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Subclavian-to-Subclavian Bypass Graft Access via Transradial Approach for Percutaneous Coronary Intervention
Abstracts
Background: South Australian consent forms for diagnostic coronary angiography and percutaneous coronary intervention (PCI) report a stroke risk of 0.06% and 0.30%, respectively. The objective of this study was to assess the prevalence of periprocedural stroke in contemporary Australian practice. Methods: All consecutive patients undergoing coronary angiography and percutaneous coronary intervention (PCI) in South Australian public hospitals from 2012-2013 were included, with data captured by the Coronary Angiogram Database of South Australia (CADOSA - a comprehensive registry compatible with the NCDR® CathPCI® Registry). Results: Of 10,483 patients, a total of 31 patients (0.30%) experienced a periprocedural stroke, including 0.22% during diagnostic angiography (n = 16), and 0.48% during PCI (n = 15). Patients with periprocedural stroke were older (69±9 years vs 64±13, p<0.05) with age-adjusted analysis revealing more prevalent history of prior stroke (31% vs 8%, OR 4.7, 2.0-11.0, p<0.01). There was no difference between those with/without periprocedural stroke in relation to gender, active smoking status, diabetes, hypertension, and dyslipidaemia. Periprocedural stroke more often occurred in patients undergoing emergency procedures (81% vs 52%, OR 4.0, 1.6-9.7, p<0.01), required greater use of contrast medium (171±117 ml vs. 122±87, p<0.01), or more frequent use of intra-aortic balloon pump (9.7% vs 1.2%, OR 8.1, 2.4-27.2, p<0.01). Conclusions: In a contemporary clinical practice, periprocedural stroke is three times more frequent than that reported in standard consent forms. Thus the consent forms require revision and ongoing monitoring of this adverse outcome should be routinely monitored. http://dx.doi.org/10.1016/j.hlc.2016.06.466 465 Subclavian-to-Subclavian Bypass Graft Access via Transradial Approach for Percutaneous Coronary Intervention D. Chieng ∗ , R. Alcock Royal Perth Hospital, Perth, Australia
Arterial access for invasive coronary procedures in patients with severe peripheral vascular disease can be technically difficult. We describe a challenging case of peripheral arterial access, requiring use of a pre-existing subclavianto-subclavian bypass graft to access the aortic arch and subsequently image and intervene on the circumflex coronary artery. An 80-year-old female presented with a non-ST
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elevation myocardial infarction. Her past medical history is significant for ischaemic heart disease with a right coronary artery (RCA) stent in 1997; as well as peripheral vascular disease with previous stenting to the brachio-cephalic trunk, and subsequent subclavian-to-subclavian arterial vascular bypass graft following subclavian stent occlusion. Her cardiovascular risk factors include hypertension, ongoing smoking, type 2 diabetes mellitus and chronic renal impairment. Planned coronary angiography was undertaken with arterial access unattainable via either femoral artery or the left radial artery. Computed tomography (CT) angiography previously had demonstrated a patent subclavian-to-subclavian bypass graft with reflux of contrast from the distal right brachio-cephalic trunk into the common carotid artery (figure A). A decision was made to perform coronary angiography via the right radial artery approach, through the subclavian-to-subclavian artery conduit, into the ascending aorta via the left subclavian artery (figure B). Angiography showed a new severe obtuse marginal lesion, which was successfully treated with a 2.75 x 26 mm drug eluting stent (Resolute Integrity, Medtronic) via a 6 French guiding catheter (Cordis Vista Brite Tip). Primary success was achieved and patient was discharged on dual anti-platelet therapy. http://dx.doi.org/10.1016/j.hlc.2016.06.467 466 Successful Snare and Retrieval of a Free Intra-Coronary Rotawire During Complex Unprotected Left Main Coronary Artery Bifurcation Percutaneous Coronary Intervention in a High-Risk Individual R. Chetty ∗ , R. Alcock, J. Spiro Royal Perth Hospital, Perth, Australia A 46-year-old female with longstanding haemodialysisdependent ESRF, presented with NSTE-ACS, decompensated biventricular heart failure and significant ascites. Coronary angiography demonstrated severe, calcified distal LMCA bifurcation disease (Medina 1,1,1). Echocardiography revealed moderate LV dysfunction and severe RV dysfunction. Surgical intervention was declined due to excessive risk (EuroSCORE 45%; STS 9% mortality, 57% morbidity/mortality). Following intensive haemodialysis for volume optimisation, she came forward for LMCA PCI. 7Fr femoral access was gained using an ultrasoundguided micro-puncture technique. Using a 7Fr XB3.5 guiding catheter, rotational atherectomy (1.75mm burr) was performed sequentially from LMCA to LAD; then LMCA to circumflex. Whilst burring into the angulated ostium of the circumflex, the burr sheared through the rota-wire. Following predilatation of the ostial circumflex, the free rota-wire was snared using a 2mm Gooseneck snare. The LMCA bifurcation was then treated using a conventional Culotte technique; 4 x 28mm (LMCA-LAD) and 4 x 32mm (LMCA-circumflex) Promus Premier drug-eluting stents; with final kissing balloon inflation using 3.5mm NC balloons at 12atm. Upon return to the ward, the patient rapidly deteriorated secondary to pericardial tamponade requiring urgent pericardiocentesis and heparin reversal. Review of angiography
