Images and Case Reports in Interventional Cardiology Recanalization of a Chronic Radial Artery Occlusion Allowing Subsequent Complex Coronary Intervention

A 65-year-old man with previous coronary artery bypass grafting and recent recurrence of angina was referred for coronary angiography. His medical history included myelodysplasia with significant anemia (hemoglobin, 7.7 g/dL) and thrombocytopenia (platelets, 77 10/L). A percutaneous coronary intervention was performed 4 years previous to an occluded native right coronary artery via the left radial artery. Given the increased risk of bleeding complications and a patent left internal mammary artery graft, coronary angiography was planned again via the left radial artery. The result of a modified Allen test was positive, demonstrating satisfactory ulnar arterial supply to the hand. Arterial puncture using a SURFLO micropuncture needle (Terumo Medical Corporation; Somerset, NJ) resulted in pulsatile blood flow back, but it proved impossible to advance the 0.021-inch introducer wire more than a few centimeters into the vessel. Therefore, the cannula on the introducer needle was advanced over the wire to secure arterial access and radial angiography was performed, which demonstrated radial artery occlusion (RAO; Figure 1; online-only Data Supplement Movie I). The occlusion was not believed to be due to spasm because it was proximal to the site of needle entry and did not relieve with administration of 200 g of glyceryl trinitrate. Given the issues with alternative arterial access, an attempt was made to reopen the vessel. A Y-connector was connected (Figure 2A) to allow contrast injection, and a 0.014-inch Fielder XT coronary guide wire (Asahi Intecc; Japan) (Figure 2B) was successfully negotiated through the occlusion. The vessel was dilated using a 4F dilator, followed by insertion of a 4F sheath. Angiography via the sheath demonstrated that the proximal radial artery was free of disease (Figure 3). A standard 0.035-inch J-tip wire was passed up to the brachial artery, and further dilatation was performed with 5F and 6F dilators, followed by insertion of a 6F sheath. Coronary angiography demonstrated that the previously stented ungrafted right coronary artery had reoccluded, but the left anterior descending coronary artery and intermediate grafts remained patent and the native circumflex was unobstructed (Figure 4A). A percutaneous coronary intervention was performed to the right coronary artery occlusion (Figure 4B). Radial angiography at the end of the procedure showed that the radial artery was widely patent at the site of original occlusion, with no residual stenosis (Figure 5; online-only Data Supplement Movie II). At clinic follow-up at 3 months, the patient was angina free and no further intervention was planned. The left radial pulse was palpable, and ultrasonography of the wrist demonstrated moderate stenosis of the distal artery, with good anterograde flow.