Torsten Schwalm, MD
Sana Krankenhaus Hürth, D-50354 Hürth/Germany, Krankenhausstrasse 42
A 56 year old female presenting with Non-ST-Elevation myocardial infarction and ST-segment depression in the inferior leads. Coronary angiography showed a single-vessel disease with a calcified stenosis within a tortuous segment of the proximal RCA. Conventional PCI using a 6 French guide failed to dilate the severely resistant plaque.
Decision was taken to maintain radial access and to rotablate using a 2 mm burr requiring a large bore guiding catheter.
First a temporary pacing lead was placed in the apex of the right ventricle through the groin.
A coronary 0.014’’ (Balance Middleweight, Abbott Vascular Santa Clara, CA, USA) wire was introduced through the 6 French sheath (Terumo Co, Tokyo, Japan) that was still in place. Fluoroscopy confirmed the position in the subclavian artery.
An inflated 2.0 x 20 mm semi-compliant balloon (Maverick™, Boston Scientific Corporation, MA, USA) was introduced in a 7 French AL 0.75 guiding catheter (Cordis Corporation, Miami, FL, USA) so that half of the balloon protruded the tip of the guide (picture 1). The sheath was then pulled out and balloon and guide were introduced in the radial artery and further advanced (video 1).
In the brachiocephalic trunk the wire and balloon were pulled out of the guide and a standard 0.035’’ wire (Cordis Corporation, Miami, FL, USA) was introduced. The guide was then placed in the ostium of the RCA.
Picture 2 shows the guide already introduced in the radial artery, the Y-connector (Copilot bleedback control™, Abbott Vascular Santa Clara, CA, USA) and the rotablator burr prior to insertion in the catheter.
A floppy Rotawire (Boston Scientific Corporation, MA, USA) was placed in the distal coronary artery (video 2). Under high rotational speed a 2 mm burr (Boston Scientific Corporation, MA, USA) was advanced several times through the stenosis (video 3).
Images after rotablation showed a large type C dissection over almost the whole length of the vessel, the first stent already in place (video 4). The dissection could be completely covered with 4 overlapping drug-eluting stents (Promus Element™, Boston Scientific) (video 5, most proximal stent) and the final result was good (video 6).
Sheathless access allows for the use of large bore coronary guiding catheters even in smaller radial arteries. The sheath itself is mostly 2 French sizes larger than the guiding catheter, thus absence of a sheath allows for a larger size of the guide. Simultaneous 2-stent techniques, some dedicated bifurcation devices and rotablator burrs larger than 1.5 mm require the use of >6 French guides, which otherwise would favour transfemoral approach. By choosing one of the different methods of sheathless transradial access the inhererent advantages of the radial approach can be maintained.
Balloon-assisted tracking is one of mainly three methods of sheathless PCI. Besides this technique dedicated sheathless guiding catheters are available that serve all in one as sheath, dilator and guide (picture 3, ASAHI INTECC CO., LTD., Japan). The third method is the use of a 5 French 125 cm coronary diagnostic catheter within a 7 French 100 cm guide catheter, advanced over a standard 0.035’’ wire (picture 4, all Cordis Corporation, Miami, FL, USA).
In this case balloon-assisted tracking allowed the use of a 7 French guide. Also 8 French guides can safely be used. Dissection probably occurred because of the more aggressive intubation with the Amplatzer guide configuration and unlikely in consequence of rotablation, but as a consequence of rotablation stent implantation was without problems.
I have no conflicts of interest.