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Use of an ultra short sheath in a patient with a tiny radial artery
Interventional cardiologist F. Kiemeneij, MD, PhD,
Center Amsterdam Department of Interventional Cardiology - OLVG
History A 53 year old female patient was referred for PTCA because of unstable angina pectoris caused by a complex lesion in the proximal RCA.

Transfemoral diagnostic angiography at the referring hospital revealed a severe stenosis in segment 1.

At examination the patient had a small radial artery as assessed by simple palpation. The Allen's test was positive.

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Pre PTCA

Strategy

Transradial approach, direct stenting
Procedure Radial artery puncture was somewhat difficult. Following a first false puncture, the radial artery pulse was barely palpable. Following several attempts the artery was punctured successfully, followed by intra-arterial administration of  200 microgram nitroglycerin and 5 mg Verapamil.

Advancement of a 0.025" wire was associated with some friction.

Since it was anticipated that sheath introduction and later sheath removal would be painful, a 6F Emcee sheath with lubricious coating  (Boston Scientific Scimed Schneider) was used. This sheath was 21 cm long. However, introducing the dilator (O.D. 2.14 mm) was associated with much friction and mild discomfort. Introducing the sheath over its full length would not have been possible or very painful, while sheath removal would have been impossible without damaging the artery or without any further actions (see chapter on radial artery spasm in the Technique section). Therefore a short sheath was required, but unfortunately unavailable in our lab. The sheath was cut to appr. 4 cm of length. This short sheath could be introduced without problems after predilatation of the entrysite with the dilatator and after having made an adequate skin incision. The guidingcatheter (Kimny wiseguide; O.D. 2.14 mm) Boston Scientific Scimed Schneider) could be introduced with slight discomfort

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PTCA was uneventful. The RCA was easily cannulated without major friction and with good torque of the catheter. The lesion was stented directly with a S670 3.5/18 mm stent (Medtronic). The result was good.

Removal of the catheter and sheath again were associated with mild discomfort but no further sequelae.

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Post PTCA
Comments This case describes the use of an ultra-short sheath in a patient with a very small radial artery. This is one of the methods to deal with small radial arteries. A long sheath can not always be advanced completely in a small artery because of friction, spasm and mechanical deformation of the vessel. The procedure is usually associated with pain as long as the guide catheter is manipulated by the operator. Sheath removal might be impossible in such situations with risk of radial artery damage and even avulsion. When a very short sheath is used, the advantages of the sheath are maintained (dry entrysite, side-port, possibility of easy guide exchange). The larger part of the radial artery has to deal with the 6F guide catheter only and not with the 6F compatible sheath (having the O.D. of a 7F guide). Last but not least, the ultra-short sheath will be easier to retrieve, even in case of spasm, since spasm does not invlove the whole length of a long sheath.

The disadvantage of a short sheath (i.e. the fact that the catheter does encounter friction from the radial artery wall and does not move free within the sheath) has to be balanced against the possible problems during sheath removal.

Cutting the sheath in the cathlab might result in a sharp non tapered edge of the sheath with possible radial artery damage. Thus it is recommended to have short sheaths in stock.

An alternative strategy was the use of a 5F guide with or without sideholes. We did not have a 5F guide available being compatible with a 3.5/18 mm stent, thus this was no option in this case.