Bilateral Distal Radial Artery Access for Percutaneous Coronary Intervention for Chronic Totally Occluded Left Anterior Descending Artery
Adel El Hosieny*, MBBCh, MRCP, MSc, George Hunter, MRCP and Chetan Varma, MBBS, FRCP, MD
Birmingham City Hospital, Birmingham, United Kingdom
Submission: August 19, 2019; Published: October 14, 2019
*Corresponding author: Adel El Hosieny, MBBCh, MRCP, MSc, Birmingham City Hospital, Dudley Road, B18 7QH Birmingham, United Kingdom
How to cite this article:Adel El Hosieny, George Hunter and Chetan Varma. Bilateral Distal Radial Percutaneous Coronary Interventional for Chronic Totally
Occluded Left Anterior Descending Artery. J Cardiol & Cardiovasc Ther. 2019; 15(2): 555907.
Despite advances in new devices, equipment and expertise, percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remains difficult and technically challenging. Arterial access is an important consideration when deciding on how to treat the lesion at hand as this has implications on catheter sizing and support as well as facilitating contralateral coronary angiography. Radial artery access has been increasingly adopted by operators with similar success rates and safety to femoral artery access. Distal radial artery access is a relatively recent concept and provides more comfort for the patient as well as for the operator. We present here a challenging case of left anterior descending artery CTO in a 63-year-old male diabetic, in which the successful PCI was achieved via bilateral distal radial access.
Chronic total occlusion percutaneous coronary intervention still represents the most challenging settings for percutaneous coronary intervention, with recent optimal procedural success obtained thanks to advance in tools and techniques. In recent years, successful percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) of the coronary arteries has been achieved through improvement of guidewires  and supportive devices [2,3]. In addition, successful CTO re-canalisation has been demonstrated to relieve ischaemic symptoms, improve left ventricular (LV) function and improve long-term survival. Despite these advances, PCI for CTO remains technically challenging. Scoring algorithms have been created and validated to assist the operator plan the approach based on lesion complexity.
Arterial access is an important factor for consideration as this has implications on catheter size and support. The transradial approach (TRA) for percutaneous coronary intervention (PCI) has gained widespread acceptance during the past decades. The radial artery is easily compressible, not surrounded by major venous and nervous structures, and an adequate collateral arterial network is present. As a result, the risk of vascular complications after TRA is negligible . Multiple randomized trials demonstrated that a transfemoral approach (TFA) is associated with a significantly
higher risk of bleeding, pseudoaneurysm and arteriovenous fistula formation, cardiac events, and mortality after PCI [4,5]. This has been demonstrated in PCI for stable coronary artery disease and acute coronary syndromes both with and without persistent ST-segment elevation. Moreover, vascular complication rates after TFA are only modestly reduced with the use of vascular closure devices .
However, PCI of chronic total occlusion (CTO) is mostly performed with (bilateral) femoral access to facilitate the use of large bore guiding catheters for optimal support and freedom in technique selection. Nevertheless, previous reports suggest that TRA CTO PCI is feasible [7-12].
Distal radial artery access [13,14] is a novel method that has yet to be widely used but from anecdotal data it appears to be more comfortable for patients and operators and facilitates successful completion of complex PCI procedures. We present herein a case of bilateral distal radial PCI with antegrade approach for CTO of the left anterior descending artery (LAD).
A 63-year old African male, a type 2 diabetic on metformin with hypercholesterolaemia and hypertension presented with symptoms suggestive of a late presentation myocardial infarction
His index event had likely occurred 4 months previously in
Gambia, for which he had not sought medical attention. He had
presented to his GP, now asymptomatic and had been found to have
an abnormal ECG with persisting anterior ST elevation and deep
T wave inversion. He had an echocardiogram which demonstrated
a left ventricular ejection fraction of 40% with a hypokinetic
anterior wall and apex with preserved LV wall thickness in
the LAD territories but a likely apical LV thrombus. His bloods
demonstrated a normal haemoglobin, an estimated glomerular
filtration rate of 52 ml/min. 1.7 m2 and normal troponins. He
underwent coronary angiography via a distal right radial artery
approach using a 6 French Terumo Glide-sheath Slender. A 5.2
French (F) diagnostic Super Torque Plus JR4 catheter (Cordis) and
6 F 3.5 MACH 1 Guide Catheter CLS Curve (Boston Scientific, MA)
were used for the diagnostic images. These demonstrated single
vessel coronary artery disease (CAD) with CTO with a ambiguous
proximal cap in the mid LAD which started at a trifurcation point
involving the second diagonal and septal branches (Figure 1).
There was significant backfilling of the distal LAD from an
extensive collateral system from the right coronary artery (RCA)
A second point of arterial access was obtained via the left
distal radial artery with a second 6F Terumo Glide-sheath Slender
and a 6 F ADROIT JR4 (Cordis) guide catheter was used to intubate
the RCA to provide dual acquisition and revealed a J- CTO score
3- lesion at mid-LAD (Figure 3).
