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Heart Treatments

6

Trans Radial Coronary Intervention,

Rotational Atherectomy and

Complex Angioplasty

Background

Traditionally, the femoral artery

has been considered to be the most

convenient approach to perform

percutaneous coronary angioplasty.

This is because its large calibre

facilitates arterial cannulation and

catheter manipulation.There are,

however, several disadvantages of

this technique.The femoral artery

is deep, particularly in patients with

an elevated Body Mass Index (BMI).

This and the close proximity of the

femoral vein and nerve may lead to

iatrogenic injury when angioplasty

is performed through this route.

Furthermore, whilst therapeutic

advances, including more potent

anti-platelet agents and GPIIbIIIa

inhibitors, have improved patient

outcomes, this is associated with

an increased risk of bleeding

complications if the femoral

artery is used. Finally, prolonged

bed rest is essential following

a femoral procedure even with

careful haemostasis or the use of

percutaneous closure devices.

Campbeau reported the first series of

patients in whom trans-radial coronary

angiography was performed in 1989.

The first trans-radial angioplasty and

stenting procedures were performed in

Amsterdam in 1992.The technique is

technically more demanding compared

to the traditional femoral route as

the artery is smaller and the vascular

anatomy of the arm can, on occasion,

reveal some obstacles such as arterial

loops.There is a dual arterial supply in the

forearm which allows radial angioplasty

to be performed safely without risk to

the arm itself.The radial artery is prone

to spasm and agents such as verapamil

can be given to prevent this.

The major advantages of the trans-radial

technique include the fact that the radial

artery lies quite superficially over a

bony prominence thus easily allowing

haemostasis and reducing the chance of

bleeding complications to virtually zero.

The risk of nerve damage is minimal as

the median nerve is distant from the

artery and the absence of major veins

means that formation of arteriovenous

fistulae is extremely rare.The patient can

mobilise immediately – in fact, they can

walk out of the catheter lab straight after

the angioplasty has finished.This allows

angioplasty to be performed on an

outpatient basis and reduces costs.

Rotational atherectomy is a technique for

dealing with highly calcified arteries and

can now be performed via the trans-

radial route.This involves the use of a

high-speed diamond tipped burr or drill

to remove hard plaques and increase

the success of coronary angioplasty

and stenting in complex disease. It is

often used when a stent cannot be

passed through an obstruction because

of the calcium. It also allows better

stent deployment and may reduce stent

thrombosis.This is a highly specialised

procedure and only a few operators

perform it. Rotational atherectomy has

been on the increase because we are now

able to perform more and more complex

interventions.

Professional Background:

Akhil Kapur BMed Sci (Hons) MD

MRCP is an Interventional Cardiologist

and Senior Lecturer at the London

Chest Hospital, Barts and the London

NHS Trust. He is an elected Council

Member of BCIS.

He undertook specialist training at

The Hammersmith and Royal Brompton

Hospitals, London, and Clinique

Pasteur, Toulouse, France. His particular

interest is in coronary artery disease

and the prevention and treatment of

angina and heart attacks, particularly,

complex coronary intervention

including rotational atherectomy. He is

experienced in intravascular ultrasound

and pressure wire technologies.

He performs angioplasty via the

radial (wrist) route. His expertise

encompasses the whole spectrum of

cardiac disease including risk factor

modification, heart failure and valve

disease. His research interests include

revascularisation in patients with

Figure1: Significant lesion in

Left Anterior Descending

artery (LAD).

Figure 2: Result in same LAD

following use of stent in a

radial angioplasty.

Figure 3: Rotational

atherectomy being undertaken

in another patient with Left

Anterior Descending artery

disease – the diamond tipped

burr is shown being delivered

through the lesion.

multivessel disease and diabetes. He is

the Principal Investigator of the CARDia

Trial which recently reported at the

European Society of Cardiology in

Munich. He has numerous publications

covering the full spectrum of adult

cardiology.

Other Languages:

French (fluent), Spanish (fluent),

Hindi (conversational)

Contact:

Dr Akhil Kapur’s secretary

Rosemary Gray

Tel:

020 7234 2255