Ask the Transradial Expert

“In the past few weeks, I have read a lot about complex procedures and that they can’t be done via the transradial approach, due to its complexity. Orlando, our physicians state that the necessary tools and medical devices can’t be used through the transradial approach. What is your experience with transradial and complex procedures?”

All physicians are comfortable with their default femoral approach for complex procedures. I have assisted in many complex procedures from the femoral and transradial approach. Dr. Zaheed Tai, Winter Haven Hospital, Winter Haven, Florida, and many others use the transradial approach as their default and can perform all complex procedures via the transradial approach. 

I will share with you one of many complex procedures that were performed via the transradial approach. The following case, performed by Dr. Zaheed Tai, involves measurement of fractional flow reserve (FFR), and use of intravascular ultrasound (IVUS) and the Rotablator (Boston Scientific).

Case report

A 65-year-old male had a positive stress test and underwent diagnostic catheterization. The right coronary artery (RCA) demonstrated a stenosis of 40 to 50% with calcification and a distal 95 to 99% of the posterior descending artery (PDA) (Figure 1). Left main and left anterior descending coronary artery (LAD) were angiographically unremarkable, with mild irregularities. The left circumflex also demonstrated no significant stenosis and the second obtuse marginal (OM 2) had a 50% stenosis. 

The diagnostic 5 French sheath was upsized to a 6 French Glidesheath (Terumo). A Hockey stick guide catheter was utilized to engage the right coronary system. Bivalirudin (Angiomax, The Medicines Company) was our choice of antiplatelet therapy. We initially performed FFR (Volcano Corporation) for the proximal portion of the RCA and the FFR was negative; therefore, at this point, the initial plan was to just stent the distal lesion. However, in an attempt to deliver a 2.5 x 12 mm Promus drug-eluting stent (Boston Scientific) into the distal lesion, the guide backed out, and could not get though the calcification of the proximal portion. We elected to use IVUS to see the calcium (Figure 2). There were some difficulties passing the IVUS catheter. Minimum lumen diameter (MLD) was 3.19 with a percent diameter stenosis of 60% by IVUS, based on the reference vessel. Given the calcific nature of the disease and the IVUS finding, we elected to go ahead and proceed with revascularization of the proximal/mid RCA with the Rotablator. The Runthrough wire (Terumo) was removed and a Rotawire (Boston Scientific) was advanced. A 1.5mm burr was utilized (Figure 3) and four passes were made, then a polishing run to finish. After the debulking, we easily advanced a .014” 190 cm Runthrough wire. We left the Rotawire as a buddy wire to pass the 2.5 x 12 mm Promus stent distally and deployed it at 8 atm. We removed the Rotawire before deployment of the stent. We then predilated the proximal RCA with a 3.0 x 15 mm Apex balloon (Boston Scientific). The mid to proximal area was stented with a 3.5 x 28 mm and 3.5 x 12 mm Promus, and post dilated with a 3.75 x 20 mm Quantum Maverick (Boston Scientific) at 16 atm. Post IVUS demonstrated stents apposed to the vessel wall.

On completion, the patient had TIMI-3 flow in the RCA without dissection, perforation or embolization, and excellent angiographic result. The patient tolerated the procedure well and a pressure dressing was applied over the radial artery. 

In conclusion, it is safe and feasible to perform complex transradial procedures. There are a few exceptions, such as cases that require a 7 or 8 French guide, although this can be done in select patients. Debulking, either with rotational or laser atherectomy, or use of a GuideLiner catheter (Vascular Solutions) may facilitate stent delivery if guide support is not adequate.

Always keep it simple and put the patient first. There are many opportunities for didactic training. Dr. Zaheed Tai offers an advanced transradial course (contact him at zaheedtai@gmail.com) and AIM–Radial is offering an advanced master class (September 13-15, in Québec City, Canada, www.aimradial.org).

Orlando Marrero can be contacted at orlm8597@yahoo.com.

Disclosure: Orlando Marrero reports that he is an employee of IDEV Technologies.