case report balloon-assisted tracking to overcome radial...

Case ReportBalloon-Assisted Tracking to Overcome Radial Spasm duringTransradial Coronary Angiography A Case Report

N J W Verouden1 and F Kiemeneij2

1 Department of Cardiology B2-137 Academic Medical Center-UvA Meibergdreef 9 1105 AZ Amsterdam The Netherlands2Department of Cardiology Tergooi Rijksstraatweg 1 1261 AN Blaricum The Netherlands

Correspondence should be addressed to N J W Verouden cjveroudenamcuvanl

Received 4 November 2013 Accepted 26 November 2013 Published 8 January 2014

Academic Editors R Akdemir G Devlin and K Shimada

Copyright copy 2014 N J W Verouden and F Kiemeneij This is an open access article distributed under the Creative CommonsAttribution License which permits unrestricted use distribution and reproduction in any medium provided the original work isproperly cited

Spasm of the radial artery is the most important cause of failure to perform coronary angiography via the transradial approachSpasmolytic cocktail may prevent radial artery spasm but is relatively contraindicated in patients with aortic stenosis or diminishedleft ventricular function In this case report we describe a recently published technique to overcome severe radial spasm duringtransradial coronary angiography in a patient with moderate aortic valve stenosis

1 Introduction

After a two-decade evolution the transradial approach(TRA) in coronary angiography and percutaneous coronaryintervention (PCI) has become a viable and attractive alterna-tive for the femoral approach [1ndash4] The increased adoptionof the TRA originates from high procedural success reducedrisk for major access site related bleeding complicationslower mortality increased patient comfort and cost reduc-tion [5ndash7]

One of the most encountered problems is radial arteryspasm In a multicenter registry containing over 1900 tran-sradial procedures the incidence of radial spasm was 27with multiple puncture attempts and use of larger introducersheaths (7F) being independent predictors of radial spasm[8] Another prospective study reported female gender as anindependent contributor to the incidence of radial spasm [9]Furthermore spasm can be triggered by excessive manipu-lation of intra-arterial wires and guides especially if there issomemismatch in diameter between a small radial artery anda large bore catheter

Radial artery spasm can be prevented by administrationof intraarterial spasmolytic cocktails [10] However in someinstances these cocktails may result in hypotension andbradycardia Patients with a significant aortic stenosis havea fixed stroke volume and therewith are at high risk of

refractory and life threatening hypotension after administra-tion of spasmolytic cocktail

In this case report we describe a recently publishedtechnique [11] to overcome severe radial spasm in a patientwith moderate to severe aortic valve stenosis who underwentTRA coronary angiography

2 Case

A 70-year-old male patient was referred for coronary angiog-raphy because of chest pain on exertion In preceding yearshe visited our outpatient department for echocardiographicfollow-up of a moderate aortic valve stenosis During thelast visit he expressed typical anginal complaints whileechocardiographic evaluation of the aortic valve displayed astable function

Patient underwent coronary angiography via right radialaccess After uneventful puncture and cannulation of a 5Fintroducer sheath (Arrow Arrow International Inc) 5000 IUof heparinwas administered Initially no spasmolytic cocktailwas used because of patientrsquos moderate aortic stenosis A 5FJL catheter (Medtronic Inc Minneapolis MN USA) overa 003510158401015840 standard guide wire could uneventfully cannulatethe left main ostium After visualization of the left coronaryartery over the wire exchange for a 5F JR catheter resultedin severe patient discomfort of the forearm resulting from

Hindawi Publishing CorporationCase Reports in CardiologyVolume 2014 Article ID 214310 3 pageshttpdxdoiorg1011552014214310

2 Case Reports in Cardiology

Figure 1

Figure 2 The BAT assembly Kimny guiding catheter protrudingballoon (black arrow) and Sion guide wire

spasm Half-dose spasmolytic cocktail (5mg of verapamilplus 200 ug nitroglycerine in 10mL of normal saline) did notpermit the JR catheter to pass and resulted in a significantfall of intra-arterial blood pressure Visualization of the radialrevealed severe and refractory spasm (Figure 1)

