Case Files by Dr. George

Transradial Approach to Percutaneous Coronary Intervention of an Anomalous Single Coronary Artery Using Intravascular Ultrasound

Aaron VanHise, DO, and Jon C. George, MD
Division of Cardiovascular Medicine, Deborah Heart and Lung Center, Browns Mills, New Jersey

Aaron VanHise, DO, and Jon C. George, MD
Division of Cardiovascular Medicine, Deborah Heart and Lung Center, Browns Mills, New Jersey

Abstract

Transradial (TR) percutaneous coronary intervention (PCI) has gained progressive interest with growing emphasis on minimizing post-procedural bleeding complications while maintaining procedural success. We describe a unique case of a single coronary artery that underwent TR-PCI using intravascular ultrasound imaging, demonstrating the feasibility of this approach even in complex and anomalous coronary arteries.

Introduction

The transradial (TR) approach was first described in 1948 for central arterial catheterization1 and subsequently for transradial angiography in 19892 and coronary stenting in 1993.3 Since then, percutaneous coronary intervention (PCI) via the TR approach has gained increasing popularity in an effort to minimize post-procedural bleeding complications while maintaining procedural success.4 We describe a unique case of a single coronary artery that underwent TR-PCI using intravascular ultrasound (IVUS) imaging, demonstrating the feasibility of this approach even in complex and anomalous coronary arteries.

Case report

A 70-year-old female with an anomalous single coronary ostium was referred for evaluation of progressive angina with coronary angiography, after a noninvasive stress test by her cardiologist demonstrated significant anterior wall ischemia. The patient was morbidly obese (body mass index 47) with a history of hypertension, diabetes mellitus, and aortic stenosis status post mechanical valve replacement (Medtronic-Hall) 10 years prior. Additionally, the patient was significantly limited in her activity level, with bilateral hip and knee replacements.

Coronary angiography via the TR approach revealed a single coronary ostium with a 60-70% stenosis in the proximal left anterior descending artery (LAD) (Figure 1). Further evaluation of the borderline lesion was performed using IVUS (Atlantis Pro, Boston Scientific, Natick, Mass.) over a Choice Intermediate guidewire (Boston Scientific) using a 6-French Radial Runway guiding catheter (Boston Scientific), which confirmed a significant lesion with 62% area stenosis and cross-sectional area of 3.4 mm2 in a 4.5 mm reference vessel (Figure 2). A Veriflex 4.5 mm x 24 mm bare-metal stent (Boston Scientific) was deployed across the lesion with good angiographic result and TIMI-3 flow (Figure 3). Repeat IVUS confirmed adequate stent expansion and luminal apposition, with no significant residual stenosis. Radial artery hemostasis was achieved using the RadAR band (Advanced Vascular Dynamics, Portland, Oregon) and the patient discharged home the following day without complications.

Discussion

Across the United States, TR access has increasingly become the preferred approach for PCI due to a shorter recovery time, diminished bleeding risk, and lack of severe access-site complications.4 In general, high-volume TR interventionalists perform PCI without significant differences compared to a femoral approach. Similar procedural times, reduced bleeding, cost, and post-procedure monitoring, an ability to cross lesions with equivalent long-term outcomes, and modest increases in fluoroscopy time have been demonstrated by multiple studies.5-8 In addition to a reduction in bleeding events (by up to 73%), the TR approach allows advantages in certain patient populations such as those with significant peripheral arterial disease and obesity.7 With continued innovation and production of improved guiding catheters, including sheathless catheters, the TR approach is a reasonable alternative to transfemoral access for PCI. In addition, as demonstrated in this case, other adjunctive diagnostic strategies, such as IVUS of complex coronary anatomy, is feasible via the TR approach.

Isolated single coronary arteries are rare, with an incidence of 0.016%, comprising only 1.8% of all coronary anomalies.9 Few reports have been published of PCI of a single coronary artery via a TR approach.10 Herein, we demonstrate that complex cases of anomalous coronary arteries can be performed safely via a TR approach.

The authors can be contacted at jcgeorgemd@hotmail.com.

This article received a double-blind peer review from members of the Cath Lab Digest Editorial Board.

Disclosure: Dr. VanHise reports no conflicts of interest regarding the content herein. Dr. George reports that he is a consultant for Boston Scientific Corp.

References

  1. Radner S. Thoracal aortography by catheterization from the radial artery; preliminary report of a new technique. Acta Radiol 1948;29:178-180.
  2. Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn 1989;16:3–7.
  3. Kiemeneji F, Laarman GJ. Percutaneous transradial artery approach for coronary stent implantation. Cathet Cardiovasc Diagn 1993;30:173–178.
  4. Rao S, Cohen MG, Kandzari DE, Bertrand OF, Gilchrist IC. The transradial approach to percutaneous coronary intervention: historical perspective, current concepts, and future directions. J Am Coll Cardiol 2010;55:2187–2195.
  5. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;44:349–356.
  6. Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv 2008;1:379–386.
  7. Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or interventions and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J 2009;157:132–140.
  8. Spaulding C, Lefevre T, Funck F, et al. Left radial approach for coronary angiography: results of a prospective study. Cathet Cardiovasc Diagn 1996;39:265–270.
  9. Yildiz A, Okcun B, Peker T, et al. Prevalence of coronary artery anomalies in 12,457 adult patients who underwent coronary angiography. Clin Cardiol 2010; 33(12): e60–64.
  10. Shalganov TN. Percutaneous coronary intervention for acute myocardial infarction in a single coronary artery anomaly. Clin Cardiol 2009 Nov;32(11):E49–51.