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Bilateral transradial approach for PCI of LAD and RCA occlusions
Interventional cardiologist Carlo Trani MD, Francesco Burzotta MD, Antonio Maria Leone MD
Center Cardiac Catheterization Laboratories, Institute of Cardiology, A. Gemelli Hospital, Rome Catholic University of the Sacred Heart
History A 36 year old man, with prior inferior myocardial infarction and two previous PCI with stent on LAD and RCA, was referred to our centre for coronary angiography because of recurrence of angina. Cardiac risk factors included hypertension, hypercholesterolemia, and obesity.

Coronary angiography revealed diffuse coronary atherosclerosis with an intra-stent occlusion of both the LAD after the first diagonal branch (fig.1.) and the RCA before the crux (fig.2.). Collateral branches were present from the first diagonal branch and from LCX to the LAD and from the distal LAD and from the septal branches to RCA.

 
fig.1. fig.2. fig.3.
Strategy

We decided to treat first intra-stent occlusive restenosis on LAD and then to re-open the RCA.
Procedure The first intervention was performed via a 6Fr Terumo sheath in the right radial artery. The left coronary artery was cannulated by a 6F XB LAD 3.5 guiding catheter. LAD occlusion was crossed with a Cross-It XT 200 wire and reopened with predilatation (Voyager 1.5 x 12 mm at 10 atm) and stenting (Taxus 2.75 x 32 mm 12 atm) (fig.3).  Two weeks later we approached RCA occlusion. Considering the good visualization of the RCA by LAD collaterals, we decided to perform a simultaneous contra-lateral injection in the LCA to visualize the mid and distal tract of the RCA. Thus, right and left radial arteries were punctured with a Terumo needle, followed by insertion of a 6Fr 25cm long Terumo sheath in the right radial artery and 4Fr 11 cm long Terumo sheath in the left radial artery. Heparin (5000 IU) and nitrates (5mg) were injected in both sheaths. A 4Fr Judkins left 3.5 angiographic catheter was used for the contra-lateral injection and a 6 Fr Judkins right 4 guiding catheter was used for the RCA. With a simultaneous double right and left injection we obtained an almost complete visualization of the RCA (fig.4.) that facilitated the wiring of the artery with a Choice Pt graphix standard wire( fig.5.). Predilatation was performed with Maverick 1.5 x 20 mm at 8 atm and subsequently with a Hayatè 2.5 x 20 mm at 6 atm. Then a balanced heavy weight wire was exchanged for the choice Pt and a stent Vision 3 x18 mm was deployed at 14 atm with an optimal angiographic final result (fig.6.). Finally the two sheaths were immediately removed and two TR-Band bracelets were used for haemostasis.

                                                           

 
  fig.4 fig.5 fig.6.  
Comments We here demonstrated that a complex PCI with a contra-lateral injection can be easily and effectively performed via a bilateral trans-radial approach. This strategy warranted to the patient a very limited vascular trauma and allowed for an early ambulation avoiding the discomfort of a long supine position that would have been required if bilateral trans-femoral approach had been chosen.