1. The Radial Approach for CTO PCI Utility in the Retrograde and the Antegrade Approaches Shigeru Saito, MD, FACC, FSCAI, FJCC Shonan Kamakura General Hospital

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

3. PCI for a CTO still remains the greatest challenge to the interventional cardiologist
Increased procedural complexity and complications
Low procedural success rate
The most important point during PCI for CTO lesions is:
To perform PCI successfully without causing the patients to have a worse clinical conditions than before.

4. Trans-radial intervention (TRI)
Sometimes TRI with retrograde approach can make possible what seems to be impossible to treat by PCI.

5. The Case in which femoral access is limited
Old CTO
CRF on hemodialysis
Leriche syndrome
Poor LV function (EF 38%)
Functional Severe Mitral Regurgitation
Refused surgical treatment by the cardiac surgeons
Failed at the previous hospital

6. A 71-year-old man Chief complaint: Chest pain on effort History:
December of 2009: Chest pain
#2 99%, #3 total, #12 75%
PCI for #12 75% (Vision 3.0x12)
August of 2010: Chest pain on effort
PCI via the rt. radial artery for a #3 CTO (failed)
→ referred to our hospital
Risk factors: HT, Former smoker (1P/day for 21 years)
Past history:
1995～　Hemodialysis for CRF (CGN)

7. RCA

9. Collateral from the LAD RCA
Occluded lesion
Occluded lesion
Collateral from the LAD
RCA

10. Abdominal aorta occlusion
Occluded abdominal aorta

11. Shunt for hemodialysis
6F SAL for RCA
6F EBU for LCA
Our strategy was a bi-directional approach, so we needed 2 vascular access sites. We selected the Rt. radial and brachial arteries and used two 6F guiding catheters.
Occluded abd aorta

12. Angio RCA RCA ostial 90% mid Total
It seems that the antegrade approach was quite difficult, so initially we started with the retrograde approach from the LAD.

13. Angio LCA Retrograde Via the Rt. radial 6F EBU 3.5
A 6F 3.5 EBU via the Rt. radial artery was inserted into the LCA.

14. Selection of the Septal Channel
After several attempts, finally this septal channel was crossed with a Fielder FC guidewire with a Corsair.

15. Retrograde
Corsair
+ Fielder FC

16. Retrograde
Corsair
+ Fielder FC

17. Retrograde
Corsair
+ Fielder FC

18. Retrograde Corsair + Fielder FC
We changed the micro-catheter from a Corsair to a FINECROSS, which could be advanced forward.

19. Crossed into the Aorta cusp
Retrograde
FINECROSS
+ULTIMATE bros 3 ↓
+ Wizard 3
Crossed into the Aorta cusp
Finally a 3.0 Wizard successfully crossed into the Aortic cusp.

20. Retrograde
FINECROSS
+ULTIMATE bros 3 ↓
+ Wizard 3
Crossed into the Aorta cusp

21. Antegrade Via the Rt. brachial 6F SAL 1.0SH FINECROSS + Runthrough HC↓
Not cross #2
An Angtgrade Runthrough HC did not cross the mid RCA.

22. We repeated a dilatation at the occlusion site using a Tazuna 1.25
Antegrade
Anchoring at #1
by a Tazuna OTW
3.0mm
Anchoring
Retrograde
We repeated a dilatation at the occlusion site using a Tazuna 1.25
Under balloon anchoring at #1, we repeated a dilatation at the occlusion site of the distal RCA using a Tazuna 1.25

23. Anchoring

24. Anchoring

25. Anchoring

26. Antegrade Anchoring at #1 by a Tazuna OTW 3.0mm + X-treme ↓
Conquest Pro
Wizard 3
Crossed into #4PL
Anchoring
Wizard 3
An antegrade Wizard 3 wire successfully crossed into #4PL

27. Antegrade Tazuna 1.25 Retrograde Anchoring at #3 by a Tazuna OTW 3.0mm
Under retrograde anchoring at #3, we repeated a dilatation from the mid to distal RCA using an antegrade Tazuna 1.25 and Tazuna 2.5x15
Anchoring

28. Antegrade Tazuna 1.25 Retrograde Anchoring at #3 by a Tazuna OTW 3.0mm

29. Antegrade Tazuna 1.25 Retrograde Anchoring at #3 by a Tazuna OTW 3.0mm

30. Antegrade Tazuna 2.5x15 Retrograde Anchoring at #3 by a Tazuna OTW
3.0mm
Anchoring

31. Antegrade Tazuna 2.5x15 Retrograde Anchoring at #3 by a Tazuna OTW
3.0mm
Anchoring

32. Antegrade Tazuna 2.5x15 Retrograde Anchoring at #3 by a Tazuna OTW
3.0mm
Anchoring

34. Antegrade mother-child technique of 4-in-6 Endeavor 3.0x30
(4.5F ASAHI CoKatte)
Endeavor 3.0x30
We deployed an Endeavor 3.0x30 to the occlusion site using a mother-child technique of 4-in-6.

