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PATIENT CASE

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A 48-year-old male hypertensive smoker with no previous heart disease but a strong family history of coronary artery disease developed epigastric discomfort similar to “indigestion.” After 3 hours of antacids and “waiting it out,” his wife insisted that he call 911. Upon arrival at our emergency department, he had anterior ST-segment elevation on his electrocardiogram (ECG), and a “STEMI (ST-segment elevation myocardial infarction) alert” was called. After assembling the catheterization, or “cath,” lab team, the patient was given 324 mg of aspirin and 600 mg of clopidogrel, his right wrist and groin were prepped per protocol, and the fellow began obtaining radial artery access under our “3-minute rule” protocol (ie, if radial access is not obtained in 3 minutes, operator number 2 is to obtain femoral artery access). The fellow was successful in obtaining radial access, and the left coronary angiogram revealed a 99% stenosis of the proximal left anterior descending (LAD) artery with Thrombolysis in Myocardial Infarction (TIMI) 1 flow (flow did not reach the end of the vessel). Unfractionated heparin had already been given via the radial artery as a part of our pre-transradial cocktail, and an intravenous glycoprotein IIb/IIIa antagonist was given to rapidly achieve maximal platelet inhibition. Next, a hydrophilic guide wire was advanced across the occlusion and into the distal LAD, followed by several passes of a thrombectomy catheter to minimize the thrombotic burden of the lesion. Direct placement of a drug-eluting stent was then performed without complication, and brisk, TIMI 3 flow was restored into the LAD. The patient’s discomfort and ECG changes abated shortly thereafter. The total door-to-balloon time was 17 minutes. Afterward, the patient wanted to see his angiogram (he is a physician) and asked if he could stand to see it better. As he had not been sedated, per his request, he was helped to a standing position and studied the angiographic images. A photograph was taken of this special moment (Figure 7-1). He was ambulating around the nurses’ station 1 hour after myocardial infarction and was discharged on day 3, having had no complications. He has successfully quit smoking.

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Figure 7-1

Patient standing 5 minutes after transradial coronary stent treatment for his anterior STEMI. Note radial hemostasis band on right wrist.

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INTRODUCTION

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The most common cause of death in the United States, coronary atherosclerotic heart disease, is most often detected clinically by performing coronary angiography. Over 1 million coronary angiograms and coronary interventions are performed annually, with most performed by puncturing the femoral artery and advancing a catheter retrograde up the aorta to engage the coronary ostia. Alternate arterial access sites for coronary angiography include the brachial, ulnar, and radial arteries. Despite years of data indicating that the radial artery access site offers significant advantages of safety, patient convenience, and a reduction in complications, the majority of ...

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