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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, 1* 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  and earlier patient mobilization . 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 2 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: firstname.lastname@example.org 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.  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 . 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 . 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.  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 ing along its entire length. Hydrophilic coatings have 1. Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der been shown to signiﬁcantly reduce discomfort and re- Wieken R. A randomized comparison of percutaneous translumi- trieval force when applied to radial sheaths . nal coronary angioplasty by the radial, brachial and femoral A 6.5F sheathless guide system is also available approaches: The access study. 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