35. A total of 5 stents were placed from the distal to proximal RCA.

43. Cypher 3.5x13
Endeavor 3.0x18
Endeavor 3.0x30
Endeavor 3.0x30
Endeavor 3.0x24

44. Final angiogram

45. Final angiogram Procedure time 175min Fluoro time 72.8min
Contrast media
300ml

46. Because of a severe calcified lesion, catheter procedure was difficult, but the CTO lesion was ultimately opened.
This case was challenging in that no mechanical devices for hemodynamic support were available to use because of bifemoral occlusions and even only one complication could have become very serious and potentially fatal.
We performed a PCI for the CTO with a bidirectional approach via the ipsilateral radial and brachial arteries due to necessity.

47. Various Procedure Techniques for CTO Angioplasty
Double guidewire technique
Side branch technique
Anchoring balloon technique
Use of Tornus device
Mother-and-Child catheter technique
Retrograde (Bi-directional) approach
IVUS-guided technique

48. Limitation of TRI for CTO
Limited size of guiding catheter (Maximum 7F )
Decreased backup support　
→Calcified lesion & Long lesion
Limited device & technical selection
→IVUS-guided technique not available
(Side-branch IVUS & Co-axial IVUS)
Time delay if intra-aortic balloon pump or temporary pacing is needed

49. Recommendation in TRI for CTO
Based on the understanding of the limitation of TRI and various kinds of techniques used in CTO angioplasty, we can perform TRI in various types of CTO lesions such as:
CTO with microchannels
CTO with clear distal anatomy
CTO without calcification or tortuosity
The case in which femoral access is limited

50. Kamakura experience
Consecutive review of 381 patients (417 CTO lesions)
First-time PCI attempt for a CTO via radial or femoral access (January August 2011)
The patients on hemodialysis were excluded.
CTO: coronary obstruction with a TIMI flow grade 0 for  3 months.
Indications for PCI for the CTO Viable myocardium by echocardiography and ventriculography.
Technical success: TIMI flow grade 3 and a < 50% final residual stenosis on all views.

51. Results: Baseline clinical characteristics
TRI group
TFI group
p Value
Number of patients
175
206
Age, yr
68 ± 10
66 ± 10
0.10
Male sex, n (%)
143 (81.7)
167 (81.1
0.87
Height, cm
162 ± 8
165 ± 8
0.017
BMI, kg/m2
24.1 ± 3.5
24.8 ± 3.6
0.19
Current smoking, n (%)
34 (19.4)
45 (21.8)
0.74
Hypertension, n (%)
111 (63.4)
131 (63.6)
0.84
Hyperchoresterolemia, n (%)
117 (66.9)
139 (67.5)
Diabetes mellitus, n (%)
65 (37.1)
84 (40.8)
0.69
LVEF, %
58 ± 13
57 ± 12
0.21
Prior MI in other area, n (%)
29 (16.6)
42 (20.4)
0.34
Multi-vessel, n (%)
88 (50.3)
113 (54.9)
0.37
Prior CABG, n (%)
4 (2.3)
17 (8.3)
0.011

52. Target vessel
P<0.001
Total
Instent occlusion

53. Sheath size (Antegrade) Bidirectional approach

54. Procedure complications
TRI (n=194)
TFI (n=223)
Bleeding requiring transfusion
0 (0%)
6 (2.7%)
4:Access site bleeding
2:Retroperitoneal hematoma
Pseudoaneurysm
2 (0.9%)
Contrast-induced nephropathy
3 (1.3%)
Cardiac tamponade
(all wire perforation)
3 (1.5%)
2:Pericardiocentesis
1:Surgical + CABG
1:Pericardiocentesis
1:Surgical procedure
Myocardial infarction
1 (0.4%)
1: Coronary dissection
with retrograde GC
Cerebral infarction
Need of IABP
2 (1.0%)
Death
1:Access site bleeding

55. With an appropriate patient/lesion selection, TRI for CTO lesions may result in more favorable short-term outcomes with acceptably high procedural success and lower complication rates.
At least 35% of the total CTO lesions can be successfully recanalized by TRI. Therefore, given the correct circumstances, TRI should be considered as an appropriate first-line intervention for CTO lesions.