A Q&A for Cath Labs with Physicians Performing Radial Access

I see your hospital does a lot of training courses focusing on laser atherectomy. Do your physicians utilize transradial for chronic total occlusion procedures? Yes, we do coronary chronic total occlusions (CTOs) with the Spectranetics Excimer Laser (Colorado Springs, CO) via the transradial approach. We use many different tools for CTOs, but we always go transradial first. Figure 1 demonstrates bilateral injections via the right and left radial, with a 5 French (Fr) JL4 and a 6 Fr hockey stick to engage the right coronary artery (RCA) via the right radial. Our decision to engage both systems was made to facilitate visualization of the RCA collateral from the left in order to cross the CTO. Figure 2 demonstrates the visualization of the collateral from the left. In Figure 3, we are using a 1.5 by 8 over-the-wire Apex balloon (Boston Scientific Corp., Natick, MA) and a Miracle Bros 6 180cm wire (Abbott Vascular, Redwood City, CA) to cross the lesion. Initially, the wire did not pass into the distal vessel, but we pulled back and rewired, and were able to cross distally into the posterior descending artery (PDA), which was confirmed via dual injection (Figure 4A). The 1.5 by 8 mm Apex was unable to cross, so we floated the balloon out (Figure 4B). We then used the 0.9 mm Excimer Laser. Laser atherectomy was performed initially at a setting of 45/25, then 60/40. After 2 passes, we were able to easily pass a 2.5 by 15 mm Apex balloon. After balloon inflation, it was noted that the large posterolateral ventricular branch (PLVB) was occluded, and we therefore proceeded with a 1.5 by 8 Apex and a Pilot 150 wire (Abbott) to reestablish flow. After crossing, we removed the wire and confirmed placement via injection through the balloon. We replaced the Pilot 150 with a Runthrough wire (Terumo Medical Corp., Somerset, NJ), then floated the balloon out. After a 4 atm inflation, TIMI-3 flow into the PLVB was restored. We advanced a 2.75 by 38 mm Taxus paclitaxel-eluting stent (Boston Scientific) into the distal RCA and overlapped it proximally with 3.0 by 20 mm Taxus stent. We then post dilated with a 3.0 by 15 NC balloon (Abbott). Figure 6 demonstrates TIMI-3 flow into the PLV and PDA, without any embolization. Email your transradial question to Orlando at: orlando.marrero@winterhavenhospital.org

Winter Haven Hospital’s next transradial courses are October 13th and October 27th. For information on training, contact your local Terumo representative or Orlando Marrero, at Orlando.Marrero@WinterHavenHospital.org

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