A 57-year-old white male with history of previous tobacco abuse and hypertension presented to another facility with acute onset of chest discomfort. He was found to have acute inferior wall ST elevation (Figure 1). The patient was transferred to Winter Haven Hospital for an emergent left heart catheterization.
Left anterior descending: The LAD is patent.
Left circumflex (LCX): The LCX is patent.
Ramus: The ramus artery is patent.
Right coronary artery (RCA): The RCA is 100% occluded distally, just prior to the bifurication of the posterior descending artery (PDA) and posterior left ventricular branches (PLV).
Left ventricular end diastolic pressure is 18mmHg.
Ejection fraction is 50% with inferiorbasal hypokinesis (Figure 2). No transvalvular gradient is noted on pullback.
Given the patient’s angiographic findings, we proceeded with the revascularization at the RCA. The procedure began by engaging the RCA using the Ikari right guide catheter (Terumo). Bivalirudin was administered and a Runthrough wire (Terumo) easily passed distally. The lesion involved the distal RCA and extended into the PDA and PLV (Figure 3). We did a primary stent with a 2.5 x 14mm Resolute Integrity drug-eluting stent (Medtronic) and post dilated with a 3.0 x 8 mm Quantum balloon (Boston Scientific) in the proximal portion (Figure 4). There was what appeared to be distal reflow, but no reflow in the PLV branch. We passed the wire distally and did a low pressure inflation with a 2.0 x 20mm Apex balloon (Boston Scientific) in that small PLV branch, which resulted in better flow and resolution of the patient’s EKG changes (Figure 5). The patient tolerated the procedure well.
Door-to-balloon time is of paramount importance in the treatment of ST elevation myocardial infarction. Recent strategic changes for the treatment of STEMI has resulted in the many operators adopting a culprit artery first strategy, with a guide catheter followed by subsequent imaging of the remaining coronaries, as well as assessment of the left ventricle. The Ikari guides can be used as universal catheters to engage both the left and right coronary tree. Based on this operator’s experience, the Ikari left tends to be easier to use for universal engagement and is usually the catheter of choice for treatment of STEMI, particularly when the culprit vessel is uncertain. In this case, there was strong suspicion that the RCA was the culprit, so the Ikari right was chosen. The radial approach was chosen as the access site. It is the default approach for this operator in over 90% of cases, including chronic total occlusions, prior bypass, and STEMIs. Recent data has demonstrated that the radial approach reduces major adverse cardiac events (MACE) and mortality compared to the transfemoral approach in the treatment of STEMI.1,2
This case demonstrates that the transradial approach for acute coronary syndromes (ACS) can be safe and efficacious. This case also demonstrates that a one-catheter technique from beginning to end is possible with the proper tools at the disposal of the interventional cardiologist. The Ikari right 1.0 is an excellent guide catheter for this technique and should be available to all radialists.
Donnie Whatley, RN, CCRN, can be contacted at: email@example.com.
- Barthelemy O, Silvain J, Brieger D, et al. Bleeding complications in primary percutaneous coronary intervention of ST-elevation myocardial infarction in a radial center. Catheter Cardiovasc Interv 2011; 79(1): 104-112.
- Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomized, parallel group, multicentre trial. Lancet 2011; 377(9775): 1409-1420.