In order to cross the spastic segment a 5F Kimny guide(Boston Scientific) was loaded with a 20 times 15mm MiniTrek PTCA catheter (Abbott Vascular) over a 001410158401015840 Sioncoronary guide wire (Asahi)The balloon catheter which waskept partially outside the distal end of the guiding catheterwas inflated at 4 bars to ensure fixation of the guidingcatheter onto the coronary wire (Figure 2) As such theguide catheter tapered perfectly over the soft balloon and theballoon over the guide wire Balloon-assisted tracking (BAT)of the guiding catheter over the 001410158401015840 coronary wire resultedin smooth and uncomplicated engagement of the assemblyinto the ascending aorta in the absence of complaints of thepatient After exchange for the standard 003510158401015840 guide wire

Figure 3

subsequent cannulation of the right coronary artery resultedin adequate visualization of this coronary artery

The patient underwent PCI of the ostial lesion of the RCA1week later Radial artery angiography revealed a smooth andundamaged vessel (Figure 3)

3 Discussion

The evolution of the TRA in the preceding two decadesbrought along newprocedural difficulties that should be over-come by evolving techniques and equipment As in above-described case spasm of the radial artery are amajor obstacleto a successful TRA and may result in catheter-inducedperforation or conversion to a transfemoral approach

The tunica media of the muscular radial artery is com-prised of concentric layers of smooth muscle cells Bothcirculating catecholamines and mechanical stimuli (sheathintroduction wire and catheter manipulation) may causesmooth muscle cell contraction and hereby spasm of theradial artery Forced cannulation of a spastic radial arterymay cause the catheter tip to brush the endothelium whichmay aggravate spasm and cause vascular damage BAT ofthe guiding catheter was recently described by Patel andcolleagues [11] to overcome complex arm vasculature likesmall size tortuosity and sclerosis Key factor of success ofthis technique is the conical shape of the partly protrudingballoon with its coated surface which gives the assemblya tapered tip and a smooth surface Low pressure ballooninflation (3 bar) keeps the tipmore flexible and hence suitablefor extreme tortuosity and obstructions of the peripheralarteries Better pushability to overcome spasm or smallvessel diameter can be obtained by medium pressure ballooninflation (6 bar) [12]

In conclusion BAT was successful in this patient withradial artery spasm refractory to low dose spasmolytics

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this article

Case Reports in Cardiology 3

References

[1] O F Bertrand S V Rao S Pancholy et al ldquoTransradialapproach for coronary angiography and interventions resultsof the first international Transradial practice surveyrdquo Journal ofthe American College of Cardiology vol 3 no 10 pp 1022ndash10312010

[2] D N Feldman R V Swaminathan L A Kaltenbach etal ldquoAdoption of radial access and comparison of outcomesto femoral access in percutaneous coronary intervention anupdated report from the national cardiovascular data registry(2007ndash2012)rdquo Circulation vol 127 pp 2295ndash2306 2013

[3] F Kiemeneij G J Laarman D Odekerken T Slagboom and Rvan der Wieken ldquoA randomized comparison of percutaneoustransluminal coronary angioplasty by the radial brachial andfemoral approaches the access studyrdquo Journal of the AmericanCollege of Cardiology vol 29 no 6 pp 1269ndash1275 1997

[4] M Hamon C Pristipino C Di Mario et al ldquoConsensusdocument on the radial approach in percutaneous cardiovascu-lar interventions position paper by the European Associationof Percutaneous Cardiovascular Interventions and WorkingGroups on Acute Cardiac Carelowastlowast and Thrombosis of theEuropean Society of Cardiologyrdquo EuroIntervention vol 8 pp1242ndash1251 2013

[5] C J Cooper R A El-Shiekh D J Cohen et al ldquoEffectof transradial access on quality of life and cost of cardiaccatheterization a randomized comparisonrdquo American HeartJournal vol 138 no 3 I pp 430ndash436 1999

[6] S S Jolly S Yusuf J Cairns et al ldquoRadial versus femoral accessfor coronary angiography and intervention in patients withacute coronary syndromes (RIVAL) a randomised parallelgroup multicentre trialrdquo The Lancet vol 377 pp 1409ndash14202011

[7] E Romagnoli G Biondi-Zoccai A Sciahbasi et al ldquoRadialversus femoral randomized investigation in ST-segment eleva-tion acute coronary syndrome the RIFLE-STEACS (Radial Ver-sus Femoral Randomized Investigation in ST-Elevation AcuteCoronary Syndrome) studyrdquo American College of Cardiologyvol 60 pp 2481ndash2489 2012

