This document summarizes key points from a presentation on performing CT0 PCI (percutaneous coronary intervention for chronic total occlusions) via the radial approach. It discusses the radial artery diameter being on average 2.6 mm, allowing the use of 7 or 8 French guides. Bilateral radial access was used in 90% of cases in one study of 31 CT0 PCIs. The presentation provides an algorithm for radial CT0 PCI and discusses tools and techniques that can be used, noting some limitations of smaller sheath sizes. Overall success rates from one study are reported as 82.8% for the radial approach. Considerations for when femoral access may still be preferred are also outlined.

1. CTO PCI via The Radial approach
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
 Terumo: consultant

3. J Am Coll Cardiol Intv. 2012;5(4):367-379. doi:10.1016/j.jcin.2012.02.006
Access does not matter with the hybrid algorithm.
Success & safety are more important

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

5. 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

6. Is there any data to support CTO PCI via
bilat RA access?

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
CCI, 2011

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 – 2pm

9. 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

10. 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

11. 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

12. International Journal of Cardiology, Volume 101, Issue 3, 2005, 421–427
Can we place 7 Fr. or 8 Fr. Guides in the RA?
Radial Artery Diameter (mean, cm)
Mean RA diameter was 2.60±0.41 mm, range diameter was from 1.15-3.95 mm

13. 8 French Radial Access for CTO PCI
Edward Gildeh, Mir Basir, Gerald Koenig, Mohammad Alqarqaz, Akshay Khandelwal, Michele Voeltz, Henry Kim, William O’Neill,
Khaldoon Alaswad
 J-CTO score was 3.3 +/- 1.4.
 Bilateral 8F RA access in 90% of
patients
 Total 52 transradial 8F guides were
used of which 11.5% were
sheathless.

14. 31 CTO PCIs were performed in 29
patients
Demographics Mean SD/%
Age 67.9 8.98
Male 27 93.1%
PAD 2 6.9%

15. Procedure Characteristics
Mean SD
Average Proc Time
in hr:min
2:57 1:10
Average Contrast
Used in ml
287.1 106.2
Antegrade
Approach
14 48.3%
Successful 24 82.8%

16. No major access site complications
Discharge 20.7%
Within 1 month 30.0%
• Minor access site complications: 30% of pts had
short lived numbness, tingling, pain or swelling.
• Quality of Life: 100% of patients preferred a
transradial approach.

17. Algorithm for TR CTO PCI
Do not compromise support
1 • Short 8 Fr Sheath, and 8 Fr. guide
2
• Sheathless 8 Fr Guide
3
• 7 Fr if cannot tolerate 8 Fr.
4
• 6 Fr. If cannot tolerate 7 Fr.
5
• CFA 8 Fr Long sheath if cannot tolerate 6 Fr.

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

19. Toolbox for TR CTO PCI

20. What do we need to change If the
radial artery cannot fit 7 or 8 Fr
 Smaller Tornus (2.1 F vs 2.6 F)
 Cannot perform Simultaneous IVUS stent
Stent or balloon

21. 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

Curtsey Stéphane Rinfret, MD, SM

22. 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

23.  Suture the sheath
 Bring the hand over after placing the tip of the J Wire in the subclavian artery
 Support the left arm (bean bag)

24. Right RA to the LMCA
Left Radial Artery to the RCA

25. Common Femoral Artery Access is Preferred
During CTO PCI
Absent radial artery
RA that cannot accommodate 6 Fr. guiding catheter
Anatomic variations or significant tortuosity
Needs or will need permanent hemodialysis access
Ostial or very proximal CTO

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

27. 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

28. 47 year old with h/o NSTEMI in 2012

29. Antegrade 2016

32. Kal Alaswad, MD
Mobile: 313-693-8972
kalaswa1@hfhs.org
CTOfundamentals.org