Retrograde recanalization of radial artery occlusion in patients with need for repeated wrist procedure

1. Retrograde Recanalization of Radial
Artery Occlusion in Patients with Need
for Repeated Wrist Procedure
Author (s):
Igor Spiroski MD, Sasko Kedev MD PhD FESC
Laboratory for Interventional Cardiology, University Clinic of
Cardiology, Faculty of Medicine, St. Cyril and Methodius, University of
Skopje, Republic of Macedonia

2. Disclosure: Igor Spiroski, MD
• Dr. Igor Spiroski has no relevant financial
interests to disclose
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3. background
• Wrist approach (Trans Radial or Trans Ulnar) is
getting the place of a standard access site in many
PCI centers around the world.
• Some patients need several coronary procedures
due to treatment of only the culprit lesion in Primary
PCI, multi vessel disease or complication as in stent
thrombosis and restenosis.
• Some of them additionally will have another
procedure as CAROTID STENTING or CABG where
the operator needs fresh radial artery for grafting usually the left radial artery
• Radial artery occlusion (RAO) occurs in 2-8% of all
cases and is one of the biggest limitations for
additional or repeated wrist procedure in the future.
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4. purpose
• To present a technique of retrograde
recanalization of radial artery occlusion with and
without balloon dilatation in patients with need
for repeated wrist procedure.
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5. Material and methods
• In our transradial registry during the period of March
2011 – June 2013, we have documented 10,487
transradial procedures. In 317 patients we have
found radial artery occlusion (RAO).
• In 281 ipsilateral transulnar approach (TUA) was
performed.
• We selected the other 36 consecutive patients for
retrograde recanalization of RAO.
• Patients with documented anatomic variations of
radial artery from previous trans radial
procedure, such as tortuosity of the vessel and high
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take off, were excluded from this group
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6. Material and methods
• We performed retrograde recanalization of RAO
in 14 patients with balloon dilatation and in 17
patients (from our early practice) without balloon
dilatation.
• In 5 patients (14%) we didn’t manage to cross
the occluded segment with the wire.
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7. Material and methods
• Primary outcome was successfully completed
procedure.
• Secondary outcomes were procedural
complications: forearm pain, access site
bleeding events, clinically evident hand
ischemia.
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8. Baseline characteristics of patients with retrograde recanalization of
radial artery occlusion with and without balloon dilatation
Age (years)
Male
BMI (kg/m2)
CAD risk factor
Hypertension
Diabetes mellitus
Dyslipidemia
Smoking
Prior STEMI with PCI
Prior CABG
PAD
Prior Stroke
Prior CAS
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Without balloon
dilatation
N=17
59.41
7 (41.2 %)
26.3
With balloon dilatation
N=14
9
5
5
6
6
1
2
1
0
8
4
5
5
4
2
2
2
0
8
55.93
7 (50%)
27.1
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9. Baseline characteristics of patients with retrograde recanalization
of radial artery occlusion with and without balloon dilatationtechnical aspects
Without balloon
dilatation
N=17
No of previous TR
procedures
1
2
Time of previous radial
procedure
<1months
1-6 months
6-12 months
>12 months
Previous used sheet
5F
6F
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With balloon dilatation
N=14
8
6
12
5
1
5
7
4
1
7
3
2
2
15
1
13
9
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10. palpations
In all patients there was the absence or
a shallow pulse signal over the right
radial artery previous puncture site
In all patients there was a shallow
pulse signal distally of a previous
puncture site over the styloid
processus
This signal was coming from superficial
palmar arch of the ulnar artery or
interosseal artery collaterals
10
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11. Radial angiography
After the successful puncture of the radial artery we performed
manual radial artery angiography throughout the small 20-G plastic
cannula from the entry needle RADIOFOCUS INTRODUCER II
TERUMO set
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12. Radial artery occlusion
Subocclusion
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Short occlusion <3cm
12
Occlusion
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13. Technique of retrograde opening of RAO without
balloon dilatation
Hydrophyllic wire
Pilot 200
Radial angiography
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14. Introducing the 5fr sheet , diagnostic guidewire
0,035”, Coronary angio
sheetless guiding catheter 7.5 F PBU
Short occlusion to
RA
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Bifurcational lession
to LAD
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15. Technique of retrograde opening of RAO without
balloon dilatation
Xience SBA
3,0/18mm
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Final result
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16. Final RA angio
Dissection (-) ; Pain (-)
Fluoroscopic time 6.6
Contrast 150ml
16
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17. Technique of retrograde opening of RAO with balloon
dilatation
Interosseal artery ( collaterals
)
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Guide wire ?
