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PTCA and stenting via RIMA and LIMA by the right transradial approach
Interventional cardiologist Dr. Yves Louvard, MD
Center Institut Cardiovasculaire Paris Sud, Massy, France
History A 67 years old male was admitted foro CAG 6 yrs after bypass surgery. The RIMA was implanted on the distal RCA and the LIMA on the distal LAD. The patient was asymptomatic but had significant ischemia in the posterior and anterior wall as demonstrated by stress thallium imaging.

CAG via the right radial approach showed complete occlusions of the RCA and LAD. The RCA had a tight lesion distal to the graft anastomosis (fig.1a.) and the distal LAD, filled by a tortuous LIMA (fig.2.) had a slightly calcified significant lesion (fig.3a.). The selective cannulation of the LIMA via the right RA was easily performed with a 5F left internal mammary catheter from Medtronic.

 RCA pre.jpg (5785 bytes)

Fig 1a. RCA pre

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Fig. 1b. RCA post

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Fig. 2. LIMA

 

 
Strategy Right radial approach

Materials:

Guides: Mammary shape 6F guiding catheter for the right mammary graft (ZUMA, Medtronic)
Mammary shape 6F guiding catheter for the left mammary  graft (ZUMA , Medtronic).

Wire: 0,014 Balance wire (Guidant)                      

Balloon:   Viva  3 mm (Boston)

Stents : Velocity 3,5x13 mm (Cordis), Tristar 3x13 mm  (Guidant)
Procedure Distal  RCA was dilated first. The 6F mammary catheter was selectively inserted in the ostium easily, the lesion crossed wire the wire and predilated with the Viva 3 mm balloon. The Velocity stent was then deployed at 14 atm. with a good result (fig. 1b). The Left Mammary graft was catheterized selectively with the 6F Mammary catheter, the wire crossed the lesion despite a severe loop. The Viva 3 mm balloon did not cross the lesion. We decided to change the guiding catheter for a 5F Mammary shape. With deeper intubation of the guiding, the lesion was predilated (2.5 and 3 mm Viva balloon).  A very deep intubation of the 5F guiding (figure 4) was necessary to cross the lesion with the Tristar stent. It was deployed at 11 atm. with an excellent result (figure 3b).

 
LAD pre.jpg (12769 bytes)

Fig. 3a. LAD pre

 LAD post.jpg (11279 bytes)

fig. 3b. LAD post

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Fig. 4. Deep intubation
Comments Bilateral mammary graft is considered as a contra-indication to radial (brachial)  approach for coronary angiography or intervention on or through both mammary arteries. Right transradial approach of left mammary artery is feasible with a 80% success rate (including learning curve). The most successful technique is to use a mammary shape catheter, to turn it clockwise in the aorta to enter the horizontal portion, to push it to be just below the subclavian artery (injection), to turn it slightly conterclockwise and to push very deeply in the left arm a 0.035’’ Terumo wire (LAO 30°). In favorable cases the catheter is then advance in the distal subclavian artery, the wire withdrawn, and the mammary artery searched in AP projection.

A deep intubation in the mammary artery with a 6F catheter, even through left radial approach, is at risk of dissection (even in this very big mammary graft…). In this case it was done with a 5F catheter on the balloon and then on the mounted stent to help stent crossing. Nevertheless, I think this maneuver has to be done only after failure of others options : Good predilatation with  low profile balloon, low profile stent, extra support wire…

A 6F guiding catheter offers probably a better support at the vessel ostium, but this support can be replaced by a deep intubation of a 5F catheter, specially in RCA but also in LAD. Circumflex artery remains a difficult problem for deep intubation (sometimes selectively intubated by Amplatz catheter).