Case ReportA 63-year-old patient had undergone robotic totally endoscopic coronary artery bypass (TECAB) involving the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) 2 years prior. Subsequently, the patient developed distal LIMA anastomotic stenosis, as well as severe progression of disease in the left circumflex artery (LCX) and right coronary artery (RCA). At repeat bypass surgery (with sternotomy), 3 saphenous vein grafts (SVG) and ligation of the LIMA distal anastomosis (to enhance SVG-LAD flow) were performed. Subsequently, the patient again developed angina. Nuclear stress test revealed anterior and lateral reversible defects. Right transradial catheterization was performed using a 5 French Tiger (Terumo Corporation, Somerset, New Jersey) diagnostic catheter. The catheter was initially advanced into the high ascending aortic segment, and the SVG to the LAD was easily engaged with counterclockwise torque. This SVG was occluded ostially (Figure 1). Next, the catheter was advanced gently and the SVG to the obtuse marginal branch (OM) was engaged with clockwise torque. This bypass was patent with good distal flow (Figure 2). Further advancement to the lower ascending aortic segment, accompanied again by clockwise rotation, resulted in engagement of SVG to the right posterolateral branch. This SVG was also patent (Figure 3). The catheter was then advanced into the aortic root and gently retracted with slow, clockwise torque until engagement of the native left coronary system. Imaging revealed a chronic occlusion of the LAD ostium and a heavily calcified native circumflex system (LCX) with a sharp proximal arc, as well as serial 90% ostial and mid lesions (Figure 4). The 0.035” wire was then inserted into the catheter to the level of the primary curve, simulating a Judkins right conformation. Gentle, clockwise torque with retraction resulted in easy engagement of the native RCA. Angiography revealed a patent posterior descending branch; the posterolateral branch was totally occluded and bypassed (Figure 5). After disengagement of the RCA, the 0.035” wire was once again replaced; and the aortic valve was crossed in the left anterior oblique position. This view is important to avoid traumatizing the thin-walled septum when accessing the left ventricle (LV) with an end-hole, as opposed to pigtail, catheter. Left ventriculography was subsequently performed in the right anterior oblique position; the LV function was within normal limits (Figure 6). Thus, all 3 SVGs, both native coronaries, and the LV were imaged using a single Tiger catheter. The patient then underwent complex transradial percutaneous coronary intervention (PCI) with overlapping drug-eluting stents (DES) in the LCX system with a 6 French Amplatz-2 guiding catheter and 5 French “child-in-mother” catheter technique (Figure 7). The final result was excellent (Figure 8). For complete revascularization, hybrid robotic bypass surgery was subsequently performed, using a free right IMA (RIMA) segment as a “skip” graft from the distal LIMA to the LAD. Unfortunately, a few months later, the patient again developed severe stenosis of the free RIMA segment, necessitating further DES implantation through the LIMA conduit. A previous hypercoagulable workup revealed no significant abnormalities.
DiscussionThis case illustrates the feasibility and the technique of transradial catheterization for post-bypass patients using a single, versatile, 5 French diagnostic catheter. While left transradial access is usually necessary in patients with patent LIMA conduits, a right transradial approach can be utilized with only SVGs, avoiding the logistical nuisances of a left-sided setup. Additionally, complex PCI, even with a “child-in-mother” system, is possible from the transradial approach. We are hopeful that the last intervention will provide the patient with some degree of longevity of patency. Disclosure: Dr. Chen reports that he is a consultant and speaker for Terumo Corporation.