Use of transradial approach for chronic total occlusion (CTO) percutaneous coronary intervention (PCI)

1. Use of Transradial Approach for
Chronic Total Occlusion PCI
Khaldoon Alaswad, MD, FSCAI, FACC
Director, Catheterization Laboratory
Henry Ford Hospital and Health System
Detroit, Michigan

2. Disclosure
 Boston Scientific: Consultant, Speaker
Bureau
 Abbott: Consultant, Speaker bureau
 Asahi Intecc: consultant

3. J Am Coll Cardiol Intv. 2012;5(4):367-379. doi:10.1016/j.jcin.2012.02.006
Hybrid CTO PCI Algorithm

4. Common CTO PCI Terms
Procedures
 Grenadoplasty
 Knuckle dissection
 Power knuckle
 IVUS guided puncture
 Crossboss dissection
 Trapping technique
Complication
 6% perforation
 2% pericardiocentesis
 CART and reverse CART

5. Common CTO PCI Terms
• Need extra guide support
• Need to place >1 device in the guide
• Need to use bulky devices
• Need to have enough room to manage complications

6. Can we do all that from the radial
artery?

7. Bilateral radial approach 37 (88%)
6 Fr antegrade catheter 30 (71%)
6 Fr retrograde catheter 38 (91%)
Retrograde Corsair channel
dilator usage
38 (90%)
Procedural success (TIMI 3,
<30% stenosis)
37 (88%)
Antegrade crossing 2/37 (5%)
Pure retrograde crossing 11/37 (29%)
Reverse CART 22/37 (60%)
CART 1/37 (3%)
Kissing/knuckle wire 2/37 (5%)
Procedure time (min) 189 ± 63
Fluoroscopic time (min) 85 ± 37

8. Transradial Approach for Coronary
Chronic Total Occlusion
Interventions: Insights from a
Contemporary Multicenter Registry
Khaldoon Alaswad, MD1*, Rohan V. Menon, BS2*, Georgios Christopoulos, MD2, William L.
Lombardi, MD3, Dimitri Karmpaliotis, MD4, J. Aaron Grantham, MD5, Steven P. Marso, MD5,
Michael R. Wyman, MD6, Nagendra R. Pokala, BS2, Siddharth M. Patel, BS2, Anna P. Kotsia,
MD2, Bavana V. Rangan, BDS, MPH2, Nicholas Lembo, MD7, David Kandzari, MD7, James Lee,
MD7, Anna Kalynych, MD7, Harold Carlson, MD7, Santiago A. Garcia, MD8, Craig A.
Thompson, MD9, Subhash Banerjee, MD2, Emmanouil S. Brilakis, MD, PhD2
September 16, 2014

9. 16.9%
4%
26%
7%
63% Bilateral radial
Bilateral radial
and femoral
Unilateral radial
Unilateral radial
and femoral
83.1%
Femoral
650 patients

10. Angiographic characteristics
Overall
(n=665)
Transradial
(n=114)
Transfemoral
(n=551)
p
CTO target vessel
0.99
RCA (%) 59 58 59
LCX (%) 14 16 14
LAD (%)
Other (%)
20
7
21
5
20
7
Moderate/severe calcification (%) 55 61 54 0.14
Moderate/severe tortuosity (%) 31 32 31 0.88
Prior failed CTO PCI (%) 18 15 19 0.34
In-stent restenosis (%) 11 6 12 0.12
J-CTO score 2.7±1.2 3.1±1.0 2.6±1.2 <0.001
Dual injection (%) 74 53 80 <0.001

11. 93.0
90.0
1.8
92.6 91.1
1.7
0
20
40
60
80
100
Technical
success
Procedural
success
MACE
% Radial
Femoral
p=0.87 p=0.95 p=0.99

