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PCI in CTO performed by radial
approach: a single center initial
experience
Maria De Vita, Fabio Tarantino, Filippo Ottani, Ottorino
Catapano, Marcello Galvani
UO di Cardiologia
Laboratorio di Emodinamica
Ospedale GB Morgagni
Forlì
GISE 2013
October 9th-11th Genova
BACKGROUND
- The use of trans-radial approach (TRA) to treat coronary
complex lesions like chronic total occlusions (CTO), is going
to widespread thanks to the reduction of access site
complications with good percutaneous coronary interventions
(PCI) results and also to the advancement in material
technology.
- We prospectively collected the initial results of TRA PCI
for selected CTO lesions in our center in the last 2 years.
METHODS
- Radial approach was used in “selected CTO cases” with double radial
approach for visualization of collateral circulation
- CTO PCI strategy: antegrade approach with first guidewire selection
according to the lesion morphology
- Primary end-points were PCI success (stent implantation with residual
stenosis< 20% and TIMI 3) and patient success (PCI success in a first
or second attempt).
-Access site complications, cardiac intraprocedural complications and
in-hospital major adverse events (MACE) were also assessed.
Transradial approach for PCI on CTO lesions:
study population
N of procedures
25
N of patients
24
CTO vessel:
- LAD
11 (45%)
- LCX
3 (10%)
- RCA
11 (45%)
Failed previuos attempt
1 (5%)
CTO morphology:
- Tapered
11 (45%)
- Microchannels
9 (40%)
- Occlusion site not evident
1 (5%)
- Bridging collaterals or caput medusae
3 (10%)
- CTO length < 20 mm
- Bifurcation involvement
17 (75%)
7 (30%)
Transradial approach for PCI on CTO lesions:
technical features, complications and success
Double radial approach
Crossover to femoral approach
6 (24%)
2 (8%)
Guiding catheter 6 F
23 (90.4%)
Microcatheter to start
17 (70.4%)
OTW balloon to start
6 (24%)
Fielder XT to start
13 (57%)
Fielder XT successful to cross
Anchoring balloon technique
DES implantation (in case of success)
10/13 (77%)
3 (10%)
100%
Transradial approach for PCI on CTO lesions:
technical features, complications and success
Double radial approach
21
Crossover to femoral approach
3 (15%)
Guiding catheter 6 F
19 (95%)
Microcatheter to start
15 (75%)
OTW balloon to start
5 (25%)
Fielder XT to start
12 (60%)
Fielder XT successful to cross
9 (45%)
Anchoring balloon technique
2 (20%)
DES implantation (in case of success)
100%
CARDIAC COMPLICATIONS
(perforation, dissection, pericardial
effusion or tamponade)
NONE
ACCESS SITE COMPLICATIONS
NONE
MACE IN HOSPITAL
NONE
Transradial approach for PCI on CTO lesions:
technical features, complications and success
Double radial approach
21
Crossover to femoral approach
3 (15%)
Guiding catheter 6 F
19 (95%)
Microcatheter to start
15 (75%)
OTW balloon to start
5 (25%)
Fielder XT to start
12 (60%)
Fielder XT successful to cross
9 (45%)
Anchoring balloon technique
2 (20%)
DES implantation (in case of success)
100%
CARDIAC COMPLICATIONS
(perforation, dissection, pericardial
effusion or tamponade)
NONE
ACCESS SITE COMPLICATIONS
NONE
MACE IN HOSPITAL
NONE
PROCEDURAL SUCCESS
21/25 (67%)
PATIENT SUCCESS
21/24 (70%)
Clinical case presentation
- 66 y/o man
- dyslipidemia
- Admitted to our Cardiology ward for previous undatable anterior MI
at EKG with QS in V1-V6 leads with apical akinesis and LVEF 50%
at echocardiogram
-
At coronary angiogram 2 V disease: 90% distal RCA and proximal
