Importance of a Hydrophilic Coronary Wire in Anatomically Challenging Transradial Access: An Extended Case Series
Abstract: Anatomic variations during transradial (TR) procedures are relatively common and represent a significant cause of technical failure, even for experienced radial operators. In this study, we present an interesting alternative technique to overcome these anatomical anomalies. A significant amount of TR procedures in various and challenging anatomical conditions were successfully completed with the use of a 0.014˝ hydrophilic coronary guidewire.
J INVASIVE CARDIOL 2012;24(6):290-293
Key words: transradial access, radial approach, coronary wire
In recent years, the transradial (TR) approach has gained popularity and is increasingly used by many operators as the preferred access route for percutaneous coronary intervention (PCI). Compared to a transfemoral (TF) approach, the TR approach has been shown to reduce vascular complications,1-3 to promote early ambulation4 and to shorten hospital stay.5 However, in 1%-5% of TR procedures, technical failure occurs.6-10 This is mainly caused by the presence of upper-limb arterial anatomic variations.9,10 After successful radial sheath insertion, these variations can cause difficult advancement of a standard (non-hydrophilic) guidewire or catheter, and a retrograde arteriography is recommended to detect underlying anatomical anomalies. Generally, a hydrophilic-coated 0.035˝ guidewire is then used to attempt to cross the anatomical anomaly. If this conventional approach fails, most operators will change to another access route, such as the contralateral radial artery, femoral arteries, or even the homolateral ulnar artery,11 increasing procedural time and patient discomfort. Compared to a 0.035˝ hydrophilic guidewire, a 0.014˝ coronary guidewire is thinner and more steerable. In this study, we demonstrate the advantage of a hydrophilic coronary guidewire in various and challenging anatomical conditions during TR procedures.
Patient selection. All TR cases, performed by the authors between January 2010 and July 2011, were analyzed retrospectively. In this study, a case was used if anatomical variations of the radial artery were confirmed by angiography, and the following two conditions were met: (1) failure to overcome this variation with the use of a 0.035˝ hydrophylic-coated guidewire; and (2) subsequent attempt with a 0.014˝ hydrophilic coronary guidewire.
TR procedure and technique description. After local skin anesthesia with 2 cc of lidocaine 2%, the radial artery puncture was performed with a radial cannulation needle and guidewire according to operator expertise. A 4-6 Fr, 11 cm sheath was then inserted and a drug cocktail of verapamil (2 mg) and isosorbide dinitrate (200-400 μg) was injected through the side arm of the sheath. Heparin (5000 IU) was given intravenously in all patients. Initially, a 4 or 5 Fr diagnostic catheter was advanced carefully without fluoroscopy on a standard 150 cm, 0.035˝ non-hydrophilic J-tipped guidewire (Cordis Corporation). In case of difficult advancement of the standard guidewire, a retrograde arteriography was performed to evaluate underlying arterial anatomy. Based on the angiogram and under fluoroscopic guidance, a second attempt was made with a hydrophilic-coated 150 cm, 0.035˝ J-tipped guidewire (Glidewire; Terumo). In case of failure with this guidewire, a hydrophilic-coated 152 cm, 0.014˝ Choice PT coronary guidewire (Boston Scientific) was used in all patients. In most cases, a Y-connector allowing contrast injection to assess the correct progression of the Choice PT was utilized. If crossing was successful, the hydrophilic coronary guidewire was exchanged for a standard or stiff guidewire, and the diagnostic catheter was advanced to complete coronary angiography. In case of PCI, an adjunctive bolus of heparin was given if needed according to activated clotting time monitoring (therapeutic range, 250-300 seconds). Administration of glycoprotein IIb/IIIa inhibitor depended on the discretion of the operator. After completion of the TR procedure, the arterial sheath was removed and hemostasis was achieved using a unilateral radial compression system (TR band; Terumo).
Definitions. Procedural success was defined as completion of the planned procedure through the initially selected radial access route. In case of failure of the TR approach, a TF approach was chosen. Vascular spasm was defined as an inability to manipulate the guidewire or catheter in a smooth and pain-free manner.
