Ultrasound guided distal transradial („snuff box” area) angiography and angioplasty using

5F guiding or 6F sheathless guiding system

Ruzsa Z., Tóth J., Molnár L., Édes I. F., Bárczi Gy., Merkely B.

AimRadial 2017

Disclosures

• I have no conflict of interest to declare

Background• First introduced for haemodialysis access in 1996

• Snuff box access published in 1998

• My first case in 2010 for Cimino fistula intervention and my fisrt coronary case in 2014

• Avtandil Babunashvili started the TENDERA study

• Snuff box access published by F Kiemeney in 2017

Background- Anatomy

Methods

• Prospective study performing all transradial diagnostic catheterrisationsand interventions from the anatomical „snuff box” area with a 5F guidingor 6F sheathless guiding

• (150 patients and 76 fully analysed)

• Primary end-point• Technical success of the intervention

• Procedural complications

• Secondary end-point• MACCE at 2 months and one year

• Procedural releated factors (Radiation, Contrast, Hospitalisation)

Ultrasonography

• Vivid 5 US

• US guided puncture in all cases

• US dimensions: distal RA diameter, calcification

• Control US on the next postoperative day

Coronary angiography and intervention• US guided puncture

• 5F TR sheath

• 5F diagnostic catheter

• PCI with 5F guiding (Launcher) or 6.5F sheathless guidingcatheter

• Rotational atherectomy with 1.25 mm Burr

• Bifurcation strategy: T stent and TAP

• CTO: Biradial access- for left 5F and for right 7F sheathless

• FFR measurement – 5F guiding

• IVUS- 5F Boston or 6F Volcano but with 6.5 F sheathless

Postoperative management

Compression bandage for 4 hours

Results

• 150 pts

• 100% success and no cross over to femoral access site

• 5F guiding or diagnostic catheter in 108 cases and 6.5F guiding in 42 patients

• Procedure releted factors• Mean contrast consumption. 115 [86-14.3] ml

• DAP: 34.8 [18.7-51.5] Gy

• Fluoroscopy time 7.1 [4.5-9-8] minute

• Hospitalisation 0.6 day

Complications

• Vascular complications• Radial artery occlusion 0%

• Forearm haematoma 1/150 (0.6%)

• MACCE• No MACCE at one month

Limitations and advantages

• Limitations• RAO is the major limitation• Left arm must straighten !!!!• Due to 5F guiding many techniques are not available therefore we need new

strategy in bifurcation, left main, CTO, calcification• 6.5 sheathless guiding has the same uter diameter as the 5F sheath

• Advantages• Compression is very easy• Fast ambulation (4h ??, 2 h)• For CTO cases the left arm position is comfortable and the operateur radiation

is low

Limitation - RAO

LAD Rotablationand BVS implantation

Current clinical admission

• CCS 3 angina

• Rutherford class 3 claudication

• Positive stress test

• Positive stress echo

• Echo: inferior hypokinesis

Plan: - LAD PCI via right radial access (snuff box)- Right coronary CTO recanalisation??

US guided radial artery puncture

Coronary angiography 2017.03 Right radial artery recanalisation(US guided- snuff box)

1. LAD PCI 2017.03

2. RCA stent CTO recanalisation

RCA CTO recanalisation

What to do??- Bilateral angiography5F left radial JL3.5

Caravel microcatheterMiracle Bross

Selective angiography

Contralateral angio

Pd or PL branch??

RCA PD ballooning

RCA ballooning

RCA stenting

Onyx 3.5x18, Onyx 3x32, Onyx 2.75x28, Onyx 2.5x18 mm

Final angiography

Conclusion

• Ultrasound guided distal transradial access from the snuff box area is safe and effective and the rate of radial artery occlusion is extremely low