6_sheatless_atraumatic_complex_transradial_intervention by xiuliliaofz


									                                                      Catheterization and Cardiovascular Interventions 72:357–364 (2008)

Case Reports

      Atraumatic Complex Transradial Intervention Using
           Large Bore Sheathless Guide Catheter
            M.A. Mamas,1,2                                                   1
                                  MA, DPhil, BM BCh, MRCP, F. Fath-Ordoubadi, BSc, MB BChir, MD, FRCP,
                                      and D.G. Fraser, BA, MB BChir, DM, MRCP
                    The Asahi sheathless guide catheter system is a hydrophilic catheter with a central dila-
                    tor that does not require an introducer sheath during transradial percutaneous coronary
                    intervention. Conventional sheath introducers are often 1- to 2F larger than the catheter
                    itself; therefore, this system enables the use of a larger French catheter during proce-
                    dures than would otherwise be possible using conventional techniques. We describe the
                    use of a 7.5F sheathless guide catheter system with a smaller outer diameter than a
                    conventional 6F introducer sheath in 16 cases performed transradially involving rotabla-
                    tion, crush stent bifurcation lesions, 7F proximal protection, and thrombectomy devices.
                    Such cases would otherwise not always be possible if performed using conventional
                    transradial techniques in patients with smaller radial artery sizes. ' 2008 Wiley-Liss, Inc.

                    Key words: angiography; sheathless guide catheter system; PCI

INTRODUCTION                                                       lesions in mid LAD was admitted for elective PCI to
                                                                   his LAD (Fig. 1 A and B). A 7.5F power back up
   The transradial approach is becoming increasingly
                                                                   (PBU) 3.5 sheathless guide catheter was inserted via
used in percutaneous coronary interventional (PCI) proce-
                                                                   the right radial artery to optimize visualization whilst
dures because of lower major access site complications
                                                                   performing rotablation. A rota floppy wire was passed
[1] and earlier patient mobilization [2]. Miniaturization of
                                                                   into the distal LAD, and rotablation was carried out in
equipment over the last 10 years has enabled the majority
                                                                   a long heavily calcified section of disease in the ostial
of PCIs to be performed via 5 and 6 French (F) systems
                                                                   and mid LAD with a 1.5-mm burr (Fig. 1C). The
that are well tolerated in the majority of patients. How-
                                                                   lesion was then predilated with a 2.5 mm 3 15 mm
ever, a major limitation of this approach has remained the
                                                                   quantum balloon distally and a 3 mm 3 15 mm quan-
inability to use larger bore 7F guide catheters in many
                                                                   tum balloon in the ostium. The vessel was then stented
patients because of the size of the radial artery. The outer
                                                                   using overlapping stents from just distal to the second
diameter of radial sheaths is typically 1- or 2F sizes larger
                                                                   diagonal branch, up to the ostium of the LAD using
than the outer diameter of the guide catheter, which would
                                                                   the four overlapping Promus stents (the stent sizes
further limit the size of guide catheters which can be used
                                                                   were 2.5 mm 3 28 mm, 2.75 mm 3 28 mm, 3.0 mm 3
to perform transradial coronary interventional procedures
using conventional techniques. One potential solution for          1
                                                                    Manchester Heart Centre, Manchester Royal Infirmary, Man-
the use of large bore guiding catheters is therefore to use a      chester M13 9WL, United Kingdom
sheathless guide catheter system. We report our preliminary         Department of Cardiology, Stopford Building, University of
experience performing complex transradial intervention             Manchester, Manchester M13 9PT, United Kingdom
using a 7.5F hydrophilic coated sheathless guide catheter          Conflict of interest: Nothing to report.
(Sheathless Eaucath, Asahi Intecc Co, Japan) with a nar-
rower outer diameter than a 6F radial introducer sheath.           *Correspondence to: Doug Fraser, Manchester Heart Centre, Man-
                                                                   chester Royal Infirmary, Manchester, M13 9WL, United Kingdom.
                                                                   E-mail: doug.fraser@cmmc.nhs.uk

CASES                                                              Received 30 March 2008; Revision accepted 22 April 2008
Case 1
                                                                   DOI 10.1002/ccd.21637
  A 63-year-old male with severely calcified ostial                 Published online 25 August 2008 in Wiley InterScience (www.
LAD lesion and several consecutive severe calcified                 interscience.wiley.com).

