We would like to go transradial for all procedures; however, one of our interventionalists stated that you cannot do complex procedures and utilize 7 or 8 French sheaths for patients. In your experience, is this true?

   As you can see from Figure 1, it is possible to insert a large sheath in the radial artery on a case-by-case basis. With females, I would tend to be more careful, and with men, it is more advantageous to insert a large sheath.

   Complex cases can be done transradially. I will share a chronic total occlusion (CTO) of the right coronary artery (RCA) utilizing the Crosser CTO Recanalization system by Flowcardia (Sunnyvale, CA). This case was done by Dr. Zaheed Tai.

Case Report

   A 62-year-old male with history of hypertension, diabetes, and hypercholesterolemia underwent diagnostic angiography via the right radial artery. He was found to have a CTO of the RCA. The right radial was prepped and we accessed with a 6 Fr Terumo Glide sheath (Somerset, NJ). The sheath was upsized to a 7 Fr sheath. An AL .75 guide wire was used to engage the coronary system. Using the Flowcardia Crosser device and a cougar wire, we were able to cross the CTO and achieve luminal entry. Following the removal of the Crosser, the cougar was advanced into the PDA. We used a 2.0 x 40 mm Apex to predilate the lesion. We then placed a Promus (Boston Scientific Corp., Natick, MA) 3.0 x 28 mm and a 3.0 x 15 mm stent. We post dilated with a 3.25 Quantum Maverick balloon. At this point, we administered 200 mcg intracoronary nitroglycerin and revealed TIMI-3 flow, with no perforation or embolization. After removal of wire and guide, a TR Band (Terumo) was applied.

   As demonstrated by the procedure below, you can utilize the radial artery for any procedure as long as the artery can handle the sheath. We routinely will do our complex cases via the transradial approach, including rotational atherectomy and laser atherectomy. Normally, we will start with a 6 Fr sheath; however, if the patient can accommodate a 7 Fr sheath, we will upsize.

Acknowledgements. I would like to express my gratitude to Dr. Zaheed Tai for sharing this complex procedure.