Efficacy and safety of sheathless guiding catheter for distal radial approach

OBJECTIVES

This study aimed to assess the efficacy and safety of a sheathless guiding system in patients who underwent percutaneous coronary intervention (PCI) with distal radial access (DRA).

BACKGROUND

Hyperion™ Sheathless® guiding catheter (Asahi Intecc, Japan), one of the latest 6-Fr guiding systems for transradial PCI characterized by novel outer dilator, is considered to facilitate smooth insertion of the catheter to the artery and may contribute to further reduction of access site complications in DRA.

METHODS

Between October 2018 and January 2023, 286 patients underwent PCI with a Hyperion™ Sheathless® guiding catheter with DRA at two Japanese hospitals. Procedural success, bleeding complications, and radial artery occlusion (RAO) detected by Doppler ultrasonography were assessed.

RESULTS

Mean age of the patients was 72.7 years, and 236 patients (82.5 %) were male. The target lesions were located in the right coronary artery, left anterior descending artery, left circumflex artery, and left main trunk in 81, 44, 50 patients, and 18 patients respectively. Procedural success rate was 99.7 % with no patients requiring conversion to conventional radial access. Two patients presented with a forearm hematoma equivalent to an Early Discharge After Transradial Stenting of Coronary Arteries Study hematoma classification Grade II and 23 with Grade I. No patient presented minor or major bleeding according to the Thrombolysis in Myocardial Infarction bleeding classification. RAO at 30-day follow-up was observed in 6 out of 277 patients (2.2 %).

CONCLUSIONS

6-Fr sheathless guiding system for PCI via DRA is feasible and associated with a low incidence of access site complications.

Access-site complications of transradial percutaneous coronary intervention using sheathless guiding catheters for acute coronary syndrome: a prospective cohort study with radial ultrasound follow-up

The advantages of sheathless guiding catheters over the conventional approach using sheaths in percutaneous coronary intervention (PCI) regarding access-site complications, particularly ultrasound-diagnosed radial artery occlusion (RAO), remain unknown. The present study investigated the incidence of access-site complications of transradial primary PCI using sheathless guiding catheters in acute coronary syndrome (ACS). This prospective study evaluated access-site complications in 500 patients with ACS undergoing sheathless transradial primary PCI. Doppler ultrasound evaluation of the radial arteries was performed 2 and 30 days after the procedure. Sheathless guiding catheters (7.5-Fr) were used in 91.0% of the patients. The procedural success rate was 98.4%. Ultrasound-diagnosed RAO rates were 2.0% and 3.8% at 2- and 30-day follow-ups, respectively. Logistic regression analysis identified that the sheath-to-artery ratio (per 0.1) (odds ratio [OR] 5.71; 95% confidence interval [CI] 1.18-27.71; p = 0.001) was associated with more frequent RAO and that hypertension (OR 0.22; 95% CI 0.06-0.81; p = 0.023) was associated with less frequent RAO. Receiver operating characteristic curve analysis revealed that a sheath-to-artery ratio of 1.47 was the cutoff for 30-day post-procedural RAO (sensitivity 72%, specificity 81%). Sheathless transradial primary PCI for ACS was associated with a low incidence of access-site complications and a higher sheath-to-artery ratio cutoff for RAO than that expected from conventional PCI using sheaths based on historical data, demonstrating the access-site safety of sheathless guiding catheters and their benefit in PCI for ACS (University Hospital Medical Information Network-Clinical Trial Registry Number UMIN000019931).

Postprocedural radial artery occlusion rate using a sheathless guiding catheter for left ventricular endomyocardial biopsy performed by transradial approach

Background

For coronary interventions the arterial access via the radial artery is associated with fewer vascular access site complications, and has been shown to reduce major bleeding when compared to the femoral approach. But the endomyocardial biopsy (EMB) approach is usually done by a transfemoral or cervical access known to be associated with an increased risk of artery puncture and its potential complications (i.e., false aneurysm, artery-venous fistula) and needs post-procedural immobilization. A transradial approach for EMBs is not standardized. The aim of our study is to validate safety and efficacy of the transradial access approach for left ventricular EMB, and to define patients eligible for a safe and successful procedure.