[8] A Goldsmit F Kiemeneij I C Gilchrist et al ldquoRadial arteryspasm associated with transradial cardiovascular proceduresresults from the RAS registryrdquo Catheterization and Cardiovas-cular Interventions 2013

[9] S Gorgulu T Norgaz T Karaahmet and S Dagdelen ldquoInci-dence and predictors of radial artery spasm at the beginningof a transradial coronary procedurerdquo Journal of InterventionalCardiology vol 26 pp 208ndash213 2013

[10] F Kiemeneij B U Vajifdar S C Eccleshall G Laarman TSlagboom and R van derWieken ldquoEvaluation of a spasmolyticcocktail to prevent radial artery spasm during coronary pro-ceduresrdquo Catheterization and Cardiovascular Interventions vol58 no 3 pp 281ndash284 2003

[11] T Patel S Shah and S Pancholy ldquoBalloon-assisted tracking ofa guide catheter through difficult radial anatomy a technicalreportrdquo Catheterization and Cardiovascular Interventions vol81 pp E215ndashE218 2013

[12] T Patel S Shah S Pancholy et al ldquoBalloon-assisted trackinga must-know technique to overcome difficult anatomy dur-ing transradial approachrdquo Catheterization and CardiovascularInterventions 2013

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Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

2 Case Reports in Cardiology

Figure 1

Figure 2 The BAT assembly Kimny guiding catheter protrudingballoon (black arrow) and Sion guide wire

spasm Half-dose spasmolytic cocktail (5mg of verapamilplus 200 ug nitroglycerine in 10mL of normal saline) did notpermit the JR catheter to pass and resulted in a significantfall of intra-arterial blood pressure Visualization of the radialrevealed severe and refractory spasm (Figure 1)

In order to cross the spastic segment a 5F Kimny guide(Boston Scientific) was loaded with a 20 times 15mm MiniTrek PTCA catheter (Abbott Vascular) over a 001410158401015840 Sioncoronary guide wire (Asahi)The balloon catheter which waskept partially outside the distal end of the guiding catheterwas inflated at 4 bars to ensure fixation of the guidingcatheter onto the coronary wire (Figure 2) As such theguide catheter tapered perfectly over the soft balloon and theballoon over the guide wire Balloon-assisted tracking (BAT)of the guiding catheter over the 001410158401015840 coronary wire resultedin smooth and uncomplicated engagement of the assemblyinto the ascending aorta in the absence of complaints of thepatient After exchange for the standard 003510158401015840 guide wire

Figure 3

subsequent cannulation of the right coronary artery resultedin adequate visualization of this coronary artery

The patient underwent PCI of the ostial lesion of the RCA1week later Radial artery angiography revealed a smooth andundamaged vessel (Figure 3)

3 Discussion

The evolution of the TRA in the preceding two decadesbrought along newprocedural difficulties that should be over-come by evolving techniques and equipment As in above-described case spasm of the radial artery are amajor obstacleto a successful TRA and may result in catheter-inducedperforation or conversion to a transfemoral approach

The tunica media of the muscular radial artery is com-prised of concentric layers of smooth muscle cells Bothcirculating catecholamines and mechanical stimuli (sheathintroduction wire and catheter manipulation) may causesmooth muscle cell contraction and hereby spasm of theradial artery Forced cannulation of a spastic radial arterymay cause the catheter tip to brush the endothelium whichmay aggravate spasm and cause vascular damage BAT ofthe guiding catheter was recently described by Patel andcolleagues [11] to overcome complex arm vasculature likesmall size tortuosity and sclerosis Key factor of success ofthis technique is the conical shape of the partly protrudingballoon with its coated surface which gives the assemblya tapered tip and a smooth surface Low pressure ballooninflation (3 bar) keeps the tipmore flexible and hence suitablefor extreme tortuosity and obstructions of the peripheralarteries Better pushability to overcome spasm or smallvessel diameter can be obtained by medium pressure ballooninflation (6 bar) [12]

In conclusion BAT was successful in this patient withradial artery spasm refractory to low dose spasmolytics

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this article


References


















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















References


















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















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