LAD chronic occlusion
- The patient had a dobutamine echo-stress with documentation of
apical and anterior wall ischemia
- PCI with DES on RCA
- Medications: ASA, clopidogrel, beta-blocker, ACE-inhibitor, statin
Coronary angiogram
Rigth radial approach
JR4 and JL 3.5 6 F catheters
PCI on LAD/D1 CTO (I)
Double radial approach: Rigth radial for PCI and Left radial for RCA controlateral injection
Guiding Catheter for PCI : EBU 3.75 6 F
RCA cannulation: JR 4 5 F + BMW universal for catheter stabilization
PCI on LAD/D1 CTO (I)
Double radial approach: Rigth radial for PCI and Left radial for RCA controlateral injection
Guiding Catheter for PCI : EBU 3.75 6 F
RCA cannulation: JR 4 5 F + BMW universal for catheter stabilization
PCI on LAD/D1 CTO (II)
FIRST STEP. FINECROSS + FIELDER XT: guidewire NOT ABLE TO CROSS THE CTO
PCI on LAD/D1 CTO (II)
FIRST STEP. FINECROSS + FIELDER XT: guidewire NOT ABLE TO CROSS THE CTO
SECOND STEP. FINECROSS + MIRACLE 3: guidewire and microcatheter ABLE TO CROSS THE CTO
Finecross
Miracle 3
PCI on LAD/D1 CTO (III)
LAD predilation 1: Minitrek 1.20x8 mm; 12 atm
LAD predilation 2: Maverick 2.5x30 mm; 10 atm
PCI on LAD/D1 CTO (III)
LAD predilation 1: Minitrek 1.20x8 mm; 12 atm
LAD predilation 2: Maverick 2.5x30 mm; 10 atm
Post LAD predilation 2
PCI on LAD/D1 CTO (IV)
D1 predilation: Maverick 2x15 mm; 12 atm
D1 wiring with a BMW universal guidewire
PCI on LAD/D1 CTO (IV)
D1 predilation: Maverick 2x15 mm; 12 atm
D1 wiring with a BMW universal guidewire
Post D1 predilation
PCI on LAD/D1 CTO: stenting and final result
LAD Stent position and Stent dilation: XIENCE PRIME 2.75 x 33 mm; 16 atm
PCI on LAD/D1 CTO: stenting and final result
Scientific data on TRA for CTO PCI
Scientific data on TRA for CTO PCI
Scientific data on TRA for CTO PCI
Data on CTO lesions angiographic features not reported in 9 out of 13 studies
MAIN ANTEGRADE APPROACH IN 11 STUDIES
ONLY RETROGRADE BIRADIAL APPROACH IN 2 STUDIES
All centers and operators expert in TRA
TRA CTO PCI: Procedural Features
CROSSOVER TO TFA
6%
5.7%
3.3%
3%
2.3%
Mean
0%
0%
0%
Kim et al
Quesada
et al
Rathore
et al
Liu et al
Burzotta
et al
Reported causes: anatomic variants of radial and subclavian arteries
Burzotta, De Vita et al, CCI 2013
TRA CTO PCI
ACCESS SITE COMPLICATIONS
6%
3.5%
3.5%
3%
0.8%
0%
0%
0%
0%
Kim et al
Rathore
et al
Liu et al
Burzotta
et al
Wu et al
Rinfret
et al
Reported complications: only small ( < 2 cm) hematoma
COMPARISON BETWEEN TRA AND TFA (Rathore et al): 3.5% vs 11.3% p<0.001
Burzotta, De Vita et al, CCI 2013
TRA CTO PCI
PROCEDURAL SUCCESS
STUDY
PROCEDURAL SUCCESS
Saito et al.
78%
Kim et al.
65.5%
Wu et al.
77.3%
Quesada et al.
78.9%
Rathore et al.
82%
Katsuki et al.
76%
Yang et al.
69.25%
Liu et al.
80%
Ferrante et al.
70.3%
Burzotta et al.
67.2%
Asgedom et al.
Wu et al.
Rinfret et al.
73%
87.1%
88%
High variability due to different definition of procedural success among the studies,
different complexity of CTO lesions, and different study periods
Burzotta, De Vita et al, CCI 2013
TRA CTO PCI
PROCEDURAL SUCCESS: TRA vs TFA
RADIAL BETTER
FEMORAL BETTER
Burzotta, De Vita et al, CCI 2013
TRA CTO PCI
PROCEDURAL SUCCESS:
impact of the learning curve
Burzotta, De Vita et al, CCI 2013
CONCLUSIONS
According to and our small experience and to the
literature data overview, TRA for CTO PCI is
feasible, safe and effective with good PCI
success rates, at least for operators expert in
radial approach and for selected and probable
more simple CTO lesions.