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Retrograde recanalization of radial artery occlusion in patients with need for repeated wrist procedure

Retrograde recanalization of radial artery occlusion in patients with need for repeated wrist procedure

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  • 1. Retrograde Recanalization of Radial Artery Occlusion in Patients with Need for Repeated Wrist Procedure Author (s): Igor Spiroski MD, Sasko Kedev MD PhD FESC Laboratory for Interventional Cardiology, University Clinic of Cardiology, Faculty of Medicine, St. Cyril and Methodius, University of Skopje, Republic of Macedonia
  • 2. Disclosure: Igor Spiroski, MD • Dr. Igor Spiroski has no relevant financial interests to disclose Aim-Radial 2013 2 9/26/13
  • 3. background • Wrist approach (Trans Radial or Trans Ulnar) is getting the place of a standard access site in many PCI centers around the world. • Some patients need several coronary procedures due to treatment of only the culprit lesion in Primary PCI, multi vessel disease or complication as in stent thrombosis and restenosis. • Some of them additionally will have another procedure as CAROTID STENTING or CABG where the operator needs fresh radial artery for grafting usually the left radial artery • Radial artery occlusion (RAO) occurs in 2-8% of all cases and is one of the biggest limitations for additional or repeated wrist procedure in the future. Aim-Radial 2013 3 9/26/13
  • 4. purpose • To present a technique of retrograde recanalization of radial artery occlusion with and without balloon dilatation in patients with need for repeated wrist procedure. Aim-Radial 2013 4 9/26/13
  • 5. Material and methods • In our transradial registry during the period of March 2011 – June 2013, we have documented 10,487 transradial procedures. In 317 patients we have found radial artery occlusion (RAO). • In 281 ipsilateral transulnar approach (TUA) was performed. • We selected the other 36 consecutive patients for retrograde recanalization of RAO. • Patients with documented anatomic variations of radial artery from previous trans radial procedure, such as tortuosity of the vessel and high Aim-Radial 2013 5 take off, were excluded from this group 9/26/13
  • 6. Material and methods • We performed retrograde recanalization of RAO in 14 patients with balloon dilatation and in 17 patients (from our early practice) without balloon dilatation. • In 5 patients (14%) we didn’t manage to cross the occluded segment with the wire. Aim-Radial 2013 6 9/26/13
  • 7. Material and methods • Primary outcome was successfully completed procedure. • Secondary outcomes were procedural complications: forearm pain, access site bleeding events, clinically evident hand ischemia. Aim-Radial 2013 7 9/26/13
  • 8. Baseline characteristics of patients with retrograde recanalization of radial artery occlusion with and without balloon dilatation Age (years) Male BMI (kg/m2) CAD risk factor Hypertension Diabetes mellitus Dyslipidemia Smoking Prior STEMI with PCI Prior CABG PAD Prior Stroke Prior CAS Aim-Radial 2013 Without balloon dilatation N=17 59.41 7 (41.2 %) 26.3 With balloon dilatation N=14 9 5 5 6 6 1 2 1 0 8 4 5 5 4 2 2 2 0 8 55.93 7 (50%) 27.1 9/26/13
  • 9. Baseline characteristics of patients with retrograde recanalization of radial artery occlusion with and without balloon dilatationtechnical aspects Without balloon dilatation N=17 No of previous TR procedures 1 2 Time of previous radial procedure <1months 1-6 months 6-12 months >12 months Previous used sheet 5F 6F Aim-Radial 2013 With balloon dilatation N=14 8 6 12 5 1 5 7 4 1 7 3 2 2 15 1 13 9 9/26/13
  • 10. palpations In all patients there was the absence or a shallow pulse signal over the right radial artery previous puncture site In all patients there was a shallow pulse signal distally of a previous puncture site over the styloid processus This signal was coming from superficial palmar arch of the ulnar artery or interosseal artery collaterals 10 Aim-Radial 2013 9/26/13
  • 11. Radial angiography After the successful puncture of the radial artery we performed manual radial artery angiography throughout the small 20-G plastic cannula from the entry needle RADIOFOCUS INTRODUCER II TERUMO set Aim-Radial 2013 11 9/26/13
  • 12. Radial artery occlusion Subocclusion Aim-Radial 2013 Short occlusion <3cm 12 Occlusion 9/26/13
  • 13. Technique of retrograde opening of RAO without balloon dilatation Hydrophyllic wire Pilot 200 Radial angiography Aim-Radial 2013 13 9/26/13
  • 14. Introducing the 5fr sheet , diagnostic guidewire 0,035”, Coronary angio sheetless guiding catheter 7.5 F PBU Short occlusion to RA Aim-Radial 2013 Bifurcational lession to LAD 14 9/26/13
