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Transradial Direct Symbiot stent implantation
Interventional cardiologist Dr. F. Kiemeneij
Center Amsterdam Department of Interventional Cardiology- OLVG
History A 72 year old male patient, with previous coronary bypass surgery was referred to our center because of unstable angina pectoris, caused by a subtotal stenosis in a venous bypass graft to the LAD (TIMI 2 flow) [fig.1]. The patient was pretreated with aspirin, low molecular weight heparin, clopidogrel and tirofiban. Not surprising that this adipose patient (length 157 cm ; weight 68 kg) had a hematoma deep in his right groin following diagnostic coronary angiography (fig.2)

   

Fig.1.                                            Fig.2.
Strategy

1. Prevention of no reflow:

  • IIbIIIa blocker
  • covered stent
  • direct stenting

2. Prevention of bleeding by transradial approach
Procedure

The right radial artery was punctured with a Terumo needle, followed by insertion of an 8F 10 cm sheath. A Medtronic Zuma 8F JR4 was advanced towards the proximal anastomosis of the LAD bypass graft without resistance. Over a BMW 0.014" wire, a Boston Scientific Symbiot 4.0/31 mm stent was advanced directly into the lesion. During this maneuver much friction had to be overcome. After deployment of the stent, postdilatation was performed with a 4.0/30 mm balloon. Result was good and flow was normal (fig.3). After sheath removal and placement of a compression bandage hemostasis, the patient was able to walk (fig. 4 and 5)

Fig.3.

Fig.4.

Fig.5.
Comments This case clearly illustrates the advantages of TRI. The patient used 4 antithrombotic drugs at admission. In the right groin a hematoma was palpable deep under a layer of subcutaneous fat. An 8F procedure was indicated since the Symbiot stent is 8F compatible. Despite the short length of the patient, the right radial artery was big enough to house an 8F sheath and catheter.