' 2008 Wiley-Liss, Inc.
358      Mamas et al.

                   Fig. 1. PA caudal (A) and PA cranial (B) views of severely calcified ostial and mid LAD
                   lesions. Rotablation being performed with 1.5-mm burr (C).

                                   Fig. 2. Final result seen in PA caudal (A) and PA cranial (B) views.

28 mm and 3.5 mm 3 12 mm; Boston Scientific). The                          diagonal vessel (D2) (Fig. 3A). The disease at this bifur-
final result is illustrated in Fig. 2A and B.                              cation was approached using a crush stenting strategy.
                                                                          A 7.5F PBU 3.5 sheathless guide catheter was used,
Case 2                                                                    and both arteries were predilated using 2.5-mm bal-
   A 60-year-old male admitted with an acute coronary                     loons. The LAD was stented distally to proximally
syndrome underwent coronary angiography via the                           using three overlapping Promus stents (2.5 mm 3
right transradial approach. This demonstrated a long                      28 mm, 2.75 mm 3 28 mm and a 2.75 mm 3 18 mm).
segment of calcific disease in the mid LAD as well as                      Extensive disease in the D2 branch was treated with a
a severe long segment of disease in a large second                        2.5 mm 3 28 mm Promus stent overlapping proximally
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
                                                                                PCI Using Sheathless Guide Catheter                  359

               Fig. 3. (A) illustrates bifurcation lesion LAD/D1 in the PA cranial view. Positioning of the LAD/
               D1 stents in preparation of the crush (B) and final result in the PA cranial view (C).

with a 2.5 mm 3 15 mm Promus stent, with the tail of              jump graft which supplied PDA and PLV branches of
the latter stent crushed in the LAD (Fig. 3B). A final             right coronary artery. A 7.5F AL 1 sheathless guide
kissing balloon dilation was performed with 2.5-mm                catheter was used with a 7F Proxis proximal protection
and 2.75-mm balloons in the LAD and D2 branches,                  device (St Jude, St Jude Medical, St. Paul, MN). A
respectively, and the final result is shown in Fig. 3C.            long segment of severe disease with a large plaque
                                                                  burden was treated in the distal vein graft close to the
Case 3                                                            point of insertion to the PLV (Fig. 5A). This was pre-
   A 55-year-old male with an acute inferior ST eleva-            dilated with a 3-mm balloon and then directly stented
tion myocardial infarction 72 h previously was admit-             with a Taxus 4 mm 3 32 mm stent. The final result is
ted for cardiac catheterization. Cardiac catheterization          illustrated in Fig. 5B. During this procedure, the
demonstrated a dominant right coronary artery with                patient sustained significant radial spasm during the
mild disease in the proximal segment and a total                  initial stage of the procedure when diagnostic cardiac
occlusion in the distal vessel (Fig. 4A). A 7.5F AL1              catheterization was performed through a 6F introducer
sheathless guide catheter (Asahi Intecc Co, Japan) was            sheath. On exchange for the 7.5F sheathless guide
used to intubate vessel, and a guide wire was passed              which has a smaller external diameter to the 6F intro-
into the distal vessel. A large volume of thrombus was            ducer sheath, radial spasm resolved, and the procedure
visualized in the distal right coronary artery as well as         was undertaken without further complications.
in both posterior left ventricular (PLV) and posterior               A further 12 PCI cases were performed using a 7.5F
descending (PDA) branches (Fig. 4B). A 7F Export                  sheathless guide catheter. A summary of these 16 cases
thrombectomy catheter (Medtronic, Minneapolis, Min-               is presented in Table I.
nesota) was passed down into the distal vessel. This
aspirated a large volume of thrombus, first in the distal          Sheathless Guide Catheter System
RCA and then from the ostea of both the PDA and                      The sheathless guide catheter system (Asahi Intecc
PLV branches. Following thrombectomy, a focal tight               Co, Japan) does not require the use of a sheath intro-
stenosis was visualized in the distal RCA (Fig. 4C)               ducer during PCI and is available in 6.5F and 7.5F
which was directly stented with a 3 mm 3 13 mm                    outer diameters. In this study, we exclusively used the
Prokinetic stent (Biotronik) and postdilated with a               7.5F version which has an external diameter of 2.49 mm
3.25-mm balloon (Fig. 4D).                                        which is significantly less than external diameter of a
                                                                  conventional 6F introducer sheath (2.62 mm). The
Case 4                                                            catheter has an advanced hydrophilic coating along its
  A 62-year-old male with a recent inferior myocar-               entire length and is supplied with its own removable
dial infarction underwent PCI to a saphenous vein                 central dilator that extends beyond the distal tip
                                                                         Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
                                              Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
360      Mamas et al.

