Treating a Chronic Total Occlusion Via the Transradial Approach

Complete total occlusion (CTO) of a coronary artery vessel is among the most common reasons patients are referred for surgery rather than attempting percutaneous coronary revascularization. To date, treating CTOs remains one of the major challenges in interventional cardiology. In the last 20 years, the procedural success rates for CTO interventions have significantly increased as a result of improved guide wires and devices, as well as operator technique and experience. Success rates for percutaneous coronary intervention (PCI) of CTOs now range from 65–80% and have steadily improved over time.¹

Due to prolonged procedural time required to establish vessel patency in CTOs, local complications associated with femoral artery access may lead to serious clinical complications. The transradial approach has been shown to reduce vascular and bleeding complications at the access site, improve patient comfort, and decrease the length of hospitalization compared to the femoral approach.²

The radial access approach is gaining ground as interest grows in the United States. A review of the literature found the proportion of radial access was 3% in 2007, with a sharp rise to 5–7% in the last two years.^3,4 Successful attempts have been made to treat CTOs via the transradial approach in China, Japan and Europe.^5-7

In this report, we describe the successful treatment of a CTO via the transradial approach.

Case Report

A 71-year-old woman with a history of dyslipidemia, hypertension, and smoking was referred for further evaluation of chest pain. A course of treatment for symptoms of “heartburn” with a proton pump inhibitor was without meaningful improvement in her symptoms. Subsequently, she was referred to cardiology. Initial evaluation included a technetium (99mTc) sestamibi (Cardiolite) stress test that was consistent with inferior wall ischemia. She was subsequently referred for coronary angiography. It was decided to attempt the case through the right radial artery. Angiography revealed a CTO of the right coronary artery (RCA). It was decided to proceed with the transradial approach and switch to the transfemoral approach if necessary. The treatment of CTOs is more commonly attempted with 7 French (Fr) or 8 Fr systems. Lately, 6 Fr systems have been successfully introduced. We changed the 5 Fr sheath used for the diagnostic coronary angiogram to a 6 Fr sheath. A 6 Fr Launcher ECR-4 guide catheter (Medtronic, Inc., Minneapolis, Minn.) was used to engage the RCA. Attempts to cross the lesion with our workhorse wire [long Balance Middle Weight (BMW) (Abbott Vascular, Redwood City, Calif.)] were unsuccessful. Then, a long Asahi Fielder XT wire (Abbott) was used and ended up in a side branch. While the Asahi Fielder remained in a side branch, attempts were made to cross the lesion with a long BMW wire. We used the “wire drilling” technique, which means constant rotation of the wire with the right hand and simultaneous forward movement of the wire with the left hand. After a few attempts, the lesion was successfully crossed. A 1.5 x 6 mm OTW Sprinter (Medtronic) balloon was parked distal to the lesion. A small amount of contrast was injected via the wire lumen of the balloon to confirm an intraluminal position. Later, sequential angioplasty of the CTO was performed. After successful opening of the vessel, intra-coronary nitroglycerine was injected to improve chronic low-flow spasm. Depending upon the length of the lesion, different stents were used. A 2.25 x 16 mm Taxus stent (Boston Scientific, Natick, Mass.) was deployed distally, a 2.5 x 15 mm Promus stent (Boston Scientific) was deployed in the mid segment and a 2.5 x 30 mm Endeavor stent (Medtronic) deployed in the proximal segment. The stents were post-dilated with high pressure. Final angiographic images showed an excellent result in re-establishing vessel patency. As anticoagulant effects of heparin could be reversed in case of peri-procedure complication, we chose to administer heparin during the procedure. The patient was not on clopidogrel (Plavix) and we opted to administer two boluses of eptifibatide (Integrilin) during the procedure.

Although several reports have shown the safety of same-day discharge post-intervention,^8–11 we chose to keep the patient for overnight observation due to a limited experience in treating CTOs at our facility. We would also propose a large clinical trial in order to assess the safety and efficacy of the transradial approach for treating CTOs before adapting it to everyday practice.

This article received a double-blind peer review from members of the Cath Lab Digest editorial board.

The authors can be contacted via Dr. Ahmed at syedmashoodahmed@hotmail.com.

References

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3. Rao SV, Ou F, Wang TY, et al. Trends in the prevalence and outcome of radial and femoral approaches to percutaneous intervention: A report from the National Cardiovascular Data Registry. J Am Coll Cardiol Interv 2008;1:379–386.
4. Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): A randomised, parallel group, multicentre trial. Lancet 2011;377:1409–1420. 
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7. Kim JY, Lee SH, Choe HM, et al. The feasibility of percutaneous transradial coronary intervention for chronic total occlusion. Yonesi Med J 2006;47:680–687.
8. Bagur R, Bertrand OF, Rodes-Cabu J, et al. Long-term efficacy of abciximab bolus and infusion after transradial coronary stenting. Catheter Cardiovasc Interv 2009;74:1010–1016.
9. Gilchrist I, Rhodes D, Zimmerman H. Real world, same-day transradial PCI patients in the US: Do the guidelines fit practice? Society for Cardiovascular Angiography and Interventions 2010 Scientific Sessions; May 5, 2010; San Diego, CA. Abstract A-045.
10. Jabara R, Gadesam R, Pendyala L, et al. Ambulatory discharge after transradial coronary intervention: Preliminary U.S. single-center experience (same-day transradial intervention and discharge evaluation, the STRIDE study). Am Heart J 2008;156:1141–1146.
11. Ziakas A. Safety of same-day discharge radial percutaneous coronary intervention: A retrospective study. Am Heart J 2003;146: 699–704.

Disclosure: The authors report no conflicts of interest regarding the content herein.