Snare-Assisted Radial–Femoral Guidewire Externalization for Complex Primary Percutaneous Coronary Intervention In A Patient With St-Segment Elevation Myocardial Infarction And Concomitant Abdominal Aortic Aneurysm: A Case Report

Abstract

Accurate identification of the culprit vessel and distal target anatomy is critical for safe, effective primary percutaneous coronary intervention (PCI). In cases of collateralized total coronary occlusions, competitive collateral flow can impede visualization of the distal vessel, while contrast staining during wire crossing may raise concerns regarding wire-induced coronary perforation.1-4 In this circumstance, Dual arterial access offers enhanced angiographic visualization of the distal vessel, supporting accurate assessment of wire position and vessel integrity.1-3 However, concomitant aortic pathology, particularly abdominal aortic aneurysm, may hinder femoral catheter delivery and necessitate alternative procedural strategies.  This case report details a 74-year-old woman presenting with acute inferoposterior ST-segment elevation myocardial infarction (STEMI). Coronary angiography from right radial access demonstrated total occlusion of the distal right coronary artery (RCA). During antegrade recanalization, localized contrast staining prompted suspicion of wire-induced perforation. A second arterial access was obtained via the right femoral artery to enable simultaneous dual coronary injection and independent evaluation of distal vessel integrity. However, femoral catheter advancement was unsuccessful beyond the abdominal aorta, and contrast injection revealed a previously unrecognized fusiform infrarenal abdominal aortic aneurysm (AAA). A hydrophilic guidewire was advanced from the radial access into the abdominal aorta, captured with a snare from femoral access, and externalized through the femoral sheath, establishing radial–femoral through-and-through guidewire access. This enabled RCA guiding-catheter engagement and dual coronary injection, followed by successful antegrade wire crossing, balloon predilatation, and guide-extension-assisted stent implantation. Successful revascularization was achieved, with restoration of TIMI grade 3 flow and no immediate complications. Snare-assisted radial–femoral guidewire externalization may provide a feasible bailout strategy when aortic pathology hinders femoral catheter advancement during complex primary PCI.