Methods and Results

We evaluated the transradial access using a 7.5 F sheathless multipurpose guiding catheter to obtain EMBs from the left ventricle (LV). 18 patients were included. The transradial success rate was 100% (18/18). There were no periprocedural cardiac complications. Immediate post-procedural ambulation could be achieved in all patients. Although radial artery pulse was confirmed by ultrasonic vascular Doppler after removal of the guide in 100% (18/18) of the patients, 50% (9/18) of the patients showed occlusion of the radial artery RAO) by duplex sonography proximal to the access site. 33% (3/9) of the patients in the RAO group and 11,1% (1/9) of the patients in the patent radial artery (RAP) group, respectively, experienced mild pain after the procedure in the right lower arm. Colour Doppler ultrasonography of the right radial artery performed 24 h after the procedure revealed radial occlusion in 50% (9/18) of the patients. The diameter of the radial artery was significantly smaller in the RAO group (p = 0,034), peak systolic velocity (PSV) of the right ulnar artery was significantly higher in the RAO group (p = 0.012). Peak systolic velocity of the opposite radial artery was significantly lower in the RAO group (p = 0,045). Gender, sex, diabetes, radial artery inner diameter ≤2.5 mm and lower peak systolic velocity of < 50 cm/s are predictors of RAO.

Conclusion

The present study demonstrates the safety and efficacy of a transradial access for EMB using a highly hydrophilic sheathless guiding catheter.

Twisting method for reducing friction during insertion of a sheath introducer and a sheathless guiding catheter

A sheathless system that inserts a catheter directly into the artery can reduce puncture site-related complications through a 2-Fr reduction of the outer diameter. However, the gap between the dilator and the guiding catheter of the sheathless system is larger than the gap between the dilator and sheath of the introducer system, resulting in stronger insertion resistance. A twisting method with rapid alternating rotation of a device to the left and right during insertion can reduce the insertion resistance. This method can be effective with the sheathless system which has a larger gap. To examine the effect of size reduction on the sheathless system and the effect of insertion resistance reduction using the twisting method, we developed an insertion simulator and compared insertion resistance to a 5-Fr sheath introducer and a 5-Fr sheathless system, with and without the twisting method. The insertion simulator pushed a sheath introducer or a sheathless system toward a mock artery consisted with a 5-mm urethane and a 1-mm rubber sheet by an electrical motor with or without twisting motion generated by a crank shaft. Insertion resistance during the penetration was measured by a tension meter. The insertion resistance was less with the 5-Fr sheathless system than with the 5-Fr sheath introducer. The resistance reduced further with use of twisting for both the sheathed and sheathless catheters. In conclusion, the experiment suggests the benefits of twisting insertion of a sheathless guiding catheter for reduction of puncture site-related complications.

Combining balloon-assisted tracking and sheathless guiding catheter: unloosening the Gordian knot

In a patient with a small-calibre radial artery and a 360° radio-ulnar loop, we combined the balloon-assisted tracking (BAT) technique (used to track a catheter trough the loop) with the use of a 6.5FPB sheathless guiding catheter, in order to allow the extensive catheter manipulations needed for PCI despite the ongoing artery spasm.

Transradial percutaneous coronary intervention for chronic total occlusion of coronary artery disease using sheathless standard guiding catheters

Objectives

Our aim was to evaluate the feasibility and safety of routine transradial approach (TRA) percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions using the sheathless technique with standard guiding catheters.

Background

Transradial approach PCI was applied for CTO lesions. A major limitation of TRA CTO PCI is the inability to use large guiding catheters because of the relatively small size of the radial artery. Therefore, the sheathless technique for TRA PCI has been recently developed. However, reports on TRA CTO PCI using the sheathless technique are still lacking.

Methods

Sixty-eight patients with CTO lesions were enrolled for TRA PCI using the sheathless technique with standard guiding catheters. The baseline characteristics, coronary angiographic characteristics and major procedure or access site related complications were compared between procedure success and procedure failure group to determine the predictors of success in sheathless CTO PCI. In-hospital and 30-day clinical outcomes were also evaluated in this study. Routine assessments of radial artery occlusion via Doppler ultrasound and pulse oximeter were recorded during one-year clinical follow-up.

Results

The mean duration of CTO by history was 31.8 ± 42.3 months. The 7 Fr standard guiding catheter was used with the sheathless technique in 91.2%, and bilateral sheathless approach in 42.6% of the study patients. The procedure-related complications included coronary perforation needing covered stent deployment (2.9%), cardiac tamponade (2.9%), collateral perforation needing coil deployment (4.4%), and contrast induced nephropathy (2.9%). Only 2 patients (2.9%) experienced forearm ecchymosis at the radial artery access sites. In-hospital mortality and 30-day all-cause mortality were 2.9%, and 30-day MACEs were 1.5%. The rate of radial artery occlusion during one-year clinical follow-up was only 3.0%.

Conclusions

It is feasible and safe to routinely use the sheathless technique with standard guiding catheters for TRA CTO PCI, with a low incidence of procedure-related complications and long-term radial artery occlusion.