Feasibility of 5 Fr Contralateral Radial Access for Hybrid CTO Percutaneous Coronary Intervention: Experience From a Single Tertiary Center in the UK

Abstract: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using the hybrid algorithm has traditionally been performed femorally using 8 Fr sheaths. Antegrade dissection and re-entry (ADR) has facilitated procedures using 6 and 7 Fr guides via the radial artery. Radial artery dysfunction and occlusion is a recognized complication preventing future radial procedures, but is significantly less common with 5 Fr sheaths. Five Fr contralateral radial access (48% left, 52% right) was used in 33 consecutive patients undergoing elective CTO-PCI in a single United Kingdom (UK) center over a 2-year period. Procedural data were recorded in the UK Hybrid CTO registry. Antegrade access was via contralateral radial in 26 cases and via femoral access in 5 cases. Single 5 Fr access was used in 2 cases treated by antegrade wire escalation. The mean J-CTO score was 2.1 ± 1.2, with an overall success rate of 91%. A retrograde approach was used in 9 cases and ADR was used in 9 cases. The mean fluoroscopy and procedure times were 45.2 ± 30.6 min and 172.5 ± 118.1 min, respectively, and the mean volume of contrast use was 218.5 ± 83.0 mL. There was 1 radial artery complication, 1 case of periprocedural myocardial infarction, and 1 case of tamponade. In this series, 5 Fr contralateral access provided adequate visualization in all cases. A 5 Fr guide provided adequate support in all retrograde cases to cross with a microcatheter after wire passage. Down-sizing contralateral access to 5 Fr routinely is feasible and may lead to a reduction in radial artery dysfunction and occlusion, as well as a reduction in the volume of contrast used.  

J INVASIVE CARDIOL 2019;31(6):159-165. Epub 2019 February 15.

Key words: chronic total occlusion, CTO, radial artery access, radial artery intervention

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using the hybrid algorithm^1,2 has traditionally been performed via the femoral arteries using 8 Fr sheaths to maximize passive guide-catheter back-up and allow the use of multiple adjuvant devices. Recent refinements in technology have allowed antegrade dissection and re-entry (ADR) to be undertaken through 6 and 7 Fr guides, increasing the popularity of radial access.

Radial artery dysfunction and occlusion (RAO) is increasingly recognized as a complication of radial access that prevents future radial procedures. Overall RAO rates after transradial PCI vary, but are reported as >10% in some series.^3-5 The risk of RAO is greater when the external sheath diameter exceeds the radial artery diameter. In a direct comparison between 6 Fr and 5 Fr radial sheaths for transradial PCI in 171 patients, Dahm et al demonstrated RAO rates of 1.1% in the 5 Fr group vs 5.9% in the 6 Fr group at 1-month follow-up (P=.05).⁶ There have been some reports of the use of 5 Fr transradial CTO-PCI, including a study by Yu et al, who reported similar CTO-PCI success rates for 5 Fr vs 6 Fr transradial access.⁷ The hybrid CTO algorithm relies on dual injections to elucidate the coronary anatomy and plan strategy. We describe a series of sequential CTO-PCI cases performed via two access sites (predominantly biradially) utilizing 5 Fr contralateral access, with the potential benefit of reduced vascular complications and long-term radial patency while maintaining the advantages of larger-caliber antegrade access in order to facilitate a wider range of approaches including ADR.

Methods

Five Fr contralateral radial access was used in 33 consecutive patients undergoing elective or semielective CTO-PCI by a single operator in a United Kingdom (UK) PCI center from January 2016 to December 2017. The 5 Fr Glidesheath Slender (external diameter, 2.13 mm; Terumo Corporation) was used in all cases. All patients provided written consent as per hospital trust regulation. The hybrid algorithm was used in all cases. Procedural data were recorded in the UK Hybrid CTO registry⁸ and included patient and lesion characteristics, procedural strategy, outcomes, complications, markers of efficiency, contrast use, and patient radiation dose. Activated clotting time (ACT) was measured at intervals during procedures, aiming for an ACT >250 sec in antegrade cases and >300 sec in retrograde cases. Intravascular ultrasound (IVUS) was used in 7 cases. At the end of the procedure, a Helix radial compression device (Vascular Perspectives) was applied to achieve patent hemostasis.

