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Heart, Lung and Circulation (2015) xx, 1–4 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.12.165
Radial Artery Spasm and Perforation: Simple Solutions for Challenging Cases Michael Liang, MBChB, FRACP a,c, Gerard Devlin, MD, FRACP b, Scott A. Harding, MBChB, FRACP a* a
Department of Cardiology, Wellington Hospital, New Zealand Department of Cardiology, Waikato Hospital, New Zealand Department of Cardiology, Khoo Teck Puat Hospital, Singapore
b c
Received 17 August 2014; received in revised form 15 October 2014; accepted 26 December 2014; online published-ahead-of-print xxx
Transradial access for percutaneous coronary intervention and diagnostic coronary angiography has been increasingly utilised in the routine practice in most catheterisation laboratories as it reduces the incidence of major access site complications such as bleeding and haematoma. Radial artery spasm with or without perforation is one of the more frequent reasons for converting from radial to femoral access. In this article, the balloon-assisted technique and Sheathless EauCath (Asahi Intecc, Aichi, Japan) are demonstrated to overcome radial artery spasm with associated significant perforation in two cases. Keywords
Coronary intervention Sheathless Radial artery spasm Radial artery perforation Sheathless EauCath Balloon assisted technique
Case 1: Balloon-Assisted Technique A 67 year-old lady was referred to our catheterisation laboratory with angina and a strongly positive exercise stress test. Routine pre-medication with intravenous 2 mg midazolam was administered prior to obtaining successful radial artery access with a 6 Fr 10 cm Terumo radial sheath (Terumo, Tokyo, Japan). Two hundred micrograms of nitroglycerin was injected into the right radial artery via the radial sheath. A dose of intravenous 5000 IU of heparin was administered when the diagnostic 5 Fr TIG catheter (Terumo, Tokyo, Japan) reached ascending aorta. The ostial to proximal left anterior descending artery (LAD) was deemed the culprit lesion and percutaneous coronary intervention (PCI) to this lesion was planned (Fig. 1a). A 260 cm 0.03500 exchange J-wire was used to swap the 5 Fr TIG diagnostic catheter with a 6 Fr JL3.5 guiding catheter. The JL3.5 guiding catheter encountered strong resistance and was not able to pass through the forearm despite additional intra-arterial 200 mcg nitroglycerin and 1 mg of verapamil. An angiogram of the right radial artery demonstrated severe spasm with
significant perforation (Fig. 1b). It was decided to perform balloon-assisted technique to pass the guiding catheter through the right radial artery [1]. The 0.03500 J-wire was firstly removed. The tip of JL3.5 guiding catheter was parked at the sheath and the proximal-end of the guiding catheter was set up with the Y-connector as per routine angioplasty procedure. A 0.01400 Sion Blue (Asahi Intecc, Aichi, Japan) angioplasty guide wire was used to cross the affected radial artery carefully via the JL3.5 guiding catheter. A 2x15 mm balloon, loaded on the 0.01400 Sion Blue wire was placed half way out of the guiding catheter (Fig. 1c) and inflated at 4 atm, below nominal pressure, which is 6 atm. The JL3.5 catheter with a balloon at the tip was advanced slowly to pass the right radial artery without much resistance and reached the ascending aorta (Fig. 1d). Intervention to the ostial LAD was completed successfully (Fig. 1e) with additional 2000 IU heparin (100 IU/kg). A final angiogram of the right radial artery did not show any evidence of contrast extravasation (Fig. 1f). The right radial access site was secured with a TR band (Terumo, Tokyo, Japan) without additional pressure dressing. Ward review the following day showed intact right radial pulse and the patient was discharged home uneventfully.
*Corresponding author at: Department of Cardiology, Waikato Hospital, New Zealand, Email: [email protected] © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
Please cite this article in press as: Liang M, et al. Radial Artery Spasm and Perforation: Simple Solutions for Challenging Cases. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.165
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Figure 1 (a) Diagnostic coronary angiography showed significant proximal left anterior descending artery (LAD) lesion involving ostium (arrow). (b) Right radial artery angiography showed a large area of contrast extravasation with spasm. (c) The 2.0x15 mm balloon was half way out of the 6 Fr JL3.5 guiding catheter and inflated at 4 atm (arrow). (d) The JL3.5 guiding catheter was able to advance pass through the affected radial artery with the inflated 2.0x15 mm balloon at the tip (arrow). (e) A drug-eluting stent was successfully implanted at the ostial LAD. (f) Final right radial artery angiogram showed completely sealed radial artery without persistent contrast extravasation.