Background: South Australian consent forms for diagnostic coronary angiography and percutaneous coronary intervention (PCI) report a stroke risk of 0.06% and 0.30%, respectively. The objective of this study was to assess the prevalence of periprocedural stroke in contemporary Australian practice. Methods: All consecutive patients undergoing coronary angiography and percutaneous coronary intervention (PCI) in South Australian public hospitals from 2012-2013 were included, with data captured by the Coronary Angiogram Database of South Australia (CADOSA - a comprehensive registry compatible with the NCDR® CathPCI® Registry). Results: Of 10,483 patients, a total of 31 patients (0.30%) experienced a periprocedural stroke, including 0.22% during diagnostic angiography (n = 16), and 0.48% during PCI (n = 15). Patients with periprocedural stroke were older (69±9 years vs 64±13, p<0.05) with age-adjusted analysis revealing more prevalent history of prior stroke (31% vs 8%, OR 4.7, 2.0-11.0, p<0.01). There was no difference between those with/without periprocedural stroke in relation to gender, active smoking status, diabetes, hypertension, and dyslipidaemia. Periprocedural stroke more often occurred in patients undergoing emergency procedures (81% vs 52%, OR 4.0, 1.6-9.7, p<0.01), required greater use of contrast medium (171±117 ml vs. 122±87, p<0.01), or more frequent use of intra-aortic balloon pump (9.7% vs 1.2%, OR 8.1, 2.4-27.2, p<0.01). Conclusions: In a contemporary clinical practice, periprocedural stroke is three times more frequent than that reported in standard consent forms. Thus the consent forms require revision and ongoing monitoring of this adverse outcome should be routinely monitored. http://dx.doi.org/10.1016/j.hlc.2016.06.466 465 Subclavian-to-Subclavian Bypass Graft Access via Transradial Approach for Percutaneous Coronary Intervention D. Chieng ∗ , R. Alcock Royal Perth Hospital, Perth, Australia
Arterial access for invasive coronary procedures in patients with severe peripheral vascular disease can be technically difficult. We describe a challenging case of peripheral arterial access, requiring use of a pre-existing subclavianto-subclavian bypass graft to access the aortic arch and subsequently image and intervene on the circumflex coronary artery. An 80-year-old female presented with a non-ST
S199
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elevation myocardial infarction. Her past medical history is significant for ischaemic heart disease with a right coronary artery (RCA) stent in 1997; as well as peripheral vascular disease with previous stenting to the brachio-cephalic trunk, and subsequent subclavian-to-subclavian arterial vascular bypass graft following subclavian stent occlusion. Her cardiovascular risk factors include hypertension, ongoing smoking, type 2 diabetes mellitus and chronic renal impairment. Planned coronary angiography was undertaken with arterial access unattainable via either femoral artery or the left radial artery. Computed tomography (CT) angiography previously had demonstrated a patent subclavian-to-subclavian bypass graft with reflux of contrast from the distal right brachio-cephalic trunk into the common carotid artery (figure A). A decision was made to perform coronary angiography via the right radial artery approach, through the subclavian-to-subclavian artery conduit, into the ascending aorta via the left subclavian artery (figure B). Angiography showed a new severe obtuse marginal lesion, which was successfully treated with a 2.75 x 26 mm drug eluting stent (Resolute Integrity, Medtronic) via a 6 French guiding catheter (Cordis Vista Brite Tip). Primary success was achieved and patient was discharged on dual anti-platelet therapy. http://dx.doi.org/10.1016/j.hlc.2016.06.467 466 Successful Snare and Retrieval of a Free Intra-Coronary Rotawire During Complex Unprotected Left Main Coronary Artery Bifurcation Percutaneous Coronary Intervention in a High-Risk Individual R. Chetty ∗ , R. Alcock, J. Spiro Royal Perth Hospital, Perth, Australia A 46-year-old female with longstanding haemodialysisdependent ESRF, presented with NSTE-ACS, decompensated biventricular heart failure and significant ascites. Coronary angiography demonstrated severe, calcified distal LMCA bifurcation disease (Medina 1,1,1). Echocardiography revealed moderate LV dysfunction and severe RV dysfunction. Surgical intervention was declined due to excessive risk (EuroSCORE 45%; STS 9% mortality, 57% morbidity/mortality). Following intensive haemodialysis for volume optimisation, she came forward for LMCA PCI. 7Fr femoral access was gained using an ultrasoundguided micro-puncture technique. Using a 7Fr XB3.5 guiding catheter, rotational atherectomy (1.75mm burr) was performed sequentially from LMCA to LAD; then LMCA to circumflex. Whilst burring into the angulated ostium of the circumflex, the burr sheared through the rota-wire. Following predilatation of the ostial circumflex, the free rota-wire was snared using a 2mm Gooseneck snare. The LMCA bifurcation was then treated using a conventional Culotte technique; 4 x 28mm (LMCA-LAD) and 4 x 32mm (LMCA-circumflex) Promus Premier drug-eluting stents; with final kissing balloon inflation using 3.5mm NC balloons at 12atm. Upon return to the ward, the patient rapidly deteriorated secondary to pericardial tamponade requiring urgent pericardiocentesis and heparin reversal. Review of angiography