Case Study

Transradial Bifurcation Stenting With Physiologic Guidance

Arnold H. Seto, MD, MPA, FACC, FSCAI

Long Beach Veterans Administration Medical Center, Long Beach, California; Associate Clinical Professor, 

University of California Medical Center, Orange, California 

Arnold H. Seto, MD, MPA, FACC, FSCAI

Long Beach Veterans Administration Medical Center, Long Beach, California; Associate Clinical Professor, 

University of California Medical Center, Orange, California 

Transradial percutaneous coronary intervention (PCI) can accommodate the vast majority of procedures using a 6 French catheter system. In this case, we describe a transradial bifurcation stenting procedure guided by physiology. 

Case Report

A 71-year-old man with angina was able to achieve 8.2 metabolic equivalent of task (METs) on a treadmill-ECG stress test, but developed ST-segment depression and angina with exertion. In the catheterization lab, he had right radial access with a single double-wall puncture attempt with ultrasound guidance. The ultrasound confirmed an adequate radial artery size to accommodate a 6 French (Fr) GLIDESHEATH SLENDER® Introducer Sheath (5F outer diameter), which was inserted over an .025-inch plastic hydrophilic guidewire. There was no difficulty in advancement due to the hydrophilic coating on the sheath. 

Coronary angiography was obtained with a 5 Fr OPTITORQUE® Coronary Diagnostic Catheter (Jacky), and showed an intermediate proximal left anterior descending (LAD) coronary artery stenosis and a more severe-appearing ostial diagonal stenosis before a diagonal bifurcation (Figure 1). No other coronary disease and no left ventricular dysfunction were found. Heparin anticoagulation was administered. A 6 Fr XB3.5 guide catheter was used to introduce a RUNTHROUGH® NS EXTRA FLOPPY Coronary Guidewire into the LAD and an ACIST RXi fractional flow reserve (FFR) catheter was inserted across the LAD stenosis. Despite a resting Pd/Pa ratio of 0.92, FFR with IV adenosine was positive at 0.75, with the pullback indicting the proximal stenosis was culprit (Figure 2). The wire and FFR catheter were moved to the diagonal artery, where the resting Pd/Pa was 0.96 and FFR was 0.87, indicating that the diagonal ostial stenosis was nonsignificant, despite its severe angiographic appearance (Figure 3). Provisional stenting was thus our treatment plan. 

A second RUNTHROUGH NS EXTRA FLOPPY Guidewire was introduced into the LAD, and a Trek 3.0 x 12 mm balloon was used to dilate the stenosis. A Xience Sierra 3.0 x 33 mm stent was deployed and post-dilated with a NC Trek 3.5 x 12 mm, trapping the diagonal wire. The LAD wire was moved and crossed the stent struts into the diagonal, and the prior diagonal wire was removed without difficulty and moved to the LAD. The FFR catheter crossed the stent struts with only mild difficulty, revealing a severely ischemic resting Pd/Pa of 0.59 (down from 0.96), presumably from carinal and plaque shift (Figure 4). The diagonal was dilated with a Trek 2.5 x 12 mm and a Xience 2.75 x 12 mm drug-eluting stent (DES) was implanted using a reverse-mini crush technique. Kissing balloon inflation was attempted with a NC Trek 2.75 x 12 mm in the diagonal and a 3.5 x 12 mm in the LAD, but the NC Trek balloon failed to cross the LAD stenosis after repeated attempts. A NC TAKERU PTCA Balloon Dilatation Catheter 3.25 x 12 mm was used instead, and easily crossed the two sets of stent struts into the LAD, allowing for high-pressure kissing balloon inflation to be performed (Figure 5). Intravascular ultrasound (IVUS) was performed and showed well expanded stents in the LAD and diagonal, and given the minimal proximal segment remaining, no proximal optimization was performed or was possible. The FFR catheter was reinserted into the LAD and showed a final resting Pd/Pa of 0.96, FFR of 0.87 (Figure 6). In the diagonal, the final resting Pd/Pa was 0.97 and FFR 0.88 (Figure 7). The guide catheter was removed, and a TR BAND® Radial Compression Device was applied. Prasugrel 60 mg was given orally at the conclusion of the procedure, along with aspirin. The patient was planned for same-day discharge, but was disoriented for several hours after only minimal sedation of 1 mg midazolam and 25 mcg fentanyl, and thus was observed overnight. He was asymptomatic and well two weeks following the procedure. 

Products used:

  • Terumo 6 Fr GLIDESHEATH SLENDER Sheath;
  • Terumo .014-inch RUNTHROUGH NS EXTRA FLOPPY Guidewire x 2;
  • Terumo 5 Fr OPTITORQUE® Coronary Diagnostic Catheter (Jacky);
  • Terumo NC TAKERU Balloon Catheter 3.25 x 12 mm;
  • Terumo TR BAND® Radial Compression Device;
  • Cordis 6 Fr XB3.5 Vista Brite guide catheter;
  • Abbott Trek 2.5 x 12 mm and 3.0 x 12 mm, and NC Trek 2.75 x 12 mm and 3.5 x 12 mm balloons (failed to cross;
  • Abbott Xience 3.0 x 33 mm and 2.75 x 12 mm DES;
  • Philips Eagle Eye IVUS catheter;
  • ACIST RXi FFR catheter.

Discussion

For this bifurcation lesion, transradial PCI was guided by physiology and imaging, allowing for progressive intervention from provisional stenting to a two-stent solution. Repeated physiologic evaluations were feasible with the ACIST RXi catheter, which was able to cross even stent struts without losing wire position, and IVUS was possible even with a solid-state IVUS catheter. The 6F GLIDESHEATH SLENDER Sheath was more than sufficient to deliver the necessary equipment for bifurcation stenting, with minimal stretching of the radial artery and no spasm. Our plan for same-day discharge after bifurcation PCI would have been feasible with radial access and TR BAND® Radial Compression Device hemostasis were it not for the patient’s idiosyncratic amnestic response to low-dose sedation. 

The Vista Brite 6 Fr guide catheter has a smaller inner diameter (.070-inch) than other guides (Terumo HEARTRAIL® Guiding Catheter [.071-inch], Medtronic Launcher [.071-inch] and Cordis Adroit [.072-inch]). Our experience has been that kissing balloon inflation with NC Trek balloons in 6 Fr Vista Brite guides is feasible but is performed with great difficulty, even with new balloon catheters. In contrast, the TAKERU balloon catheters have a hydrophilic coating and smaller entry profile, allowing for better trackability, as demonstrated in this case where the TAKERU balloon catheter crossed easily as compared with the NC Trek. 

Our facility is in the process of transitioning completely to TAKERU balloon catheters, given these favorable characteristics. We would recommend that every facility consider having at least a few sizes of TAKERU balloon catheters for rescue of ‘no-cross’ situations with other balloon catheters. 

This article is supported by Terumo Medical Corporation. Disclosure: Dr. Seto reports he is a consultant to Terumo Medical Corporation. PM-03350