The 6Fr 3.5 CLS guide catheter was used to intubate the
left main stem (LMS) via the distal right radial artery sheath.
Anterograde wire escalation1 was then attempted via the 6F
CLS guide catheter initially using a Pilot 50 (Abbott) guide-wire
with Corsair (Asahi) microcatheter support passed anterogradely
down to the lesion and was then exchanged for a Pilot 200 guidewire
via the Corsair, but its tip was flipping either to first septal
or second diagonal branch. Further escalation with exchange to
a Gaia 3 (Asahi) and Miracle Bros (MB) 4.5 (Asahi) guide-wire
was performed with the Miracle Bros 4.5 guide-wire partially
penetrating the proximal cap and moving into the body of the CTO
lesion (Figure 4).
The Corsair was then advanced over the MB wire and been
stuck within the lesion. The MB wire was then exchanged back to
the Pilot 200 guide-wire which successfully crossed through the body of the CTO and the distal cap into the distal vessel (Figure
5 & 6).
Unfortunately, the Corsair was not able to be passed through
the proximal cap of the CTO therefore this was removed. A 6Fr
Guidezilla II (Boston Scientific) was then passed over the Pilot
200 guide-wire to the proximal LAD and the vessel was predilated
along the length of the CTO with a 1x10mm Sapphire II Pro (Orbus
Neich) balloon to high pressures (Figure 7).
A larger 2x9mm Sprinter Legend NC (Medtronic) balloon
was then passed and inflated to high pressures along the length
of the CTO. Further pre-dilatation was then performed using a
2.5x30mm Sprinter Legend NC (Medtronic) balloon along the
length of the CTO to high pressures. An area of significant distal
LAD became more apparent on anterograde angiography and this
was treated using a 2.5x10mm Sequent Please Neo drug-eluting
balloon (B Braun) and a 2.25x30mm Sequent Please Neo drugeluting
balloon (B Braun) with 50 second inflations. The mid
LAD was then treated using overlapping 3x23mm and 2.5x33mm
Xience Sierra evorlimus-eluting stents (Abbott) to high pressure.
The stent overlap was post-dilated using the 3x23mm Xience
Sierra stent balloon to high pressure. Anterograde coronary
angiography post PCI demonstrated an excellent angiographic
result (Figure 8).
Haemostasis was achieved using bilateral Tracelet
compression devices (Medtronic) to the left and right distal radial
puncture sites (Figure 9).
The radial artery (RA) access has been used to perform
chronic total occlusion percutaneous coronary intervention (CTO
PCI) with similar success and safety to CTO PCI using the common
femoral artery (CFA) access. Distal radial access in the anatomical
snuffbox is a challenging new access with much comfort for the
patient and operator, reliable for complex PCI after adequate
training. There are only scarce publications [13,14] reporting
the use of distal radial artery approach in performing PCI to CTO
lesions. Herewith, we report a case of successful PCI to LAD with
JCTO score 3 using bilateral distal radial artery approach.
Michael Megaly et al.  in their meta-analysis of 9
observational studies included 10,590 patients underwent CTO
PCI, reported that CTO lesions attempted using radial artery had
lower Japan-CTO score (2.3±1.2 versus 2.5±1.3; P<0.001). Use of
RA was associated with similar technical success (78.7% versus
78.5%; odds ratio, 1.11; 95% CI, 0.94-1.31; P=0.24; I =23%),
lower risk of access-site complications (0.73% versus 1.79%;
odds ratio, 0.34; 95% CI, 0.22-0.51; P<0.001; I =0%) and major
bleeding (0.18% versus 0.9%; odds ratio, 0.22; 95% CI, 0.10-0.45;
P<0.001; I =0%), and similar risk of in-hospital adverse events
and in-hospital mortality (odds ratio, 0.36; 95% CI, 0.12-1.07;
P=0.07; I =0%) as compared to femoral access. Results were
similar when analyzing radial-only versus any femoral access and
when excluding the largest study
When the radial approach for CTO intervention is attempted,
availability of sufficient guiding support becomes a major concern
since it is generally not feasible to use a guiding catheter larger
than 7 Fr. Accordingly, transfemoral coronary intervention is
often preferred over transradial PCI for CTO because 7 or 8 Fr
guiding catheters may be used to obtain greater back-up support,
as compared to the 6 Fr guiding catheters frequently used in the
transradial approach. However, because catheter materials have
improved a great deal, and because special curvature is available
to increase support, we were able to achieve sufficient guiding
support with a 6 F MACH 1 Guide Catheter CLS Curve (Boston
Scientific, MA) as well as using a child catheter (Guidezilla II Guide
Extension Catheter-Boston Scientific) in this case.
Bilateral distal radial access is a viable option for CTO PCI.
It is safe and effective and adding more convenience to both the
patient and operator especially in complex PCI when it takes
longer time than simple PCI.