  • 15. Technique of retrograde opening of RAO without balloon dilatation Xience SBA 3,0/18mm Aim-Radial 2013 Final result 15 9/26/13
  • 16. Final RA angio Dissection (-) ; Pain (-) Fluoroscopic time 6.6 Contrast 150ml 16 Aim-Radial 2013 9/26/13
  • 17. Technique of retrograde opening of RAO with balloon dilatation Interosseal artery ( collaterals ) Aim-Radial 2013 Guide wire ? 17 9/26/13
  • 18. RADIOFOCUS INTRODUCER II TERUMO - transradial kit MINI GUIDE WIRE Plastic (hydrophilic) 45cm Terumo 0.025” HARD TIP Radial angiography performed with plastic cannula DISSECTION TRUE LUMEN Aim-Radial 2013 18 9/26/13
  • 19. Technique of retrograde opening of RAO with balloon dilatation MINI GUIDE WIRE Plastic (hydrophilic) 45cm Terumo 0.025” HARD TIP Aim-Radial 2013 Radial angiography (5 Fr. introducer) 19 9/26/13
  • 20. Technique of retrograde opening of RAO with balloon dilatation Post dilatation angiography revealed preserved radial artery with severe tortuosity Balloon dilatation 3.0/30 mm x 6 atm. Aim-Radial 2013 20 9/26/13
  • 21. Technique of retrograde opening of RAO with balloon dilatation Crossing tortuosity with the BMW 0,014” guide wire Aim-Radial 2013 JR 5 Fr. diagnostic catheter 21 9/26/13
  • 22. Technique of retrograde opening of RAO with balloon dilatation RCA Aim-Radial 2013 Lmain/LAD/LCx 22 9/26/13
  • 23. FINAL RESULT Adequate flow without any visible dissection of the radial artery Aim-Radial 2013 Ipsilateral ulnar artery occlusion 23 9/26/13
  • 24. Procedural characteristics of patients with retrograde recanalization of radial artery occlusion with and without balloon dilatation Without balloon dilatation N=17 Procedure Coronary angiography PCI Type of Radial Artery Occlusion Subocclusion Short occlusion Occlusion Sheet size 4F 5F 6F 7.5 F PBU sheetless Wire Terumo wire 0.025” 45cm Hydrophillic wire 0.014” BMW wire 0.014” Balloon Semi compliant balloon Armada 14 OTW PTA balloon 2.5/60mm 2.5/80mm Aim-Radial 2013 With balloon dilatation N=14 5 12 5 9 9 2 6 7 3 4 1 9 6 1 0 5 9 0 8 6 3 3 6 5 / / 8 6 / / 5 1 24 9/26/13
  • 25. Complications Dissection of radial artery Aim-Radial 2013 25 9/26/13
  • 26. Complications dissection of interosseal artery Aim-Radial 2013 26 9/26/13
  • 27. Complications aterothrombotic embolisation embolus Aim-Radial 2013 27 9/26/13
  • 28. Procedural complications, contrast and fluoroscopic time in patients with retrograde recanalization of radial artery occlusion with and without balloon dilatation Without balloon dilatation N=17 With balloon dilatation N=14 11 0 0 3 145.88 8.24 4 0 1 1 147.14 9.71 Procedural complications Dissection of radial artery Extravasation Dissection of interosseal artery Atherotrombotic embolisation Contrast (ml) Fluoroscopic time (min) Aim-Radial 2013 28 9/26/13
  • 29. results • The primary outcome was achieved in 26 of 31 patients (83.9%). • In patients where we performed balloon dilatation, the primary outcome was achieved in 14 of 14 patients (100%). • Forearm pain was present in 13 cases (41.9%) • Minor access site bleeding occurred in 5 patients (16.1%) and there was no single case of clinically evident hand ischemia. Aim-Radial 2013 29 9/26/13
  • 30. Primary and secondary outcome in patients with retrograde recanalization of radial artery occlusion with and without balloon dilatation Total N=31 Primary outcome Successfully completed procedure Secondary outcome Pain Access site bleeding complications Haematoma grade 1 Haematoma grade 2 Haematoma grade 3 Haematoma grade 4 Haematoma grade 5 Clinically evident hand ischaemia Major vascular complication Radial artery occlusion at 30 days Aim-Radial 2013 Without balloon dilatation N=17 With balloon dilatation N=14 Pearson’s P value 26 (83.9%) 12 (70.6%) 14 (100%) 0.007* 13 (41.9%) 9 (52.9%) 4 (28.6%) 0.171 0 2 1 0 0 0 0 2 0 0 0 0 0 0 0 0 0 17 (54.8%) 11 6 0.224 5 (16.1%) 30 0.800 0 9/26/13
  • 31. conclusion • Retrograde recanalization of the radial artery occlusion is safe and feasible • Balloon dilatation of radial artery occlusion is a key factor for successful catheterization and/or percutaneous coronary intervention • Left TRA or TUA remain a viable option in selected patient Aim-Radial 2013 31 9/26/13
  • 32. conclusion Besides the high re-occlusion rate there is a need in the “radial world” for development of a technique for radial artery opening especially in situations where not other wrist or femoral access site is available such as ipsilateral ulnar artery stenosis, harvesting of a left radial artery for CABG procedure or use of fresh artery for larger fr. devices Aim-Radial 2013 32 9/26/13