Case Report

The Utility of a Universal Guide Catheter in STEMI With Multiple Culprit Lesions

B. Clay Sizemore, MD, FACC, FSCAI, and Tim Hester, RT(R)

Cardiovascular Consultants of South Georgia, LLC

Archbold Memorial Hospital, Thomasville, Georgia

B. Clay Sizemore, MD, FACC, FSCAI, and Tim Hester, RT(R)

Cardiovascular Consultants of South Georgia, LLC

Archbold Memorial Hospital, Thomasville, Georgia

Background

Transradial access has been clearly associated with improved outcomes; specifically, reduced bleeding and reduced mortality, in the setting of ST elevation myocardial infarction (STEMI).1-4  As a result, many labs have moved to a default transradial approach. The following case represents an example of how a universal transradial guide catheter strategy can provide significant benefits and efficiencies for the patient, operator, and hospital.

Case Report

A 33-year-old male smoker with recently diagnosed hypertension and strong family history of premature coronary artery disease (CAD) developed acute onset severe substernal chest pain with associated diaphoresis and nausea. Upon arrival of EMS, he was found to have marked inferior ST elevations and dramatic ST depressions in the precordial leads. A STEMI alert was initiated from the field and he was directly transferred to the catheterization laboratory. He received oral loading doses of aspirin and ticagrelor, as well as intravenous heparin (70 units/kg) bolus. Right radial artery access was obtained with a single front-wall puncture performed under direct ultrasound guidance with a 21-gauge needle. A 6 French (F) GLIDESHEATH SLENDER® Introducer Sheath (5F outer diameter) was easily inserted over the included .025-inch guide wire. A 6F Ikari Left 3.5 HEARTRAIL® III Guiding Catheter was advanced over a .035-inch guide wire to the aortic root and was easily engaged in the right coronary artery (RCA) ostium. Angiography confirmed an acute thrombotic occlusion of the proximal RCA (Figure 1).  A RUNTHROUGH® NS Extra Floppy Coronary Guidewire was advanced into the distal RCA/posterior descending artery (PDA) without difficulty. Due to the appearance of heavy thrombus burden and lack of flow restoration with wiring, we did opt to perform aspiration thrombectomy with a PRIORITYONE® Aspiration Catheter. Limited (TIMI-1) antegrade flow was restored, revealing a discrete, high grade stenosis (Figure 2). This was predilated with a 3 x 15 mm Trek balloon (Figure 3). We then advanced and deployed a 4 x 22 mm Onyx drug-eluting stent (DES) at high pressure (Figure 4). Repeat angiography confirmed an excellent result with good step up/step down, no residual stenosis, and TIMI-3 flow (Figure 5). Despite these findings, the patient continued to have ongoing chest pain. Utilizing the universal Ikari Left 3.5 HEARTRAIL Guiding Catheter already in place, we easily engaged the left main coronary to complete the diagnostic angiography. Our suspicion for a secondary culprit lesion was confirmed in the right anterior oblique (RAO) cranial projection, with identification of a focal ruptured plaque within the mid-left anterior descending (LAD) coronary artery, resulting in a hazy 80% angiographic stenosis (Figure 6). The prior RUNTHROUGH NS Extra Floppy Guidewire wire was readvanced into the distal LAD without difficulty and this lesion was direct stented with a 3.5 x 18 mm Onyx DES at high pressure. Final angiography again confirmed an excellent result with good step up/step down, no residual stenosis, and TIMI-3 flow (Figure 7). The HEARTRAIL Guiding Catheter and GLIDESHEATH SLENDER Sheath were removed, and a TR BAND® Radial Compression Device was applied to the access site. The patient was noted to have resolution of his chest pain and he was transferred to the holding room hemodynamically stable and asymptomatic.  

Discussion

Multiple randomized clinical trials have now demonstrated the benefits of transradial access in the setting of STEMI.1-4 As a result, many centers have adopted a default radial approach to cardiac catheterization. With the continued development of dedicated transradial equipment, as well as the establishment and dissemination of best practices, this trend will likely progress. The above case demonstrates the utility of said equipment and several of these best practices.  