                   Fig. 4. Left anterior oblique (LAO) view showing occlusion of RCA in distal RCA (A). After
                   passage of guide wire thrombus is visualized in distal RCA and PDA/PLV (B). Postthrombec-
                   tomy of a focal stenosis indistal RCA (C) and final result (D).

(Fig. 6A and B). Standard guide catheter shapes are                       wire (Fig. 6C and D) into the radial artery. Once the
available including left and right Judkins, left and right                catheter has reached the proximal ascending aorta, the
Amplatz, PBU and multipurpose.                                            central dilator and wire are removed and the catheter
   Catheter insertion involves initial radial cannulation                 is advanced to achieve coronary intubation in the usual
using a standard 5- or 6F sheath, which is used to                        way (Fig. 6E). At the end of the case, the catheter is
insert a standard J tipped 150 cm 0.035 in. diameter                      removed over a standard exchange wire, and the punc-
exchange wire. The sheath is then removed and the                         ture site is sealed using a standard compression device
catheter (with its dilator) is passed over the exchange                   (Fig. 6F).
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
                                                                                         PCI Using Sheathless Guide Catheter                  361

                   Fig. 5. (A) LAO view of saphenous vein jump graft supplying PDA and PLV branch of RCA.
                   Arrow indicates edge of Proxis proximal protection device. (B) Final result.

TABLE I. Summary of 16 Cases Performed With 7.5 F Sheathless Guide Catheters
             Age              Sex              Catheter                                Procedure                                  Complications
 1            63             Male              PBU 3.5             Rotablation LAD 1.5-mm burr, PCI LAD                                No
 2            60             Male              PBU 3.5             Crush stent LAD/D1 bifurcation                                      No
 3            55             Male               AL 1               Thrombectomy (7F) and PCI RCA                                       No
 4            62             Male               AL 1               Proximal protection using Proxis device, PCI SVG                    No
 5            34             Male              PBU 3.0             PCI LAD, kissing balloons LAD/D1 bifurcation                 Forearm hematoma
 6            58             Male              PBU 3.5             Crush stent LAD/D1 bifurcation                                      No
 7            67             Female            PBU 3.0             PCI LAD, kissing balloons LAD/D1 bifurcation                        No
 8            68             Male              PBU 3.5             Crush stent LAD/D1 bifurcation                                      No
 9            67             Male              PBU 3.5             Crush stent LAD/D1 bifurcation                                      No
10            67             Female            PBU 3.0             Rotablation LMS 1.75-mm burr, PCI LMS/LAD                           No
11            43             Male              PBU 3.5             PCI LCx, Kissing balloons LCx/OM2                                   No
12            70             Male              PBU 3.0             Rotablation 1.25-mm burr, PCI LAD                                   No
13            52             Male              PBU 3.5             PCI LAD, kissing balloons LAD/D1 bifurcation                        No
14            60             Male              PBU 3.5             Crush stent LAD/D2 bifurcation                                      No
15            67             Male              PBU 3.5             Crush stent LCx/OM2 bifurcation                                     No
16            50             Male              PBU 3.5             Thrombectomy (7F) and PCI LAD                                       No
Three cases of radial spasm were observed on introducing initial introducer sheath in cases 4, 7, and 12, although this resolved on exchange to the
sheathless guide catheter.

DISCUSSION                                                                 portion of patients, and so overcome one of the major
                                                                           limitations of the transradial route.
   We report the successful use of 7.5F sheathless
                                                                              The patients in this study were consecutive patients
guiding catheters via the transradial route in 16 con-
secutive patients, who required complex coronary                           in whom a decision was made to use a large bore
intervention using large bore-guiding catheters. The                       catheter to facilitate complex intervention. Patients
sheathless guide was well tolerated in all patients, and                   were not selected on the basis of radial artery size.
coronary intervention was performed successfully in all                    The indication for the use of a large bore guide was
cases. This preliminary experience suggests that the                       bifurcation disease treated with by crush stenting in six
sheathless guide system could enable the use of large                      patients, bifurcation disease that could have required
bore guide catheters via the radial artery in a high pro-                  crush stenting but did not in four patients, thrombec-
                                                                                 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
                                                      Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
362      Mamas et al.

