Rinfret S 201111


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Transradial Approach for Chronic Total Occlusions

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Rinfret S 201111

  1. 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. 2. 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
  3. 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. 4. CTO PCI under the radar… • Real clinical benefits are often questioned • Especially when this happens
  5. 5. Independent predictors of 30-daymortality in non–ST-segment ACS Manoukian SV et al, J Am Coll Cardiol 2007;49:1362–1368.
  6. 6. Impact of bleeding Persist up to one yearMehran R et al, Eur Heart J 2009;30:1457–1466.
  7. 7. 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.
  8. 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. 9. Data on access site complication following CTO PCI
  10. 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. 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. 12. CORSAIR 300 cm GW prox300 cm GW distal
  13. 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. 14. Dual injection-Heavily Ca++ plaque
  15. 15. Dual injection-Heavily Ca++ plaque
  16. 16. After 10 minutes: Crossed
  17. 17. Tornus® antegrade/Corsair® (wire removed antegrade)
  18. 18. Reverse CART
  19. 19. Confianza Pro 12 in aorta/snaring
  20. 20. Antegrade PCI/retro injection
  21. 21. Final post DES
  22. 22. 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
  23. 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-entryConfidential
  24. 24. 1st BridgePoint case in Canada First done though 6F/radials worldwide60 yoCCS 3/4Inferior ischemiaJR4 6FXB 3.5 6F
  25. 25. CrossBoss® (1st case though 6F)
  26. 26. SingRay® balloon and wire
  27. 27. Final
  28. 28. AdvantagesEarly ambulation!
  29. 29. Catheter Cardiovasc Interv. 2011;78(3):366-74
  30. 30. 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%
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. SheathLess guide catheters
  35. 35. 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
  36. 36. 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
  37. 37. Thanks for your attention!
  38. 38. BridgePoint System Antegrade re-entry