Technical Considerations in Transradial Unprotected Left Main Stem Rotational Atherectomy-Assisted and IVUS-Guided Percutaneous Coronary Intervention Using the 7.5F Eaucath Sheathless Guiding Catheter System

Abstract

Rotational atherectomy-assisted percutaneous coronary intervention (PCI) on unprotected left main stem (LMS) bifurcation lesions is technically challenging. Intravascular ultrasound (IVUS) has become a standard part of the PCI procedure for the treatment of LMS disease. There is limited experience in performing these cases via a transradial approach using a sheathless guiding catheter (SGC) system. We report a case of a symptomatic octogenarian patient with restrictive angina and significant LMS bifurcation disease, who was successfully treated transradially with the use of the 7.5F Eaucath SGC system and we describe the technical challenges encountered with this strategy.

Access Site Selection and Outcomes for Chronic Total Occlusion Percutaneous Coronary Interventions: Insights from the VA CART Program

“…Advances in the design of CTO-crossing devices, coronary guide wires, larger bore sheathless transradial guide catheters, and guide catheter extensions provide opportunities for increased use of TRA for CTO PCI. [15][16][17] In addition, because dual arterial access is commonly necessary for collateral visualization, TRA can be used for this purpose rather than a second TFA.…”

How Should We Treat Heavily Calcified Coronary Artery Disease in Contemporary Practice? From Atherectomy to Intravascular Lithotripsy

“…In case of TF access, we recommend the use of large diameter GC such as 7 or even 8F necessary for better support, easier delivery of equipment to the lesion and adequate coronary vessel opacification. In TR approach, we previously described the feasibility and safety of 7.5F Sheathless (S) GC system for the treatment of complex calcified lesions [9,10]. SGC systems allow the passage of large-bore catheters with smaller overall diameters at the arterial insertion site, as there is no need for a sheath.…”

“…The 7.5F SGC Eaucath (ASAHI Eaucath SGC; Vascular Perspectives Ltd., Manchester, UK) has an external diameter smaller than a sheath used for a 6F GC (2.49mm vs. 2.70mm, respectively), but a significantly larger internal lumen (2.06mm vs. 1.78mm, respectively) (Figure 2 MRN 0201654 GK case) [9][10][11]. We rarely recommend the use of 8.5F SGC in selected cases only, where the use of >2mm rota burr size may be necessary for the procedure [9][10][11]. It is now possible to push the limit of TR complex PCI such that 7F GCs can be advanced and manipulated through a Slender approach when SGC are not available.…”

“…Contemporary PTRA has been refined [38], from the strategy (planned vs bailout) [38], the procedural set-up to the tools and techniques applied. The arterial access that was traditionally a large 8F TF sheath is now a contemporary 6 or 7F TR or TF sheath or STR as we previously described [9,10]. The wiring technique has been facilitated using a standard workhorse or hydrophilic wire subsequently exchanged over microcatheters or OTW balloons with the rotawire.…”

“…Fundamental elements of optimal technique include use of a single burr with burr-to-artery ratio of 0.5 to 0.6, rotational speed of about 150,000 rpm, gradual burr advancement using a pecking motion, short ablation runs of 15 to 20s, and avoidance of decelerations >5,000 rpm. The need for a temporary pacemaker has been reconsidered due to significantly lower incidence of transient heart block with smaller burrs and lower speeds, easily manageable with the use of either atropine [9,10] or aminophylline as recently demonstrated [40]. With adequate training and experience, PTRA can be a very safe technique.…”