1. Transradial Intervention: Complex Case Review Yes, They Can Be Done!
ShonanKamakura General Hospital
湘南鎌倉総合病院
Sapporo Higashi Tokushukai Hospital
札幌東徳洲会病院
Shigeru Saito, MD, FACC, FSCAI, FJCC
齋藤　滋

2. I/we have no real or apparent conflicts of interest to report.
Shigeru Saito, MD
I/we have no real or apparent conflicts of interest to report.

3. 71 years old Japanese Man Chief complaints: Past illness:
Chest pain and dyspnea on effort
Claudication on 100 meters’ Walking
CCS class 2, NYHA class 2
Past illness:
On Chronic Hemodialysis (since 15 Y ago)
Gastrectomy for tumor (10 Y ago)
Stenting for Rt-EIA (5 Y ago)
Complete Occlusion of Abdominal Aorta (Leriche’s Syndrome since 2 Y ago)

4. 71 years old Japanese Man Coronary Risk Factors:
Ex-smoking (1 pack a day for > 20 years)
CKD (on hemodialysis)
Positive Family History of myocardial infarction (Father and brother)
Hypertension

5. 71 years old Japanese Man Past CAG and PCI: 2 Y ago (2008)
Mid and Distal RCA 90%
OM 90%
Total Occlusion of Abdominal Aorta
1 Y ago (October 2009)
Mid RCA 99% with total occlusion of distal RCA
Stent implantation for OM 90% (Vision 3.0x12mm)
2 W ago (August 2010)
Failed PCI for total occlusion of RCA

6. Total occlusion of Aorta

7. Coronary Angiograms (Right brachial approach)

8. Coronary Angiograms (Right brachial approach)

9. CTO on distal RCA Collateral from the LAD RCA Occluded lesion

10. Is TRI feasible for this case?
Problems:
How we can make access to coronary arteries?
Total occlusion of abdominal aorta
Hemodialysis from left arm
Multiple comorbidity
High risk for CABG (heavily calcified aorta and coronary arteries)

11. Yes, we can do TRI! Our approach:
6 Fr TRI and 6 Fr TBI from the right arm!
6F JR for RCA
6F EBU for LCA

12. PCI using Bi-Directional Approach for CTO on RCA
Via the Rt. brachial
RCA ostial 90%
RCA mid Total

13. PCI using Bi-Directional Approach for CTO on RCA
Via the Rt. Radial
6F 3.5 EBU

14. Selection of a Septal Channel

15. Selection of a Septal Channel
Corsair (ASAHI) + Fielder FC guidewire (ASAHI)

16. Selection of a Septal Channel
Fielder FC passed a septal channel easily

17. Selection of a Septal Channel
However, Corsair could not advance due to too much tortuousity.

18. Selection of a Septal Channel
Next attempt for other septal channels

19. Selection of a Septal Channel
Next attempt for other septal channels

20. Selection of a Septal Channel
This septal channel was not so tortuous.
However, Corsair could not cross the corner of the channel.

21. Selection of a Septal Channel
Because Corsair could not advance any more, it was exchanged to Finecross (TERUMO) microcatheter.
Tip injection through Finecross reveled CTO lesion.

22. Selection of a Septal Channel
Supported by Finecross, Fielder FC guidewire could advance retrogradely.

23. Selection of a Septal Channel
Finally, the Fielder FC passed through into the Aorta.

24. Selection of a Septal Channel
Poor guiding catheter engagement into RCA due to the ostial 90% narrowing.

25. Selection of a Septal Channel
Wizard guidewire was introduced from the antegrade route.

26. Selection of a Septal Channel
Anchoring for the retrograde wire with a 3.5 mm balloon inflation was done. However, an even 1.25 mm balloon could not advance anymore from the retrograde route.

27. Selection of a Septal Channel
A 3.5 mm balloon was inflated in the distal RCA with the assistance by the antegrade anchoring balloon.

28. Selection of a Septal Channel
By applying the anchoring for the antegrade guidewire, an 1.25mm balloon on the antegrade guidewire could be advanced to the distal RCA.

29. Selection of a Septal Channel
By applying the anchoring for the antegrade guidewire, an 1.25mm balloon on the antegrade guidewire could be advanced to the distal RCA further.

30. Selection of a Septal Channel
A 4 Fr child catheter (CoKatte, ASAHI) was deeply inserted into RCA, and an Endeavor Sprint DES (3.0 x 23mm) was successfully deployed.

31. Selection of a Septal Channel
A 4 Fr child catheter (CoKatte, ASAHI) was deeply inserted into RCA, and an Endeavor Sprint DES (3.0 x 23mm) was successfully deployed.

32. Selection of a Septal Channel
Next Endeavor Sprint DES was deployed through a 4 Fr child catheter.

33. Selection of a Septal Channel
Final RCA angiogram after 3 Endeavor Sprint and 1 CYPHER DESs implantation.

34. Selection of a Septal Channel
Final RCA angiogram after 3 Endeavor Sprint and 1 CYPHER DESs implantation.

35. Selection of a Septal Channel
Endeavor 3.0x30
Endeavor 3.0x18
Endeavor 3.0x24
Cypher 3.5x13
Final RCA angiogram after 3 Endeavor Sprint and 1 CYPHER DESs implantation.

36. Summary of PCI Procedure
6 Fr TRI with 6 Fr TBI from the right arm.
Procedure summary
Total time: 175 minutes
Total fluoro time: 72.8 minutes
Total dye volume: 300 ml
Total radiation: 4,083 mGy

37. Summary of the Case
We experienced an old CTO case with Leriche syndrome and chronic renal failure on chronic hemodialysis. The vascular access was limited.
Our strategy was a bi-directional procedure and we chose a right ipsilateral approach through the radial and brachial arteries for the vascular access.
Because of a severe calcified lesion, we had a difficult time during the catheter procedure, but we ultimately opened the CTO lesion.

38. Key Techniques of the Case
Ipsilateral arterial access through the radial and brachial arteries using two 6 Fr guiding catheters.
Bi-directional approach through a septal channel among several candidate channels.
Anchoring balloon technique from both antegrade and retrograde sides.
Use of a 4 Fr child catheter (CoKatte, ASAHI).
Use of both Corsair (ASAHI) and Finecross (TERUMO) microcatheters.