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18. RADIOFOCUS INTRODUCER II
TERUMO - transradial kit
MINI GUIDE WIRE
Plastic (hydrophilic) 45cm
Terumo 0.025” HARD TIP
Radial angiography performed with
plastic cannula
DISSECTION
TRUE LUMEN
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19. Technique of retrograde opening of RAO with balloon
dilatation
MINI GUIDE WIRE
Plastic (hydrophilic) 45cm
Terumo 0.025” HARD TIP
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Radial angiography
(5 Fr. introducer)
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20. Technique of retrograde opening of RAO with balloon
dilatation
Post dilatation angiography
revealed preserved radial artery
with severe tortuosity
Balloon dilatation
3.0/30 mm x 6 atm.
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21. Technique of retrograde opening of RAO with balloon
dilatation
Crossing tortuosity with the
BMW 0,014” guide wire
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JR 5 Fr. diagnostic catheter
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22. Technique of retrograde opening of RAO with balloon
dilatation
RCA
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Lmain/LAD/LCx
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23. FINAL RESULT
Adequate flow without any
visible dissection of the radial
artery
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Ipsilateral ulnar artery
occlusion
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24. Procedural characteristics of patients with retrograde
recanalization of radial artery occlusion with and without balloon
dilatation
Without balloon
dilatation
N=17
Procedure
Coronary angiography
PCI
Type of Radial Artery
Occlusion
Subocclusion
Short occlusion
Occlusion
Sheet size
4F
5F
6F
7.5 F PBU sheetless
Wire
Terumo wire 0.025” 45cm
Hydrophillic wire 0.014”
BMW wire 0.014”
Balloon
Semi compliant balloon
Armada 14 OTW PTA
balloon
2.5/60mm
2.5/80mm
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With balloon dilatation
N=14
5
12
5
9
9
2
6
7
3
4
1
9
6
1
0
5
9
0
8
6
3
3
6
5
/
/
8
6
/
/
5
1
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25. Complications
Dissection of radial artery
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26. Complications
dissection of interosseal artery
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27. Complications
aterothrombotic embolisation
embolus
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28. Procedural complications, contrast and fluoroscopic time in patients with
retrograde recanalization of radial artery occlusion with and without
balloon dilatation
Without balloon
dilatation
N=17
With balloon dilatation
N=14
11
0
0
3
145.88
8.24
4
0
1
1
147.14
9.71
Procedural complications
Dissection of radial artery
Extravasation
Dissection of interosseal artery
Atherotrombotic embolisation
Contrast (ml)
Fluoroscopic time (min)
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29. results
• The primary outcome was achieved in 26 of 31
patients (83.9%).
• In patients where we performed balloon
dilatation, the primary outcome was achieved in
14 of 14 patients (100%).
• Forearm pain was present in 13 cases (41.9%)
• Minor access site bleeding occurred in 5
patients (16.1%) and there was no single case of
clinically evident hand ischemia.
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30. Primary and secondary outcome in patients with retrograde
recanalization of radial artery occlusion with and without balloon
dilatation
Total
N=31
Primary outcome
Successfully completed
procedure
Secondary outcome
Pain
Access site bleeding
complications
Haematoma grade 1
Haematoma grade 2
Haematoma grade 3
Haematoma grade 4
Haematoma grade 5
Clinically evident hand
ischaemia
Major vascular
complication
Radial artery occlusion at
30 days
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Without
balloon
dilatation
N=17
With
balloon
dilatation
N=14
Pearson’s P
value
26 (83.9%)
12 (70.6%)
14 (100%)
0.007*
13 (41.9%)
9 (52.9%)
4 (28.6%)
0.171
0
2
1
0
0
0
0
2
0
0
0
0
0
0
0
0
0
17 (54.8%)
11
6
0.224
5 (16.1%)
30
0.800
0
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31. conclusion
• Retrograde recanalization of the radial artery
occlusion is safe and feasible
• Balloon dilatation of radial artery occlusion is a
key factor for successful catheterization and/or
percutaneous coronary intervention
• Left TRA or TUA remain a viable option in
selected patient
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32. conclusion
Besides the high re-occlusion rate there is a
need in the “radial world” for development of a
technique for radial artery opening especially in
situations where not other wrist or femoral
access site is available such as ipsilateral ulnar
artery stenosis, harvesting of a left radial artery
for CABG procedure or use of fresh artery for
larger fr. devices
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