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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.