A Case of Sheathless Transradial Coronary Intervention for Complex Coronary Lesions with a Standard Guiding Catheter
The patient was an eighty year-old male, experiencing exertional chest pain for 3 months. His coronary risk factors were hypertension and smoking. The electrocardiography and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular systolic function without regional wall motion abnormalities. The coronary angiography via the right radial artery demonstrated total occlusion at distal left circumflex artery (LCX), and diffuse 70-90% stenosis with severe calcification from distal left main coronary artery to proximal left anterior descending artery (LAD) (). The right coronary angiography showed no significant stenosis. We planned to treat the distal LCX occlusion first. A 6 Fr EBU 3.75 guiding catheter (Medtronic®, Minneapolis, MN, USA) was engaged to the left coronary artery (LCA) by a conventional transradial technique. A Fielder FC wire (Asahi Intecc, Nagoya, Japan) successfully crossed the occlusion, and a Xience prime 2.5×33 mm stent (Abbott®, Redwood City, CA, USA) was implanted at distal LCX across the second obtuse marginal branch (OM) after several predilatations. Following a good stent implantation distal LCX flow, however, a dissection occurred at second OM, perhaps needing another stent implantation through the stent strut (). As the patient did not complain of chest pains and the vital signs were stable, we decided on the staged percutaneous coronary intervention (PCI) for the distal LCX bifurcation stenting and the severe calcified proximal LAD stenosis with a larger bore guiding catheter.\nTwo days after the procedure, a second PCI was performed via a radial artery, as the patient was not able to lie straightly due to right leg pain. Because a large bore guiding catheter system was required for this complex coronary anatomy, we decided to perform the sheathless transradial approach using a standard 7 Fr guiding catheter. At first, a 5 Fr introducer sheath was inserted into the right radial artery. Then a stiff 260 cm J-tipped 0.035-inch wire (Terumo®, Tokyo, Japan) was introduced near the aortic root. After the removal of the 5 Fr introducer sheath, we predilated radial artery access site with a dilator of the 7 Fr introducer sheath.\nFollowing, we inserted the Heartrail catheter (Terumo®, Tokyo, Japan) into the 7 Fr XB 3.5 guiding catheter (Cordis®, Miami, FL, USA) (). Both catheters were inserted sequentially through the skin into the radial artery (), and advanced to the aortic root along the 0.035-inch wire (). Finally, 7 Fr XB 3.5 guiding catheter was successfully engaged into the LCA.\nThe first target lesion was the distal LCX bifurcation lesion. After a guide wire was passed into the second OM, multiple predilatations were performed, and Xience prime 2.5×23 mm stent was deployed by culottes technique across the previous LCX stent (). Thereafter, kissing balloon dilatation was successfully performed (). Because proximal LAD target lesion had a severe calcification, rotational atherectomy (1.5 mm burr) was performed five times (), and 2 Xience prime stents (2.75×15 mm, 3.5×23 mm) were implanted with the support of 5 Fr, 120 cm Heartrail catheter (child-in-mother technique) after multiple predilatations ().\nThe final angiography revealed excellent results (). The patient was stable without elevation of enzymes, and was discharged without puncture site complication two days after the procedure.