Published on November 10, 2014
How to cannulate the LIMA graft from the right radial approach
1. How to cannulate the LIMA graft from the right radial approach Rodrigo Bagur, MD, PhD, FAHA Interventional Cardiologist, Quebec University Hospital Centre Cardiology Division, L’Hôtel-Dieu de Québec, Quebec City Assistant Clinical Professor, Department of Medicine, Laval University 3rd Advanced International Masterclass AIM-RADIAL 2014 Chicago (IL), USA - October 23-25, 2014
2. Disclosure Nothing to disclose
3. Background Due to patency rate, mammary arteries have become standard grafts on left anterior descending (LAD) artery for CABG surgery Right radial approach is the most common access site for diagnostic and interventions Conversely, left radial approach is frequently used in post-CABG patients for easier injection of the left internal mammary artery (LIMA) Many patients now receive bilateral mammary arteries or left radial artery graft
4. How to cannulate the LIMA graft from the right radial artery A step-by-step approach
5. How to cannulate the LIMA graft from the right radial artery Step 1: A step-by-step approach - From right radial, perform (preferably first) angiography of the left and right coronary arteries and SVGs - Advance a catheter (modified mammary) with a steep angulation at the distal tip to the descending aorta - Pull back with a clockwise movement to the distal portion of the distal arch until the ostium of the left subclavian artery is located - To better identify the anatomy of the left subclavian artery and exclude a significant stenosis, a semi-selective injection is performed and the best image is shown on a reference screen
6. How to cannulate the LIMA graft from the right radial artery Step 2: A step-by-step approach - Using a hydrophilic 0.035 inch wire (Terumo), access the left subclavian artery - In order to provide enough support for advancing the catheter, it is crucial to place the wire beyond the shoulder and if possible, deep into the brachial artery,
7. How to cannulate the LIMA graft from the right radial artery Step 3: A step-by-step approach - Since there are small branches, it is easier to use a torque to manipulate the hydrophilic wire while negotiating the ascending and horizontal portion - In some cases, use a regular PCI wire (0.014 inch BMW/BHW) - Remember: If it is not possible to advance the wire further in the brachial artery, it is useless to try to advance the catheter since it will always flip back into the aorta What to do?
8. How to cannulate the LIMA graft from the right radial artery Step 4: A step-by-step approach - If not enough support to advance the modified LIMA catheter through the left subclavian, external compression of the left arm (brachial or radial/cubital artery in order to maintain/fixe the wire and further increase support to advance the catheter Elbow flexion BP cuff inflation technique technique Patel T, et al. CCI 2012;80:316-20.
9. How to cannulate the LIMA graft from the right radial artery A step-by-step approach Step 5: - Gently advance of a modified mammary artery (or radial brachial) catheter over the Terumo wire to the distal subclavian artery - Sometimes, asking the patient to take a mid/deep breath facilitates advancing the catheter
10. How to cannulate the LIMA graft from the right radial artery A step-by-step approach Step 6: - Once the catheter is placed distally to the LIMA ostium, remove the wire and slowly pull back the catheter until it ’’jumps’’ into the ostium - Again, asking the patient to take mid/deep breath may facilitate selective cannulation
11. How to cannulate the LIMA graft from the right radial artery A step-by-step approach Step 7: - Do angiogram !
12. How to cannulate the LIMA graft from the right radial artery Step 8: perform PCI A step-by-step approach - For PCI, according to operator preference, it might be performed in 5 Fr or 6Fr, the technique is similar - With a 5 Fr guiding catheter, it is possible to deeply intubate the LIMA in order to increase support for balloon or stent delivery - After finishing the angiography, advance a PCI guidewire through the diagnostic catheter, then remove it - Advance the guiding catheter (5 Fr, 3.5 ExB) over the PCI guidewire, gently engage the LIMA and deeply intubate it, then proceed as any PCI
13. How to cannulate the LIMA graft from the right radial artery Key points: A step-by-step approach Subclavian artery angiography Favorable angulation of the catheter to engage the left subclavian artery Advance the hydrophilic wire distally to the left radial/cubital External guidewire compression to enhance support
14. Many thanks for your attention! So… go radial, go…