Results

Thirty-three consecutive CTO-PCIs were performed with 5 Fr contralateral access over a 24-month period. Table 1 outlines each case. Twenty-seven patients were men and 6 were women. Mean age was 68.3 ± 12.1 years. Twenty-six cases were performed in the context of stable angina, 2 cases in the context of acute coronary syndrome (ACS), and 5 cases as staged procedures following recent ACS. Five Fr access was gained in the left radial in 48.5% and in the right radial in 51.5% of cases. Antegrade access was most commonly via the other radial in 28 cases (85%) with a 6 Fr sheath and guide in 3 cases (9%), a 6.5 Fr sheathless guide in 2 cases (6%), a 7 Fr sheath and guide in 7 cases (21%), and a 7.5 Fr sheathless guide in 13 cases (39%). Antegrade access was via the femoral route in the remaining 15%; a 6 Fr sheath and guide were used in 1 case (3%) and a 7 Fr sheath and guide were used in 4 cases (12%). Single 5 Fr access was used in 2 cases treated by antegrade wire escalation. The occluded vessel was the right coronary artery (RCA) in 24 cases (73%), left anterior descending (LAD) coronary artery in 6 cases (18%), and circumflex artery (CX) in 3 cases (9%). The mean J-CTO score was 2.1 ± 1.2, compared with a mean J-CTO score of 2.5 ± 1.4 for cases recorded in the UK Hybrid CTO registry for the same period. The overall success rate (defined as technical success without major adverse cardiac events) was 91%.

A retrograde approach was used through a 5 Fr guide catheter in 10 cases (30%) and ADR was used in 9 cases (27%). Seven of the 10 retrograde cases were via septals (5 LAD to RCA, 1 LAD to CX, and 1 RCA to LAD), 2 were via epicardial collaterals (1 atrioventricular groove CX to RCA, and 1 apical LAD to RCA), and 1 was via saphenous vein graft (SVG). Eight out of 10 retrograde cases were successful (80%). The reason for failure in the first case was an inability to retrogradely wire an ostial RCA in-stent occlusion. Insufficient back-up from the 5 Fr retrograde guide did not contribute to failure in this case. Failure in the second case was caused by an inability to pass a microcatheter anterogradely to facilitate re-entry of retrograde equipment from the subintimal space. Septal dilation was required in 2 of the septal cases. In 1 case, the retrograde wire was trapped using an antegrade balloon to provide tension in order to pass a microcatheter.

The mean fluoroscopy and procedure times were 45.2 ± 30.6 min and 172.5 ± 118.1 min, respectively. The mean contrast use was 218.5 ± 83.0 mL and the mean patient radiation skin dose was 1.26 ± 0.82 Gy. There was 1 case of a radial artery complication (forearm hematoma managed conservatively), 1 case of periprocedural myocardial infarction (MI), and 1 case of tamponade requiring pericardiocentesis. We present the following 3 cases to illustrate the successful use of 5 Fr contralateral access to undertake retrograde CTO-PCI following the hybrid algorithm. Retrograde wire escalation was used in Case #1 after antegrade wiring was unsuccessful. Reverse controlled antegrade and retrograde subintimal tracking (CART) was used in Case #2 as the initial strategy. In Case #3, reverse CART was used after antegrade wiring and ADR were unsuccessful.

Case #1

A 63-year-old male was admitted with pulmonary edema secondary to an MI and had PCI to an occluded culprit LCX. He was brought back for elective CTO-PCI to the occluded RCA as echocardiography suggested viability in that territory (J-CTO score, 2).

