1. TRANSRADIAL ROTABLATION OF A CASE OF CTO Dr. Christian Pristipino Coronary Intervention Unit San Filippo Neri Hospital Rome, Italy

2. 76 years old man Severe, treated, hypertension Type IIb Dyslipidemia Severe Parkinson disease (bradikinesia and tremor) Sick sinus syndrome with previous pacemaker implant Anterior myocardial infarction 6 months prior the procedure Antero-lateral ischemia and anterior myocardial viability at stress/reperfusion thallium scintigraphy Clinical Features

3. Left transradial approach with 6 Fr radial sheath (Cordis) 6 Fr. XB 3.5 guiding catheter. Wiring D1 (BMW 0,014”, Guidant) followed by direct stenting (Medtronic AVE S7 3 x 15 mm @ 12 atm) Crossing LAD occlusion with Guidant Cross-it 200 guidewire but failure to cross the lesion with balloon 1,5 mm (Aqua, Cordis) Replacement of 6 Fr. transradial sheath with 7 Fr. femoral sheath positioned in left radial artery Deep seating with 7 Fr. XB 3.5 guiding catheter. Crossing LAD occlusion with extrabackup guidewire, rotablation with 1,25 mm. bur (Boston Scientific), final stenting (Cordis Cypher 3 x 33 mm @ 12 atm) Total procedure time: 60 min.; fluo time: 11 min; X ray exposition: 232 cGy Technical Details

4. 2.Wiring and direct D1 stenting 3. Final result on D1 Occluded LAD D1 D1 Procedure

5. 4. Wiring and Rotablating LAD 5. Stenting LAD 6. Final result LAD Procedure

6. Initial picture Occluded LAD D1 1 year result LAD D1 Patient remained asymptomatic at 1 year LVEF improved from 39% to 48%, NYHA class improved from 2 to 1 Follow-up at 1 year

7. Desocclusion of calcified CTOs is a complex procedure requiring rotablation in selected cases Rotablation can be performed by transradial approach, even for CTOs, but require an even stronger backup than for less complex lesions A major backup can be obtained also by transradial approach with Guiding catheters >= 7 Fr. deeply seated in coronary ostia Transradial rotablation performed by experienced operators in complex cases can be well tolerated even when patient condition are critical, such as in parkinson disease with severe tremor. Final remarks