Ultrasound guided distal transradial („snuff box” area) angiography and angioplasty using 5F guiding or 6F sheathless guiding system - Zoltan Ruzsa

1. Ultrasound guided distal transradial („snuff box” area)
angiography and angioplasty using
5F guiding or 6F sheathless guiding system
Ruzsa Z., Tóth J., Molnár L., Édes I. F., Bárczi Gy.,
Merkely B.
AimRadial 2017

2. Disclosures
• I have no conflict of interest to declare

3. Background
• First introduced for haemodialysis access in 1996
• Snuff box access published in 1998
• My first case in 2010 for Cimino fistula intervention and my fisrt coronary case in
2014
• Avtandil Babunashvili started the TENDERA study
• Snuff box access published by F Kiemeney in 2017

4. Background- Anatomy

5. Methods
• Prospective study performing all transradial diagnostic catheterrisations
and interventions from the anatomical „snuff box” area with a 5F guiding
or 6F sheathless guiding
• (150 patients and 76 fully analysed)
• Primary end-point
• Technical success of the intervention
• Procedural complications
• Secondary end-point
• MACCE at 2 months and one year
• Procedural releated factors (Radiation, Contrast, Hospitalisation)

6. Ultrasonography
• Vivid 5 US
• US guided puncture in all cases
• US dimensions: distal RA diameter, calcification
• Control US on the next postoperative day

7. Coronary angiography and intervention
• US guided puncture
• 5F TR sheath
• 5F diagnostic catheter
• PCI with 5F guiding (Launcher) or 6.5F sheathless guiding
catheter
• Rotational atherectomy with 1.25 mm Burr
• Bifurcation strategy: T stent and TAP
• CTO: Biradial access- for left 5F and for right 7F
sheathless
• FFR measurement – 5F guiding
• IVUS- 5F Boston or 6F Volcano but with 6.5 F sheathless

8. Postoperative management
Compression bandage for 4 hours

9. Results
• 150 pts
• 100% success and no cross over to femoral access site
• 5F guiding or diagnostic catheter in 108 cases and 6.5F guiding in 42
patients
• Procedure releted factors
• Mean contrast consumption. 115 [86-14.3] ml
• DAP: 34.8 [18.7-51.5] Gy
• Fluoroscopy time 7.1 [4.5-9-8] minute
• Hospitalisation 0.6 day

10. Complications
• Vascular complications
• Radial artery occlusion 0%
• Forearm haematoma 1/150 (0.6%)
• MACCE
• No MACCE at one month

11. Limitations and advantages
• Limitations
• RAO is the major limitation
• Left arm must straighten !!!!
• Due to 5F guiding many techniques are not available therefore we need new
strategy in bifurcation, left main, CTO, calcification
• 6.5 sheathless guiding has the same uter diameter as the 5F sheath
• Advantages
• Compression is very easy
• Fast ambulation (4h ??, 2 h)
• For CTO cases the left arm position is comfortable and the operateur radiation
is low

12. Limitation - RAO

13. LAD Rotablation
and BVS implantation

14. Current clinical admission
• CCS 3 angina
• Rutherford class 3 claudication
• Positive stress test
• Positive stress echo
• Echo: inferior hypokinesis
Plan: - LAD PCI via right radial access (snuff box)
- Right coronary CTO recanalisation??

15. US guided radial artery puncture

16. Coronary angiography 2017.03 Right radial artery recanalisation
(US guided- snuff box)

17. 1. LAD PCI 2017.03

18. 2. RCA stent CTO recanalisation

19. RCA CTO recanalisation

20. What to do??- Bilateral angiography
5F left radial JL3.5
Caravel microcatheter
Miracle Bross

21. Selective angiography

22. Contralateral angio

23. Pd or PL branch??

24. RCA PD ballooning

25. RCA ballooning

26. RCA stenting
Onyx 3.5x18, Onyx 3x32, Onyx 2.75x28, Onyx 2.5x18 mm

27. Final angiography

28. Conclusion
• Ultrasound guided distal transradial access from the snuff box area is safe and
effective and the rate of radial artery occlusion is extremely low