Case 2: Sheathless EauCath A 57 year-old lady was referred with a diagnosis of non-ST elevation myocardial infarction and ongoing chest discomfort. Radial artery access was obtained following sedation and a 6 Fr 11 cm ARROW radial sheath (Teleflex Medical,
NC, USA) was inserted. Routine intra-arterial 200mcg nitroglycerin and intravenous 5000 IU heparin was administered. Diagnostic angiography was performed uneventfully with a 5 Fr TIG catheter. The occluded second obtuse marginal branch was deemed the culprit lesion and PCI to this lesion was planned (Fig. 2a). A 260 cm 0.03500 long exchange wire
Please cite this article in press as: Liang M, et al. Radial Artery Spasm and Perforation: Simple Solutions for Challenging Cases. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.165
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Figure 2 (a) Diagnostic coronary angiography in the caudal projection showed occluded second obtuse marginal branch (arrow). (b) Right radial artery angiography demonstrated radial artery spasm with perforation. (c) The 6.5 Fr Sheathless EauCath can be inserted into a standard 6 Fr Sheath. The dilator at the tip of the catheter made it into a tapered tip. (d) The Sheathless EauCath passed through the affected artery without much resistance (arrow). (e) The right anterior oblique caudal projection showed that the second obtuse marginal branch was successfully opened with a drug-eluting stent. (f) The final right radial artery angiogram did not have persistent contrast extravasation.
was used to exchange the TIG catheter for a 6 Fr EBU3.5 guiding catheter. While passing the EBU guiding catheter through the forearm, a strong resistance was noted despite gentle manipulation. An angiogram of right radial artery showed significant spasm with perforation (Fig. 2b). A 6.5 Fr PB3.5 Sheathless EauCath (Asahi Intecc, Aichi, Japan), loaded on the 260 cm 0.03500 J-wire was used to pass through the affected radial artery without noticeable resistance via the 6 Fr Sheath (Fig. 2c, 2d & Fig. 3). The procedure was
successfully completed with additional 5000 IU heparin and a final radial artery angiogram demonstrated no residual radial artery leak (Fig. 2e, 2f). An intact right radial pulse was observed the following day prior to discharge.
Discussion Failure to complete procedures transradially occurs in about 5% of cases, with higher failure rates noted in less
Please cite this article in press as: Liang M, et al. Radial Artery Spasm and Perforation: Simple Solutions for Challenging Cases. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.165
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Figure 3 Outer diameter of the Sheathless EauCath in relation to standard sheath introducer. [Adapted from Asahi-Intecc Sheathless EauCath product information: http://www.asahi-intecc.com/medical/international/product/gc_se.php].
experienced operators. Reasons included access failure, presence of spasm or significant tortuosity with or without anomaly. In this report, we described two techniques to overcome severe radial spasm with or without anatomical variation and/or accompanied perforation. Both techniques described in our cases help overcome a similar technical issue. The presence of a tapered dilator in Sheathless EauCath and the low-pressure 2 mm angioplasty balloon as demonstrated in the balloon-assisted technique eliminates the ‘‘razor effect’’ at the tip of guiding catheter [1,2]. The balloon-assisted technique, which requires loading an angioplasty balloon over a 0.01400 angioplasty wire, hence re-wire the vessel or exchange wires using a 4 Fr catheter is often needed. The Sheathless EauCath has the advantage in that it can be advanced rapidly over the existing 0.03500 260 cm J-wire. The Sheathless EauCath comes in all conventional shapes and can be used by a non-interventionist during the diagnostic procedure. The balloon-assisted technique, on the other hand, has a slightly longer learning curve and requires proficiency in handling basic interventional equipment such as a guide wire and an angioplasty balloon. Thus, our preferred method is to use the Sheathless EauCath due to the greater simplicity and speed of this approach. Both techniques have high success [4_TD$IF]rates. Patel et al. described over 95% success rate in balloon-assisted technique in a series of 63 patients with complex radial anatomy. Of note, the failed cases were in those with[5_TD$IF] an extremely small radial artery and[6_TD$IF] the presence of a 360 degree radial artery loop [3]. Liang et al. recently presented a small series of
36 cases with radial artery spasm and/or perforation encountered during change of catheter, Sheathless EauCath was successfully applied in all cases [4]. Of note, one patient (9%) who had radial artery perforation with trivial contrast extravasation at the completion of the procedure was successfully managed with pressure dressing. Both techniques can be applied to overcome tortuous radial artery, however, in extreme scenarios such as the presence of a small radial artery (
