complication, and that is by immediately stopping whenever you feel resistance, do a radial artery angio, understand the problem and decide a strategy accordingly. Most of the time one can deal with this by rapid injection of 10ml of contrast through the sheath(spasm) or going on with BAT to prevent rupture(spasm or/and very tortuos vessel).
Good case, thank you very much. BAT technique is very useful to solve this complication. But in my practice i use another technique, that is more rapid and less costly i think. Despite radial artery rupture is very rare complication, but if it occur, i take "pigtail"catheter one Fr less than guide catheter and insert it inside guide. Pigtail is longer than the guide and creates a step on the tip of the guide. This system facilitates and do more safer the movement or the guide through the ruptured artery, and "pigtail" eliminate the "blade effect" of guide.