Bilateral Distal Transradial Access for Ostial Left Anterior Descending Chronic Total Occlusion Recanalization

J INVASIVE CARDIOL 2021;33(2):E138. doi:10.25270/jic/20.00079

Key words: chronic total occlusion, distal transradial access, percutaneous coronary intervention

Chronic total occlusion (CTO) represents the most challenging setting for percutaneous coronary intervention (PCI). Although transfemoral is still the most common access site, the transradial access (TRA) has been used with similar procedural success.

The adoption of distal transradial access (dTRA) as default approach for coronary angiography (CAG) and interventions was recently published. As a refinement of the conventional (proximal) TRA, this technique has many advantages in terms of patient and operator comfort, access-site bleeding, faster hemostasis, and risk of radial artery occlusion.

A 45-year-old man with hypertension, chest pain at minimal effort, and a high-risk treadmill test was referred by the assistant cardiologist to CAG, which showed ostial left anterior descending (LAD) CTO (Videos 1 and 2), with strong Rentrop 3 collaterals from the right coronary artery (RCA) (Video 3) and preserved rest left ventricular contraction (Video 4).

After consensual decision by the patient and the heart team, it was decided to perform ostial LAD-CTO-PCI. Two weeks after the baseline CAG, the procedure was done via bilateral dTRA, with two 6 Fr radial sheaths (Figure 1) for dual coronary injection (Video 5). By antegrade wire crossing and balloon predilations, the LAD was successfully recanalized, with a 3.5 x 22 mm drug-eluting stent carefully and optimally deployed at its ostial-proximal portion (Videos 6 and 7). A significant myocardial bridging (not observed at baseline CAG) was revealed at mid LAD (Video 8).

Adequate hemostasis was obtained after 2 hours of continuous handmade gauze bandage, without any bleeding. Bilateral proximal and distal radial pulses were easily palpable after hemostasis and at hospital discharge the next morning, without any minor or major access-site or clinical complications.

Bilateral dTRA for complex CTO-PCI by experienced transradial operators is feasible and safe, with patient and operator comfort and significant reduction of access-site complications.

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From the Department of Interventional Cardiology, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted February 28, 2020.

Address for correspondence: Marcos Danillo Peixoto Oliveira, MD, Department of Interventional Cardiology, Hospital São Paulo, Napoleão de Barros, nº 715 -Vila Clementino, Sao Paulo-SP, Brazil, 04024-002. Email: mdmarcosdanillo@gmail.com