From Ulnar Access to Intravascular Lithotripsy in the Emergency Setting: A Unique Case of Acute ST-Elevation Myocardial Infarction Recapitulating Several Niche Interventional Cardiology Techniques for Primary Percutaneous Coronary Intervention

Published

September 14, 2025

Title

From Ulnar Access to Intravascular Lithotripsy in the Emergency Setting: A Unique Case of Acute ST-Elevation Myocardial Infarction Recapitulating Several Niche Interventional Cardiology Techniques for Primary Percutaneous Coronary Intervention

Authors

Marco Bernardi, Luigi Spadafora, Marco Borgi, Attilio Lauretti, Giuseppe Biondi-Zoccai, Francesco Versaci

DOI

10.62684/YABN8989

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Marco Bernardi ^(a), Luigi Spadafora ^(a), Marco Borgi ^(a) , Attilio Lauretti ^(a), Giuseppe Biondi-Zoccai ^(b,c), Francesco Versaci ^(a)

^(a) Department of Cardiology, Santa Maria Goretti Hospital, Latina, Italy

^(b) Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy

^(c) Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy

Correspondence to: Prof. Giuseppe Biondi-Zoccai, Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy. Email: giuseppe.biondizoccai@uniroma1.it.

Abstract

Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) typically relies on well-established access and device strategies. However, complex anatomical constraints may necessitate unconventional approaches. We report a case of acute anterior STEMI in a dialysis-dependent patient with no usable radial or femoral access. Ulnar artery cannulation enabled emergency angiography, revealing a long, calcified proximal left anterior descending artery occlusion. A microcatheter-specialty guidewire combination achieved lesion crossing, followed by guide extension catheter support to facilitate delivery. Intravascular lithotripsy (IVL) was employed to modify extensive calcification, allowing for stent implantation with restoration of TIMI 3 flow. The patient had an uneventful recovery. This case underscores the procedural relevance of niche interventional techniques—including alternative access, advanced lesion crossing strategies, guide support augmentation, and IVL—in select, high-risk STEMI patients. The discussion contextualizes each tool within the evidence base, suggesting that such a sequential, integrative strategy may be valuable when standard PCI is inadequate. As the prevalence of severe coronary calcification rises, especially among patients with chronic kidney disease or peripheral artery disease, awareness and appropriate deployment of these adjuncts may expand the boundaries of effective emergent PCI.

Declarations

Acknowledgements

This manuscript was drafted and illustrated with the assistance of artificial intelligence tools, such as ChatGPT 5 (OpenAI, San Francisco, CA, USA), Mage (Mage, New York, NY, USA), and Napkin AI (Napkin AI, Palo Alto, CA, USA), in keeping with established best practices (Biondi-Zoccai G, editor. ChatGPT for Medical Research. Torino: Edizioni Minerva Medica; 2024). The final content, including all conclusions and opinions, has been thoroughly revised, edited, and approved by the authors. The authors take full responsibility for the integrity and accuracy of the work and retain full credit for all intellectual contributions. Compliance with ethical standards and guidelines for the use of artificial intelligence in research has been ensured.

Conflict of Interest

The Authors declare that there is no conflict of interest.

Funding

None.

Disclosure

Giuseppe Biondi-Zoccai has consulted, lectured and/or served as advisory board member for Abiomed, Advanced Nanotherapies, Aleph, Amarin, AstraZeneca, Balmed, Cardionovum, Cepton, Crannmedical, Endocore Lab, Eukon, Guidotti, Innovheart, Meditrial, Menarini, Microport, Opsens Medical, Synthesa, Terumo, and Translumina, outside the present work. All other authors report no conflict of interest.