HOW-TO-DO-IT
Heart, Lung and Circulation (2015) xx, 1–4 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.12.165
Radial Artery Spasm and Perforation: Simple Solutions for Challenging Cases Michael Liang, MBChB, FRACP a,c, Gerard Devlin, MD, FRACP b, Scott A. Harding, MBChB, FRACP a* a
Department of Cardiology, Wellington Hospital, New Zealand Department of Cardiology, Waikato Hospital, New Zealand Department of Cardiology, Khoo Teck Puat Hospital, Singapore
b c
Received 17 August 2014; received in revised form 15 October 2014; accepted 26 December 2014; online published-ahead-of-print xxx
Transradial access for percutaneous coronary intervention and diagnostic coronary angiography has been increasingly utilised in the routine practice in most catheterisation laboratories as it reduces the incidence of major access site complications such as bleeding and haematoma. Radial artery spasm with or without perforation is one of the more frequent reasons for converting from radial to femoral access. In this article, the balloon-assisted technique and Sheathless EauCath (Asahi Intecc, Aichi, Japan) are demonstrated to overcome radial artery spasm with associated significant perforation in two cases. Keywords
Coronary intervention Sheathless Radial artery spasm Radial artery perforation Sheathless EauCath Balloon assisted technique
Case 1: Balloon-Assisted Technique A 67 year-old lady was referred to our catheterisation laboratory with angina and a strongly positive exercise stress test. Routine pre-medication with intravenous 2 mg midazolam was administered prior to obtaining successful radial artery access with a 6 Fr 10 cm Terumo radial sheath (Terumo, Tokyo, Japan). Two hundred micrograms of nitroglycerin was injected into the right radial artery via the radial sheath. A dose of intravenous 5000 IU of heparin was administered when the diagnostic 5 Fr TIG catheter (Terumo, Tokyo, Japan) reached ascending aorta. The ostial to proximal left anterior descending artery (LAD) was deemed the culprit lesion and percutaneous coronary intervention (PCI) to this lesion was planned (Fig. 1a). A 260 cm 0.03500 exchange J-wire was used to swap the 5 Fr TIG diagnostic catheter with a 6 Fr JL3.5 guiding catheter. The JL3.5 guiding catheter encountered strong resistance and was not able to pass through the forearm despite additional intra-arterial 200 mcg nitroglycerin and 1 mg of verapamil. An angiogram of the right radial artery demonstrated severe spasm with
significant perforation (Fig. 1b). It was decided to perform balloon-assisted technique to pass the guiding catheter through the right radial artery [1]. The 0.03500 J-wire was firstly removed. The tip of JL3.5 guiding catheter was parked at the sheath and the proximal-end of the guiding catheter was set up with the Y-connector as per routine angioplasty procedure. A 0.01400 Sion Blue (Asahi Intecc, Aichi, Japan) angioplasty guide wire was used to cross the affected radial artery carefully via the JL3.5 guiding catheter. A 2x15 mm balloon, loaded on the 0.01400 Sion Blue wire was placed half way out of the guiding catheter (Fig. 1c) and inflated at 4 atm, below nominal pressure, which is 6 atm. The JL3.5 catheter with a balloon at the tip was advanced slowly to pass the right radial artery without much resistance and reached the ascending aorta (Fig. 1d). Intervention to the ostial LAD was completed successfully (Fig. 1e) with additional 2000 IU heparin (100 IU/kg). A final angiogram of the right radial artery did not show any evidence of contrast extravasation (Fig. 1f). The right radial access site was secured with a TR band (Terumo, Tokyo, Japan) without additional pressure dressing. Ward review the following day showed intact right radial pulse and the patient was discharged home uneventfully.
*Corresponding author at: Department of Cardiology, Waikato Hospital, New Zealand, Email: [email protected] © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
Please cite this article in press as: Liang M, et al. Radial Artery Spasm and Perforation: Simple Solutions for Challenging Cases. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.165
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Figure 1 (a) Diagnostic coronary angiography showed significant proximal left anterior descending artery (LAD) lesion involving ostium (arrow). (b) Right radial artery angiography showed a large area of contrast extravasation with spasm. (c) The 2.0x15 mm balloon was half way out of the 6 Fr JL3.5 guiding catheter and inflated at 4 atm (arrow). (d) The JL3.5 guiding catheter was able to advance pass through the affected radial artery with the inflated 2.0x15 mm balloon at the tip (arrow). (e) A drug-eluting stent was successfully implanted at the ostial LAD. (f) Final right radial artery angiogram showed completely sealed radial artery without persistent contrast extravasation.