Five Fr access was gained via the right radial artery and 6 Fr access via the left radial artery. The 5 Fr access allowed entry to the left coronary artery (LCA) with the use of an extra-back-up (EBU) 4 guide and 6 Fr access allowed entry to the RCA with the use of a Judkins right 4 guide and Corsair 150 microcatheter (Asahi Intecc). Antegrade wiring was unsuccessful, so the Corsair microcatheter was passed via the 5 Fr LCA guide and retrograde access was gained via the first septal collateral branch. A Gaia 2 wire (Asahi Intecc) was used to cross the lesion to the proximal true lumen and enter the antegrade guide, where it was exchanged for an RG3 wire (Asahi Intecc), which was externalized. The lesion was then predilated, and 3 drug-eluting stents were placed in the RCA, with TIMI 3 flow at completion. Figure 1 illustrates the key stages of this procedure.

Case #2

A 73-year-old male with a history of coronary artery bypass grafting (CABG) 10 years prior and a non-ST segment elevation MI 1 year prior presented with persistent stable angina symptoms despite optimal medical therapy. The left internal mammary artery (LIMA) supplying the LAD was patent, but the SVG supplying the distal RCA was severely aneurysmal and potentially acting as a substrate for thrombus; hence, a decision was made to sacrifice the SVG and perform CTO-PCI to the native occluded RCA (J-CTO score, 1).

Five Fr access was gained via the right femoral artery and 6 Fr access was gained via the right radial artery. The 5 Fr access allowed entry to the SVG with the use of a Judkins right 4 guide and Finecross microcatheter (Terumo Corporation). Six Fr access allowed entry to the RCA with the use of an Amplatz left 1 guide. The 5 Fr Judkins right 4 guide was intubated deeply into the SVG to maximize retrograde back-up and minimize contrast required. A reverse CART was performed through the SVG into the RCA with the aid of a 4 mm balloon at the ostium of the RCA, which allowed a Confianza Pro 12 wire (Asahi Intecc) to reach the aortic lumen, where it was snared using an EnSnare device (Merit Medical) and then swapped out for an RG3 wire. We then performed PCI with 1 drug-eluting stent in the RCA, resulting in TIMI 3 flow. Figure 2 illustrates the key stages of this procedure.

Case #3

A 77-year-old man with a background of bronchiectasis and metastatic renal cell carcinoma presented for elective CTO-PCI of his RCA (J-CTO score, 3). He had ongoing limiting stable angina despite 3 antianginal medications and significant dyspnea.

Five Fr access was gained via the right and left radial arteries. The 5 Fr left radial access was exchanged for a 7.5 Fr sheathless AL 0.75 guide to engage the RCA. A 5 Fr EBU 4.0 guide engaged the LCA via the right radial sheath. An attempt at antegrade wire escalation and ADR failed; therefore, a retrograde approach was adopted. An attempt at retrograde access via LAD septals was also unsuccessful, so a retrograde attempt was made via an epicardial collateral from the LCX via the atrioventricular groove branch to the posterior left ventricular (PLV) artery using a Sion wire (Asahi Intecc). A Turnpike LP microcatheter (Aquailant Interventional) would not pass, but its retrograde path was facilitated by knuckling an antegrade wire to perform balloon trapping of the retrograde wire with an antegrade balloon. A distal hematoma occurred as a consequence, with the loss of a small posterior descending artery. During retrograde wiring, the tip of a retrograde Confianza Pro 12 wire became detached in the vessel. A subsequent Pilot 200 wire (Abbott) was then used to perform a reverse-CART procedure, which was challenging due to a large subintimal space. This then allowed PCI with 4 drug-eluting stents from the PLV back to the proximal RCA, which resulted in TIMI 3 flow at completion. Figure 3 illustrates the key stages of this procedure.

Discussion

The purpose of this retrospective study was to demonstrate the feasibility and safety of using 5 Fr contralateral access in CTO-PCI. We describe 33 consecutive CTO-PCIs performed by a single operator with a success rate of 91%. The rates of antegrade wire escalation (55%), ADR (27%), and retrograde access (30%) were similar to other series using the hybrid approach.

