Severe peripheral arterial disease can contribute tremendous difficulty to cardiac procedures. Obtaining arterial access can be both technically difficult and a high risk for complications. We present a case of challenging access in patient requiring coronary intervention.
The patient is a 70-year-old female with a history of tobacco abuse, chronic obstructive pulmonary disease, 3-vessel coronary artery disease status post coronary artery bypass graft surgery, transient ischemic attacks, hypertension, hyperlipidemia, and bilateral iliac stents and superficial femoral artery disease. She developed angina at rest after an elective peripheral angiogram. Her troponin rose to 5.3. She returned to the cardiac catheterization lab for a coronary angiogram. The right common femoral artery was accessed the day prior (Figure 1). She had left radial artery access. The left anterior descending (LAD) coronary artery had a proximal to mid 99% stenosis with TIMI-2 flow. The left internal mammary artery (LIMA) was grafted to the second diagonal branch. We decided to perform percutaneous coronary intervention to treat the LAD stenosis. Due to significant left subclavian artery tortuosity and stent, we were unable to perform the procedure from the left radial artery. We obtained right common femoral arterial access using the modified Seldinger technique and ultrasound guidance. The common femoral artery wall was noted to be heavily calcified. After identifying the entry point at the level of the mid femoral head, the skin was entered at a 45° angle with the 18-gauge needle. The needle required a great deal of force to puncture the anterior wall. After the femoral artery was cannulated, and good pulsatile flow was observed, an .035-inch J-tip guidewire was advanced through the needle into the femoral artery, iliac artery, and descending aorta without resistance. The 6 French (Fr) sheath was advanced over the wire, but stopped at the anterior wall of the artery. We tried to cross the artery with the dilator alone, but that failed as well. We used the bevel of the 18-gauge needle to cut a small arteriotomy in the vessel wall. With the wire still in the artery, we advanced the needle over the wire into the puncture site. The needle was rotated clockwise and counter-clockwise, cutting out a small arteriotomy site, the diameter of the needle (Figure 2, Video 1 [available online with the article at cathlabdigest.com]). The needle was removed, and the sheath and dilator advanced over the wire and into the vessel without resistance. The patient tolerated the procedure and the case continued without any complications. We performed PCI in the LAD using bivalirudin. Arterial closure with hemostasis was achieved by manual sheath pull several hours after the procedure. The patient had no bleeding or other access site complications.
We refer to this technique of using the needle tip to create a small arteriotomy site as the “apple core” technique. An apple corer is a device for removing the core from an apple. The apple corer contains a tubular cutting device at the end. When pushed through the center of the apple, this cutting device removes the core. We found this technique useful for gaining access in fibrotic and calcified arteries. It does not require any extra equipment aside from the needle already on the table. Possible complications include bleeding after the sheath is removed, posterior wall stick, arteriovenous fistula, pseudoaneurysm, and plaque disturbance or emboli.
Disclosures: The authors report no conflicts of interest regarding the content herein.
The authors can be contacted via Dr. Philip Carson at firstname.lastname@example.org.