Transradial Approach for Chronic Total Occlusions

1. Transradial Angiography and Intervention: From Basic to Advanced
Transradial Approach for
Chronic Total Occlusions
Stéphane Rinfret, MD, SM
Quebec Heart and Lung Institute
Québec, Canada

2. Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship Company
• Grant/Research Support • BridgePoint Medical
• Consulting Fees/Honoraria • Abbott Vascular Canada
• Terumo US

3. Femoral approach for CTO PCI
• Advantages
 Allow for 8F catheter use
 More options
 Better support if 8F
• Disadvantages
 Higher vascular access bleeding or ischemic
complication rates
 Patient discomfort

4. CTO PCI under the radar…
• Real clinical
benefits are often
questioned
• Especially when
this happens

5. Independent predictors of 30-day
mortality in non–ST-segment ACS
Manoukian SV et al, J Am Coll Cardiol 2007;49:1362–1368.

6. Impact of bleeding
Persist up to one year
Mehran R et al, Eur Heart J 2009;30:1457–1466.

7. Femoral Access
Access-related Complication Rates
Complication Type Rate, %
Femoral-access hematoma (6 cm) 5–23
Retroperitoneal hematoma 0.15–0.44
Pseudoaneurysm 0.5–6.3
Arteriovenous fistulae 0.2–2.1
Infection 0.1
Pepine CJ et al. Circulation. 1991;84:2213–2247.

8. Risk factors
for bleeding complications
• Femoral access
• > 8 F vs. smaller
• Lower than bifurcation
• Vascular closure devices (?)
Dangas G et al, J Am Coll Cardiol. 2001;38:638–641.

9. Data on access site complication
following CTO PCI

10. Things you can’t say anymore in
interventional cardiology
• Can’t stent without pre-dilation
• Can’t stent complex bifurcation though 6 F
• Can’t do LM stenting though 6 F
• Can’t do CTO PCI though 6F/radials

11. Radial approach for CTO PCI
• More common in Canada and Europe
• Advantages:
 Reduce bleeding and vascular complication
(although no RCT)
 Earlier ambulation
• Disadvantages
 Need good non-CTO transradial experience
 Committed to the use of smaller guide catheters
 Less options

12. CORSAIR
300 cm GW prox
300 cm GW distal

13. Bilateral transradial CTO PCI
Tips and tricks
• Right radial for left guide, and left radial for
right guide (no matter where is CTO)
 Better support from the right radial in a LM
• XB 3.5 for LM, JR4 or AL 0.75 for RCA (±SH)
 Cordis guides works really well, atraumatic tip
• 6 F retrograde is usually fine (90cm)
 Rotating devices need less support
• 7F antegrade if large radial (especially in US)
• Should not be attempted with 5F system

14. Dual injection-Heavily Ca++ plaque

15. Dual injection-Heavily Ca++ plaque

16. After 10 minutes: Crossed

17. Tornus® antegrade/Corsair®
(wire removed antegrade)

18. Reverse CART

19. Confianza Pro 12 in aorta/snaring

20. Antegrade PCI/retro injection

21. Final post DES

22. The CrossBoss™ CTO Catheter
CrossBoss is designed to quickly and safely deliver a guidewire via true
lumen or subintimal pathways
• Multi-wire coiled shaft
Ratchet Handle for
FAST-Spin Technique
• Tracks via FAST Spin Technique
– Highly torqueable coiled-wire shaft
– FAST Spin reduces push required to
cross CTO
• Atraumatic distal tip advanced
across a CTO ahead of the
guidewire
• OTW 0.014” guidewire compatible
Atraumatic 1 mm
Distal Tip

23. The Stingray™ CTO Re-Entry System
Stingray System (catheter and guidewire) is designed to accurately target
and re-enter the true lumen from a subintimal position
• 6Fr. Guide/0.014” Wire
compatible
• 2.9Fr. shaft profile
• Unique self-orienting
balloon with flat shape for
true lumen targeting
• Re-entry probe at Stingray
Guidewire tip
180° opposed and offset
exit ports for selective
guidewire re-entry
Confidential

24. 1st BridgePoint case in Canada
First done though 6F/radials worldwide
60 yo
CCS 3/4
Inferior ischemia
JR4 6F
XB 3.5 6F

25. CrossBoss® (1st case though 6F)

26. SingRay® balloon and wire

28. Final

29. Advantages
Early ambulation!

30. Catheter Cardiovasc Interv. 2011;78(3):366-74

31. Procedural data N=151
Ad hoc procedure 14%
Dual access 78%
Radial 93%
Single radial access 18%
Dual radial access 60%
Radial and femoral 16%
6 Fr antegrade catheter 81%
6 Fr retrograde or contralateral catheter 96%
FineCross® microcatheter usage 70%
Retrograde Corsair® 75%
Antegrade Tornus® 36%

32. Procedural data
N=151
Radiation dose (cGy/Cm2) 24,4K [13,4K-36,2K]
Fluoroscopic time (min) 62±39
Contrast (cc) 309±132
Procedure time (min) 140±73

33. Procedural data N=151
Procedural Success 89%
Success per CTO (3 patients had >1 attempt) 91%
Retrograde approach 50%
Crossing technique
Antegrade true to true 44%
Parallel wiring 0%
Retrograde true to true 10%
Retrograde re-entry (reverse CART) 28%
Kissing wires/knuckle CART 2%
BridgePoint System 8%
Antegrade re-entry (LAST) 8%
Vascular complication 0%
Pre-post average Hb drop (g/L) -7±8

34. Limitations of 6F
Yes No
Deliver Jomed OTW covered stent (US) 
Deliver Jomed RX covered stent 
IVUS-guided prox cap puncture (microcatheter) 
Trapping balloon + Tornus 2.6/CrossBoss/StingRay 
Trapping balloon + Tornus 2.1 
Trapping balloon + Corsair 
Deep seating 
Get Asahi wires extensions

35. SheathLess guide catheters

36. Conclusions
• Transradial antegrade or retrograde
CTO PCI is feasible, very safe, and still
associated with high success rates with
modern techniques
• Reduction in access site bleeding or
ischemic complication remains a very
important goal of modern PCI
• Under-reported in most recent CTO PCI
series

37. Conclusions
• Low complication rate while maintaining
high success rate represents significant
progress towards safety
• Experienced transradial operators
should not refrain from using their
preferred access route when performing
complex CTO recanalization

38. Thanks for your attention!

39. BridgePoint System
Antegrade re-entry