I read with interest the recent submission describing the utilization of the J-wire and coronary catheter combination to fine-tune engagement. This very useful technique is accomplished using a hemostatic valve to allow simultaneous contrast injection. While the hemostatic valve is always employed in interventional cases, its routine use can increase the cost of diagnostic procedures. We propose the "poor man's" solution by substituting a 3-way stopcock. The catheter is attached to the male end, the manifold to the perpendicular female end (with optional extension tubing), with the remaining female end allowing for J-wire passage (Fig.1). Of course, contrast injection requires removal of the J-wire with closure of the stopcock to the corresponding female end. However, J-wire removal and reinsertion by this method is still much less laborious than repeated manifold connections and disconnections if done without a Touhy hemostatic valve.

We introduce a method for one-step, combined pre-and post-procedure wrist immobilization setup, without the need for subsequent additional hemostatic device application. By utilization of the Radstat device (Fig.1), the wrist is hyperextended by placement of a firm cylindrical object between the dorsal side of the wrist and the wrist board; I prefer a wide tape roll. The patient's wrist is then immobilized by circumferentially attaching the first and third straps to the corresponding velcro surface on the underside of the wrist board (Fig.2). The patient is then draped in the usual manner. We also prefer the previously described method of utilizing the right femoral hole for the wrist and the left femoral hole for the right groin. At the conclusion of the procedure, the tape roll is removed. The second or middle strap is threaded through the pressure pad sterilely and wrapped around the underside velcro surface, applying gentle but firm pressure to the puncture site (Fig.3). Hemostasis is easily achieved. In this manner, the wrist board acts both as the pre-, intra-, and post-procedure immobilization device, combining the initial preparation and final hemostasis into one, easy step.

Step 1. Advance the tip of the Kimny catheter in the left coronary sinus with the tip directed towards the left side.

Step 2. Then push on the shaft: the aortic valve forces the curve to bend towards the LCA ostium.

Step 3. Engage the LCA

RCA cannulation:

Step 1. Position the tip into the right coronary sinus (tip ditected towards the left/anterior). From the left coronary sinus this is achieved by gentle clockwise rotation over the aortic valve. If the catheter turns to the right sinus gently advance.

Step 2. Gently rotate the tip clockwise into the RCA.

Comments

As the experience with performing transradial procedures in all types of patients including those with small arteries has grown with the help of such protocols there is no reason anymore for interventional procedures not to be done transradially unless a device requires a sheath size that is not compatible with the radial artery size. In all other situations,every interventional operator must ask himself the question:` WHY FEMORAL ?`

Comments

This is an innovative technique,and this could, with modifications ,( such as addition of Papaverine)allow transradial procedures to be performed on almost every case. The only fear in radial procedures is of spasm, rightly called the Achille`s heel of transradial. This may have been conquered with this modification.

Therefore our nurses have modified the preparation of the patient and table in such a way that the operator can easily reach the patient's left wrist while the patient enjoys comfortable support of the arm.

The left arm rests upon a pile of cushions, the upper one being an Antistatic operation mattress. The arm is positioned just above groin level and parallel to the patient's body.

This preparation style indeed has increased operator's comfort for left radial coronary access.

Following removal of the sheath a small pile of gauze (appr. 4 x 4 cm) is pressed over the puncture site (fig.2.)

The first elastic strap is placed over this pile, from caudal lateral to cranial medial (fig.3.)

A second strap is placed crosswise (appr. 90 degrees) over the first one (fig.4.).

A third one is taped over the previous to from lateral to medial (fig.5.)

The puncture bandage can be left on site untill  the next morning if the patient is discharged the same day (fig.6.) Otherwise the bandage can be removed after 4 hours.

Fig..1.                                                   Fig.2.                                                     Fig.3.

Fig.4.                                                   Fig.5.                                                     Fig.6.

The technique described has the following advantages:

• Materials are commonly available in every hospital
• Cheap and effective
• Easy to apply
• Easy to remove
• Easy to control
• Most pressure over the radial artery
• No congestion
• No ischemia by patent ulnar artery
• Comfortable

If bleeding occurs, it will happen within a few minutes after application. In that case an additional tourniquet can be placed over the pressure bandage.