12. Outcome
Overall
(n=650)
Transradial
(n=110)
Transfemoral
(n=540)
p
Major procedural
complications (%)
1.7 1.8 1.7 0.99
Death
Acute MI
Pericardiocentesis
Urgent repeat PCI
0.3
0.8
0.6
0.2
0.0
0.0
1.8
0.0
0.4
0.9
0.4
0.2
0.99
0.60
0.99
0.14
Vascular complications (%) 2.5 1.8 2.6 0.99
Procedure time (min) 125±66 142±83 120±60 0.008
Fluoroscopy time (min) 50±33 58±40 49±31 0.026
Air kerma dose (Gray) 3.7±2.6 4.5±2.2 4.2±2.6 0.32
Contrast volume (mL) 287±145 270±120 291±149 0.11
Number of stents 2.5±1.1 2.8±1.1 2.5±1.0 0.025

13. Radial vs femoral access
N=650. 6 US centers
Transradial (17%): mainly cases from Alaswad
Technical success: 92.6% femoral vs. 93% radial, p=0.87
MACE: 1.7% femoral vs. 1.8% radial, p=0.99
PROspective Global REgiStry for the Study of CTO interventions
Alaswad, Menon, Christopoulos, Lombardi, Karmpaliotis, Grantham, Marso, Wyman, Pokala, Patel, Kotsia, Rangan, Lembo, Kandzari, Lee,
Kalynych, Carlson, Garcia, Thompson, Banerjee, Brilakis. Cath Cardiovasc Intv; in press

14. Despite Increased Lesions Complexity Radial
access during CTO PCI is associated with:
•Similar technical and procedural success rates
•Similar major adverse cardiac events
•Decreased CTO PCI efficiency (increased
fluoroscopy time, procedure time)

15. RA access is critically important for the
success of the CTO PCI
Post CABG when the CTO PCI requires more
than 2 arterial accesses
Need of hemodynamic support device via
CFA access
Peripheral artery disease
High risk for access site complications

16. Common Femoral Artery Access is
Preferred During CTO PCI
Absent radial artery
RA that cannot accommodate 6 Fr. guiding
catheter
Anatomic variations
Significant subclavian or brachiocephalic
tortuosity
Need of permanent hemodialysis access
Ostial or very proximal CTO

17. Ostial or Proximal RCA occlusion cap needs 8 Fr Guide
support

18. Sheath and guide Size
 Shortest Hydrophilic 8 Fr sheath
 8 Fr. Sheath and guide are well tolerated
(need data)
 Sheathless 8 F guide if cannot tolerate the
sheath
 7 Fr for those who cannot tolerate 8 Fr
 6 Fr for those who cannot tolerate 7 Fr
 8 Fr 45 cm groin sheath for those who cannot
tolerate 6 Fr

19. The largest Fr tolerated
OD 6F sheath=OD 8F guide
OD of 6F dilator=ID of 8F guide
8F sheathless
“Quebec technique”

20. Can you do this through 6F?
Yes No
IVUS-guided prox cap puncture (microcatheter)

Trapping balloon + Tornus 2.6/CrossBoss/StingRay

Deliver Jomed RX covered stent (graft master)

Trapping balloon + Tornus 2.1

Trapping balloon + Corsair

Deep seating


21. Table Set Up
Catheterization and Cardiovascular Interventions
Volume 78, Issue 3, pages 366-374, 18 MAY 2011 DOI: 10.1002/ccd.23140
http://onlinelibrary.wiley.com/doi/10.1002/ccd.23140/full#fig3

22.  Suture the sheath
 Bring the hand over after placing the tip of the J
Wire in the subclavian artery
 Tie to the right side of the table
 Support the left arm (bean bag)

23. What do we need to change during
CTO PCI from the Radial Artery
Access
 Smaller guide catheters.
 Smaller Tornus (2.1 F vs 2.6 F)
 Cannot perform Simultaneous IVUS stent
Stent or balloon

24. Real interventional
cardiologists should be
able to use any access

25. If you are learning CTO PCI and wants to learn TR PCI
Follow the AA rule do not wean yourself of
CFA while you are trying to learn CTO PCI