During the study period, 2625 TR procedures were performed by the authors. Transradial procedural success was 99%, with 1% of patients (26 patients) requiring femoral access for procedure completion. Procedural failures were due to inability to cross an anatomical variation with a hydrophilic 0.035˝ guidewire in 7 patients without attempting to use a coronary wire (this technique was not used systematically during the initial study period), to profound radial artery spasm in 6 patients, to radial puncture failure in 5 patients, to radial artery dissection in 3 patients, to difficulty in manipulating and stabilizing catheters during PCI because of major radial and/or subclavian tortuosity in 4 patients, and to hypoplastic radial artery in 1 patient. Out of these 2625 procedures, we identified 19 patients (0.7%) who met the study criteria. Clinical and procedural characteristics of these patients are presented in Table 1. The mean age was 76.5 ± 10 years and 11 patients were male (58%). Clinical indications for coronary angiography included suspected ischemic heart disease (17 patients), non-ST elevation myocardial infarction (1 patient), and ST-elevation myocardial infarction (1 patient). Seven patients had a radial loop (full 360° loop in 6 patients) with 1 patient combining radial loop and stenosis. Extreme tortuosity at the level of the radial artery was present in 7 patients (2 with additional stenosis and 1 with an additional brachial loop), at the level of the brachial artery in 1 patient (with additional stenosis) and at the level of the subclavian artery in 1 patient. Two patients had a combination of radial and subclavian tortuosity. One patient had a hypoplastic radial artery. The anatomic variation was crossed by the coronary wire in all patients within a median of 2 minutes (interquartile range, 1 to 3 minutes). Diagnostic coronary angiography was successfully completed in all patients. Overall, 10/19 patients (52%) underwent implantation of at least 1 stent during the procedure. Of these 10 patients, failure to perform coronary stenting via the TR route, and subsequent conversion to TF route, occurred in only 2 patients. Patient #9 had an acute coronary syndrome with hemodynamic instability and due to radial and subclavian tortuosity, it was difficult to manipulate the catheter. Patient #14 had a hypoplastic radial artery with highly painful diagnostic angiogram precluding the use of TR route for PCI. Three patients (15.8%) had radial spasm during the procedure, which necessitated intravenous injection of morphine. No other complications were noted.
Anatomic variations during TR procedures are relatively common and represent a significant cause of TR failure, even for experienced radial operators. Furthermore, specific anomalous patterns such as radial loop or extreme radial tortuosities are associated with higher failure rates.9,10 During TR approach, any resistance during catheter or guidewire progression should prompt early angiography in order to help accurate anatomical identification and to avoid traumatic manipulation of guidewire or catheter. Once the anatomic variation has been defined, the second step is usually an attempt to cross it with a hydrophylic 0.035˝ guidewire. In case of persistent failure, most operators will change to other access routes. This increases procedural time and patient discomfort. Interestingly, we report a simple, rapid, and effective technique to overcome complex radial anatomical variations when the conventional approach fails. For this purpose, we used a 0.014˝ hydrophilic-coated coronary guidewire in 19 consecutive patients. Potential advantages of a coronary guidewire in this setting include thinner core, increased steerablity, and the possibility to inject contrast through a Y-connector allowing precise visualization of the wire progression. With this technique, procedural success was obtained in 17/19 patients (89.4%) despite highly complex anatomical variations including complex radial loop and major arterial tortuosities. Moreover, the use of a hydrophilic coronary wire resulted in a 37% reduction in total transradial failure rate, yielding a high procedural success rate (99%) for the transradial approach. However, we must emphasize that these procedures were performed by experienced high-volume radial operators (ie, each author had personal experience with more than 3000 cases). We decided to use the Choice PT Extra Support coronary guidewire because it combines a hydrophilic coating, facilitating wire advancement through arterial tortuosities, with a high level of support which was necessary for catheter advancement. The procedure was safe and generally well tolerated, although 3 patients experienced pain due to arterial spasm. Strategies to reduce patient discomfort are careful and gentle manipulation of diagnostic and guiding catheters, the use of the smallest catheter size required to complete the procedure, and the use of hydrophilic-coated catheters. Furthermore, we strongly advocate careful manipulation of hydrophilic coronary wires under fluoroscopic and angiographic guidance to avoid subintimal dissection and vessel perforation. Of note, the present study is the largest case series reporting the importance of a hydrophilic coronary guidewire in this indication. Thus far, only one other study has been published reporting the same technique in only 7 patients.8
During TR procedure, the use of a hydrophilic-coated coronary guidewire provides an easy and effective method to overcome complex anatomical variation when the conventional approach fails.
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From the Division of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted December 20, 2011, provisional acceptance given February 7, 2012, final version accepted February 16, 2012.
Address for correspondence: Adel Aminian, MD, Centre Hospitalier Universitaire de Charleroi, Division of Cardiology, Bd Paul Janson 92, 6000 Charleroi, Belgium. Email: [email protected]