Contralateral angiography was not judged to be inadequate due to the 5 Fr guide in any case. In the retrograde cases, the 5 Fr guide catheter accepted a microcatheter without resistance or pressure damping, and although a trapping technique could not be used for microcatheter exchange, this was only required in 1 case when exchange was undertaken using an indeflator filled with saline. Guide-catheter support from the 5 Fr guide was sufficient in most cases, although septal dilation was necessary in 2 cases. A slightly longer curve for the left coronary catheter was used routinely (EBU 4.0 rather than EBU 3.75) to augment support, and deep intubation was frequently required. Due to the smaller size and greater flexibility, deep intubation of both the RCA and LAD is accomplished with greater ease with 5 Fr vs 6 Fr guides, and the risk of ischemia during this maneuver is less due to the smaller guide diameter. In 1 case, it proved difficult to cross a tortuous epicardial collateral in the atrioventricular groove from the CX to the RCA, and it was necessary to dissect further down the RCA to allow antegrade trapping of the retrograde wire to provide tension for a Turnpike LP catheter to cross. This resulted in the need for more extensive stenting and the loss of a side branch. In retrospect, a better option would have been to try a different microcatheter or to extend the coronary wire and up-size to a 6 Fr system to allow the use of a guide-catheter extension.

A number of studies have demonstrated a reduced risk of long-term RAO when using smaller sheath sizes for PCI (typically 5 Fr vs 6 or 7 Fr).^6,9,10 This is particularly important in patients undergoing CTO-PCI, as many of these patients have advanced coronary disease and may require additional procedures in the future. The use of 5 Fr guide catheters for contralateral injection also minimizes the volume of contrast media used to elucidate the coronary anatomy. A recent meta-analysis by Polimeni et al demonstrated a mean reduction in contrast media use of ∼22.2 mL in equivalent procedures when performed using 5 Fr vs 6 Fr access.¹¹ This is especially relevant, as many patients requiring CTO-PCI have reduced renal function and the complexity of these cases often necessitates repeated coronary injections. Additional benefits gained by using 5 Fr access over 6 Fr access include the reduced likelihood of causing coronary ischemia with catheter engagement if there is disease in the left main stem as well as the reduced likelihood of radial artery spasm. However, there are drawbacks to downsizing from 6 Fr to 5 Fr. Most relevant of these is reduced guide-catheter support to deliver retrograde equipment. This is a real issue, but there are widely accepted techniques able to mitigate this problem that we believe are applicable in most cases. It is also more difficult to take blood samples for ACT measurement without entraining air into the catheter through a 5 Fr system. The potential concern of not fully opacifying the coronaries with contrast during manual injections and missing clinically relevant information within the coronaries did not appear to be problematic in our study. Techniques such as trapping balloons, optical coherence tomography (OCT) catheter imaging, kissing-balloon inflations, and rotational atherectomy cannot currently be used efficiently via 5 Fr catheters, but these techniques are very rarely required via the retrograde donor guide.

Study limitations. This study was limited by its design as a non-randomized, retrospective, observational study with a small study group from a single institution, and with procedures performed by a single operator. However, there was no selection bias because consecutive cases were included.

Conclusion

Five Fr contralateral access is feasible, and in this series provided adequate visualization in all cases either as a single injection or as part of a dual-injection technique. In all retrograde cases, adequate support was achieved from a 5 Fr guide to cross with a microcatheter after a wire had crossed. We believe that down-sizing contralateral access to 5 Fr routinely is feasible and may lead to reductions in radial artery dysfunction and occlusion, as well as a reduction in the volume of contrast used.  

References

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From the ¹Trent Cardiac Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; and ²Royal Melbourne Hospital, Melbourne, Victoria, Australia.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. The authors report that patient consent was provided for publication of the images used herein.

Manuscript submitted June 20, 2018, provisional acceptance given October 12, 2018, final version accepted November 28, 2018.

Address for correspondence: Andrew Peter Vanezis, MBChB, MRCP, PhD, Trent Cardiac Centre, Nottingham University Hospitals NHS Trust, Hucknall Rd, Nottingham NG5 1PB, United Kingdom. Email: andrew.vanezis@nhs.net