                   Fig. 6. (A) Hydrophilic PBU 3.5 guide catheter illustrated with central dilator in packaging. (B)
                   Central dilator inserted into guide catheter. (C) Following cannulation of radial artery, introducer
                   sheath removed and sheathless guide passed over 150-cm guide wire (D) until catheter has
                   reached proximal ascending aorta where central dilator and guide wire removed. (E) After cannula-
                   tion of coronary artery. (F) Postprocedure with local radial compression device for hemostatis.
                   [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]

tomy using 7F thrombectomy devices in two patients,                       spasm was not associated with the use of the sheath-
to optimize vessel opacification whilst performing rota-                   less guide in any patient despite spasm associated with
blation in three patients and the use of a 7F proximal                    the prior insertion of a 6F introducer sheath in three
protection device in one patient. We found that guide                     patients. This difference may have been related to bet-
catheter manipulation was no different from manipula-                     ter tolerability of the 7.5F sheathless system than the
tion of a standard guide catheter, and there was no                       standard 6F introducer sheath.
bleeding around the skin insertion site during the pro-                      The size of guide catheters used in transradial PCIs
cedure. A small forearm hematoma postprocedure was                        is limited by anatomical considerations. The lumen of
detected in one patient postprocedure that was not                        the radial artery is frequently smaller than the outer
thought to be related to the guide catheter. Radial                       diameter of a 7- or 8F radial sheath. In a study of
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
                                                                             PCI Using Sheathless Guide Catheter                  363

250 patients, Saito et al. [3] demonstrated that the ra-       significant vascular complications were recorded using
dial artery diameter was smaller than the outer diame-         this device, and only 3.5% sustained minor local com-
ter of a 7F Terumo (Terumo Co, Tokyo, Japan) intro-            plications. Sheathless 4F catheters introduced through
ducer sheath in 28.5% of males and 59.7% of females.           the brachial and femoral arteries for diagnostic lower
Furthermore, they observed that the risk of severe flow         limb angiography have also been reported [11]. How-
reduction in the radial artery following intervention          ever, to the author’s knowledge, the use of sheathless
was much higher when the sheath diameter exceeded              guide catheters for PCIs from the radial artery has not
that of the radial lumen. These problems are poten-            previously been described.
tially increased in patients undergoing repeat transra-
dial procedures. For example, in patients who have             Limitations
undergone previous transradial coronary intervention             The principal benefit of a sheath is the ability to
procedures, a reduced radial lumen size compared to            rapidly exchange catheters. Such catheter exchange
those where a radial approach was used for first time           would be more cumbersome using such a sheathless
was observed because of a greater intimal/medial               system as described here because of the need to recan-
hyperplasia [4]. This would potentially further decrease       nulate the artery over an exchange wire for each new
the proportion of patients whose radial arteries can           catheter. This limitation would be most apparent for
accommodate 7F guide catheters using more con-                 diagnostic studies and multivessel angioplasty requiring
ventional techniques involving introducing sheaths.            several different catheters.
Furthermore, Sakai et al. [5] have demonstrated a sig-
nificant decrease in success rates following successive
radial punctures and transradial procedures using 5- and       CONCLUSION
6F conventional systems. For example, a third transradial
angioplasty (TRA) procedure was possible in 90% of the            This preliminary study suggests that the 7.5F sheath-
men and 80% of the women, whereas a fifth TRA proce-            less guide is very well tolerated from the radial artery.
dure was only possible in 70% of the men and 50% of the        This system should allow complex intervention requir-
women. This was primarily due to vessel narrowing and          ing large bore catheters to be performed transradially
occlusion occurring as a function of multiple punctures.       in a higher proportion of patients and with fewer local
   The outer diameter of the 7.5F sheathless guide             complications than standard 7- and 8F sheath and
(2.49 mm) is greater than the outer diameter of a 5F           guide combinations.
sheath (2.29 mm) but significantly less than the outer
diameter of a 6F sheath (2.62 mm). The tolerability of
this catheter is further enhanced by a hydrophilic coat-       REFERENCES
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Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

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