Case 2: Sheathless EauCath A 57 year-old lady was referred with a diagnosis of non-ST elevation myocardial infarction and ongoing chest discomfort. Radial artery access was obtained following sedation and a 6 Fr 11 cm ARROW radial sheath (Teleflex Medical,
NC, USA) was inserted. Routine intra-arterial 200mcg nitroglycerin and intravenous 5000 IU heparin was administered. Diagnostic angiography was performed uneventfully with a 5 Fr TIG catheter. The occluded second obtuse marginal branch was deemed the culprit lesion and PCI to this lesion was planned (Fig. 2a). A 260 cm 0.03500 long exchange wire
Please cite this article in press as: Liang M, et al. Radial Artery Spasm and Perforation: Simple Solutions for Challenging Cases. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.165
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Figure 2 (a) Diagnostic coronary angiography in the caudal projection showed occluded second obtuse marginal branch (arrow). (b) Right radial artery angiography demonstrated radial artery spasm with perforation. (c) The 6.5 Fr Sheathless EauCath can be inserted into a standard 6 Fr Sheath. The dilator at the tip of the catheter made it into a tapered tip. (d) The Sheathless EauCath passed through the affected artery without much resistance (arrow). (e) The right anterior oblique caudal projection showed that the second obtuse marginal branch was successfully opened with a drug-eluting stent. (f) The final right radial artery angiogram did not have persistent contrast extravasation.
was used to exchange the TIG catheter for a 6 Fr EBU3.5 guiding catheter. While passing the EBU guiding catheter through the forearm, a strong resistance was noted despite gentle manipulation. An angiogram of right radial artery showed significant spasm with perforation (Fig. 2b). A 6.5 Fr PB3.5 Sheathless EauCath (Asahi Intecc, Aichi, Japan), loaded on the 260 cm 0.03500 J-wire was used to pass through the affected radial artery without noticeable resistance via the 6 Fr Sheath (Fig. 2c, 2d & Fig. 3). The procedure was
successfully completed with additional 5000 IU heparin and a final radial artery angiogram demonstrated no residual radial artery leak (Fig. 2e, 2f). An intact right radial pulse was observed the following day prior to discharge.
Discussion Failure to complete procedures transradially occurs in about 5% of cases, with higher failure rates noted in less
Please cite this article in press as: Liang M, et al. Radial Artery Spasm and Perforation: Simple Solutions for Challenging Cases. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.165
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M. Liang et al.
Figure 3 Outer diameter of the Sheathless EauCath in relation to standard sheath introducer. [Adapted from Asahi-Intecc Sheathless EauCath product information: http://www.asahi-intecc.com/medical/international/product/gc_se.php].
experienced operators. Reasons included access failure, presence of spasm or significant tortuosity with or without anomaly. In this report, we described two techniques to overcome severe radial spasm with or without anatomical variation and/or accompanied perforation. Both techniques described in our cases help overcome a similar technical issue. The presence of a tapered dilator in Sheathless EauCath and the low-pressure 2 mm angioplasty balloon as demonstrated in the balloon-assisted technique eliminates the ‘‘razor effect’’ at the tip of guiding catheter [1,2]. The balloon-assisted technique, which requires loading an angioplasty balloon over a 0.01400 angioplasty wire, hence re-wire the vessel or exchange wires using a 4 Fr catheter is often needed. The Sheathless EauCath has the advantage in that it can be advanced rapidly over the existing 0.03500 260 cm J-wire. The Sheathless EauCath comes in all conventional shapes and can be used by a non-interventionist during the diagnostic procedure. The balloon-assisted technique, on the other hand, has a slightly longer learning curve and requires proficiency in handling basic interventional equipment such as a guide wire and an angioplasty balloon. Thus, our preferred method is to use the Sheathless EauCath due to the greater simplicity and speed of this approach. Both techniques have high success [4_TD$IF]rates. Patel et al. described over 95% success rate in balloon-assisted technique in a series of 63 patients with complex radial anatomy. Of note, the failed cases were in those with[5_TD$IF] an extremely small radial artery and[6_TD$IF] the presence of a 360 degree radial artery loop [3]. Liang et al. recently presented a small series of
36 cases with radial artery spasm and/or perforation encountered during change of catheter, Sheathless EauCath was successfully applied in all cases [4]. Of note, one patient (9%) who had radial artery perforation with trivial contrast extravasation at the completion of the procedure was successfully managed with pressure dressing. Both techniques can be applied to overcome tortuous radial artery, however, in extreme scenarios such as the presence of a small radial artery (