STEMI is a time-sensitive clinical situation. Direct ultrasound visualization allows for a timely “first pass” access. The GLIDESHEATH SLENDER Sheath facilitates easy insertion, while minimizing the risk of spasm with its hydrophilic coating and low profile. The Ikari Left 3.5 HEARTRAIL Guiding Catheter offers several advantages that increase the likelihood of success and reduce the risk of complications. The universal nature of the Ikari HEARTRAIL Guiding Catheter shape allows for cannulation of both the right and left coronary ostia. In the above case, it allowed for interventional treatment of multiple culprit lesions in a time and cost-efficient manner. In any case, a universal guide strategy, by definition, reduces catheter exchanges, which should in turn reduce procedure and fluoroscopy time, while presumably also reducing the risk for atheroembolic complications. Our preferred technique for coronary engagement with the Ikari Left 3.5 HEARTRAIL Guiding Catheter is to start with the RCA. The catheter is advanced over the .035-inch guide wire into the right cusp. With a Tuohy-Borst or Co-Pilot attached, the guide is meticulously de-aired and the wire is retracted to just within the tip. By leaving the wire in place during engagement, the secondary bend is straightened, creating a shape that very much resembles a traditional Judkins Right (JR) catheter. A simple, clockwise torque and gentle retraction usually results in easy engagement. The guide wire can then be removed, which results in relaxation of the secondary curve and a conformation with significantly more backup support than a JR. Upon completion of the RCA intervention, the Ikari Left 3.5 HEARTRAIL Guiding Catheter can be simply torqued in a counter-clockwise direction to disengage. In men with normal root diameter, continued counter-clockwise torque with gentle retraction will frequently result in left coronary engagement. In women and men with smaller aortic root diameter, once the guide tip is in the left cusp, gentle advancement will allow the soft tip to prolapse upward (Amplatz technique) and engage the ostium. It is frequently necessary to gently retract the guide, once engaged, to create a coaxial relationship to the left main. Once engaged in either coronary, the Ikari HEARTRAIL Guiding Catheter is designed to be “actively” managed. This means the operator can dial in more or less backup as needed for a given intervention. With fairly simple manipulation (usually advancement), the segment between the primary and secondary curves is made to be horizontal (ie, near perpendicular to the back wall), which substantially increases support. This maneuver can be safely accomplished due to the soft, atraumatic design of the guide tip.

In the above case, the RUNTHROUGH NS Extra Floppy Guidewire provided excellent torquability and support for the RCA intervention, while maintaining tip shape to later facilitate the subsequent LAD intervention with the same wire. We chose a PRIORITYONE® Aspiration Catheter, with its inner stylet, because we find it both highly deliverable and kink resistant. Finally, we have had great success with the utilizing the TR BAND® Radial Compression Device and the well-described “patent hemostasis” strategy.5

Conclusion

Transradial access has become a mainstay of both STEMI management and more elective percutaneous coronary intervention.6-7 Utilizing dedicated equipment and now well-described “best practices” can significantly reduce case duration and complexity. While cases with multiple culprit lesions are not common, treating non-culprit lesions in contralateral coronaries has become more frequent in recent years. Universal guides can be particularly useful in these situations, but should also be considered a potential default catheter in the case of STEMI in order to minimize exchanges and reduce time to reperfusion. 

GLIDESHEATH SLENDER® Introducer Sheath (5F outer diameter), Ikari Left 3.5 HEARTRAIL® III Guiding Catheter, RUNTHROUGH® NS Extra Floppy Coronary Guidewire, PRIORITYONE® Aspiration Catheter, and TR BAND® Radial Compression Device are all products of Terumo Medical Corporation. Additional products mentioned include the TREK balloon (Abbott Vascular), Resolute Onyx drug-eluting stent (Medtronic), and COPILOT Adapter (Abbott Vascular). 

This article is supported by Terumo Medical Corporation. 

Disclosure: Dr. Sizemore reports he is a consultant to Terumo Medical Corporation. 

PM-03731

References
  1. 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 randomised, parallel group, multicentre trial. Lancet. 2011; 377 (9775): 1409-1420.
  2. Valgimigli M, Gagnor A, Calabró P, et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet. 2015; 385 (9986): 2465-2476.
  3. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol. 2012; 60(24): 2481-2489.
  4. Bernat I, Horak D, Stasek J, et al. ST-segment elevation myocardial infarction treated by radial or femoral approach in a multicenter randomized clinical trial: the STEMI- RADIAL trial. J Am Coll Cardiol. 2014; 63(10): 964-972.
  5. Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of radial artery occlusion-patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv. 2008; 72(3): 335-340.
  6. Mason PJ, Shah B, Tamis-Holland JE, et al. An update on radial artery access and best practices for transradial coronary angiography and intervention in acute coronary syndrome: a scientific statement from the American Heart Association. Circ Cardiovasc Interv. 2018; 11(9): e000035.
  7. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39(2): 119-177.
/sites/cathlabdigest.com/files/articles/images/CLDSizemore_1020.pdf