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LAD stenting via LIMA by RIGHT radial approach
Interventional cardiologist Dr. S. Rigattieri, Dr. A. Buffon
Center Università Cattolica del Sacro Cuore, Policlinico A. Gemelli, ROMA, ITALY
History A 67-years old patient was referred to coronary angiography for recurrent episodes of ventricular tachycardia. He had an inferior myocardial infarction in 1993 and CABGx4 in 1994 (LIMA on LAD; VGS on CDX and 1st diagonal; radial artery on Cx). A week before CAG the patient underwent surgery for hip replacement, after which he developed angina and very frequent episodes of VT poorly responsive to medical therapy.

Angiography

Native vessels were occluded proximally; the venous graft to CDx was occluded; the grafts to D1 e Cx were patent; the LIMA was patent but a 70% stenosis of LAD after the anastomosis was present.
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Strategy Because of recent hip surgery we didn't perform femoral approach; left radial artery was absent (employed as free graft). Therefore we performed 6F right transradial approach.
Procedure 6F Internal Mammary guiding catheter (Cordis) and 260 cm 0.035" J-tip guidewire were used to engage the ostium of LIMA. The target lesion was then easily crossed with an ACS 0.014" Balance Heavy Weight wire and direct stenting was performed with a Carbostent Sirius 3 x 9 mm by Sorin (14 atm.)

The angiographic result was good; the stent looked well deployed and hemostasis was easily obtained by compressive bandage.

The procedure was comfortable for the patient. There has been a reduction in the number of TV episodes, although this is probably due to the incoming action of amiodarone. Moreover, at this time the patient is free from angina.
Comments Intraprocedural radial artery spasm occurred despite washing the artery with ISDN 5 mg soon after sheath insertion; however, spasm was easily resolved by intra-arterial injection of Verapamil 3 mg.

Although radial approach is not routinely performed in our Institution, we are progressively increasing the number of transradial procedure and discouraging percutaneous brachial approach, mainly because the higher risk of vascular complications in our heavily antiaggregated, anticoagulated population.