Successful Coronary Angioplasty Via the Radial Approach After Sealing a Radial Perforation
Gianluca Rigatelli, MD*,*,
Fabio Dell'Avvocata, MD*,
Federico Ronco, MD*,
Alexander Doganov, MD
* Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy
National Heart Hospital, Sofia, Bulgaria
A 78-year-old woman with a Canadian Cardiovascular Society class III angina, despite maximal medical therapy, was admitted to our center for elective coronary angiography. The clinical history was remarkable for smoking, hypertension, hypercholesterolemia, and severe peripheral atherosclerosis with moderate bilateral carotid stenosis. The coronary angiography revealed a critical stenosis in the middle portion of the right coronary artery. Stable selective cannulation of the right coronary artery could not be achieved via the femoral approach, due to severe tortuosity of the diseased iliac arteries and abdominal aorta. Coronary angioplasty was scheduled for the next day via the left radial artery approach (the Allen test was abnormal on the right radial artery).
Because of difficult advancement of the standard guidewire through the needle, a short 2.7-F pressure catheter (Vygon, Ecouen, France) was inserted over a short guidewire as previously described (1), and intra-arterial cocktail of verapamil plus nitrate was administered. A gentile contrast injection through the arterial sheath revealed a diffuse spasm of the proximal portion of the vessel associated with multiple long stenosis of the middle radial artery (Fig. 1A). The arterial sheath was exchanged for a standard radial artery sheath, but the first attempt to advance an Emerald 0.35 wire (Cordis, Miami, Florida) failed, and on the subsequent contrast injection a dissection and rupture of the radial artery in its middle portion (Fig. 1B) was observed. Despite a well-functioning palmar arch as demonstrated by the Allen test before the procedure, the patient experienced pain in the left arm and hand. A Pilot 50 guide wire (Guidant, Santa. Clara, California) was passed through the ruptured radial artery to the subclavian artery, and a peripheral Submariner balloon 2 x 60 mm (Invatech, Roncalle, Brescia, Italy) was inflated for 5 min at the bleeding site at 8 atm (Fig. 1C). Sealing and hemostasis of the artery and dilation of stenotic segments was documented with pain resolution (Fig. 1D). Then, a standard JR 6-F guiding catheter (Cordis) with gentle manipulation was advanced over the guidewire, and the procedure was accomplished without other complications with direct stenting of the right coronary artery via the same access. Three days later the patient was discharged totally asymptomatic with no ischemia of the left arm and normal velocity wave on radial artery Doppler ultrasound.
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Figure 1 Radial Artery Rupture and Salvage During Coronary Intervention Through the Radial Artery
(A) Radial artery angiography through a 2.7-F pressure arterial sheath after generous intra-arterial nitroglycerine and verapamil administration, revealing diffuse spasm of the entry site and stenosis of the middle portion of the radial artery. (B) Radial artery angiography through a 6-F sheath, revealing rupture of the radial artery. (C) Prolonged balloon inflation. (D) Sealing and stenosis resolution after prolonged balloon inflation.
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Atherosclerotic disease of the radial artery associated with diffuse spasm is unusual but still possible in elderly patients (2): the availability of peripheral balloons and knowledge of simple peripheral intervention techniques might help to resolve the otherwise painful consequences of radial artery rupture.
* Reprint requests and correspondence: Dr. Gianluca Rigatelli, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, 45100 Rovigo, Italy (Email: jackyheart{at}libero.it).
Manuscript received April 23, 2009;
accepted May 15, 2009.
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REFERENCES
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- Rigatelli G, Magro B, Maronati L, et al. An improved technique for gaining radial artery access in endovascular interventions Cardiovasc Revasc Med 2006;7:46-47.[CrossRef][Medline]
- Lo TS, Nolan J, Fountzopoulos E, et al. Radial artery anomaly and its influence on transradial coronary procedural outcome Heart 2009;95:410-415.[Abstract/Free Full Text]
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