Cath Lab Digest

The advantages of the radial approach include fewer access-related bleeding complications, improved patient comfort with early ambulation and shorter hospital stays, as well as reduced procedure cost.

A 41-year-old male with a past medical history of diabetes mellitus, obesity, and dyslipidemia presented with gradually progressing exertional angina for 6 to 8 months. His nuclear stress test revealed reversible defects in the mid and basal anteroseptal wall, lateral apex, anterior apex, and true apex, which were all of moderate intensity. Coronary angiography revealed multi-vessel disease, including a very long proximal left anterior descending (LAD) chronic total occlusion (CTO) (Figure 1) and a dominant right coronary artery (RCA) with multiple sequential severe stenosis. Right-to-left collateral flow from the septal perforators filled the distal LAD partially. Resting left ventricular systolic function was preserved without any significant wall motion abnormality. The patient had poor targets for surgical revascularization of the LAD; therefore, a percutaneous coronary intervention (PCI) was planned.

A 6-French (Fr) extra backup (EBU) 3.5 guide catheter (Medtronic) was used to engage the left main via a 6 Fr Glide sheath (Terumo) in the right radial artery. A 5 Fr JR4 diagnostic catheter was used via left radial access to perform contralateral injection of the RCA and collaterals to the LAD (Figure 2). Prowater (Abbott Vascular) and Confianza (Abbott Vascular) wires were unsuccessful in crossing the entire length of occlusion (Figure 3). A Choice PT2 (Boston Scientific) moderate support wire successfully crossed the distal occlusion. An over-the-wire Apex (Boston Scientific) 1.5mm x 8mm balloon was used to confirm intraluminal position and to predilate the occluded segments. Multiple overlapping Promus (Boston Scientific) drug-eluting stents were deployed to the diseased vessel and post-dilated at high pressure (Figure 4) with an excellent angiographic result (Figure 5). The sheath was promptly removed and a hemostatic wristband was applied for 2 hours. The patient was discharged the next morning on aspirin and prasugrel, along with other medicines.

Discussion

In the United States, the transradial access rate for cardiac catheterization has increased from 1% in 2007 to nearly 11% in 2011. The advantages of the radial approach include fewer access-related bleeding complications, improved patient comfort with early ambulation and shorter hospital stays, as well as reduced procedure cost. These advantages translate to a mortality benefit in higher risk interventional procedures.¹

Successful revascularization of CTOs in patients with viable myocardium may reduce symptoms of angina, decrease the need for bypass surgery, and provide a long-term survival benefit of up to ten additional years.² Feasibility and safety of the transradial approach is reported in a few single-center experiences. In these limited data, transradial revascularization of CTO lesions has produced similar rates of success and lower access site-related complications without increased procedural time or contrast use in comparison to the transfemoral approach.^3-5 However, the application of the radial approach for percutaneous treatment of CTOs is infrequent in the U.S., and its feasibility has been questioned. At our center, we prefer the use of radial access for CTO revascularization, unless we are limited due to a very small or diseased radial artery, extreme brachiocephalic tortuosity or when the radial artery is used for arterio-venous shunts or bypass grafts. As seen in this case report, a very difficult, long CTO can be treated successfully via the radial approach.

The following tips may be helpful for use of the radial approach for the treatment of a CTO: