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Rinfret S 201111
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Transradial Approach for Chronic Total Occlusions

Transradial Approach for Chronic Total Occlusions



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Rinfret S 201111 Rinfret S 201111 Presentation Transcript

  • 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
  • Disclosure Statement of Financial InterestWithin the past 12 months, I or my spouse/partner have had a financialinterest/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
  • 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
  • CTO PCI under the radar… • Real clinical benefits are often questioned • Especially when this happens
  • Independent predictors of 30-daymortality in non–ST-segment ACS Manoukian SV et al, J Am Coll Cardiol 2007;49:1362–1368.
  • Impact of bleeding Persist up to one yearMehran R et al, Eur Heart J 2009;30:1457–1466.
  • Femoral Access Access-related Complication RatesComplication Type Rate, %Femoral-access hematoma (6 cm) 5–23Retroperitoneal hematoma 0.15–0.44Pseudoaneurysm 0.5–6.3Arteriovenous fistulae 0.2–2.1Infection 0.1 Pepine CJ et al. Circulation. 1991;84:2213–2247.
  • 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.
  • Data on access site complication following CTO PCI
  • 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
  • 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
  • CORSAIR 300 cm GW prox300 cm GW distal
  • 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
  • Dual injection-Heavily Ca++ plaque
  • Dual injection-Heavily Ca++ plaque
  • After 10 minutes: Crossed
  • Tornus® antegrade/Corsair® (wire removed antegrade)
  • Reverse CART
  • Confianza Pro 12 in aorta/snaring
  • Antegrade PCI/retro injection
  • Final post DES
  • The CrossBoss™ CTO CatheterCrossBoss is designed to quickly and safely deliver a guidewire via truelumen 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
  • 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-entryConfidential
  • 1st BridgePoint case in Canada First done though 6F/radials worldwide60 yoCCS 3/4Inferior ischemiaJR4 6FXB 3.5 6F
  • CrossBoss® (1st case though 6F)
  • SingRay® balloon and wire
  • Final
  • AdvantagesEarly ambulation!
  • Catheter Cardiovasc Interv. 2011;78(3):366-74
  • Procedural data N=151Ad 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%
  • Procedural data N=151Radiation dose (cGy/Cm2) 24,4K [13,4K-36,2K]Fluoroscopic time (min) 62±39Contrast (cc) 309±132Procedure time (min) 140±73
  • Procedural data N=151Procedural 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
  • Limitations of 6F Yes NoDeliver 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
  • SheathLess guide catheters
  • 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
  • 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
  • Thanks for your attention!
  • BridgePoint System Antegrade re-entry