This document discusses a case of bifurcation PCI using a radial approach. A 59-year-old male presented with NSTEMI due to one-vessel coronary artery disease involving a bifurcation lesion. The intervention team used a sheathless 7.5F guiding catheter via the radial artery to deliver kissing stents to both branches of the bifurcation lesion, achieving successful outcomes. The conclusion is that sheathless guiding catheters allow complex bifurcation PCI procedures traditionally requiring femoral access to now be performed via the radial approach.

1. Bifurcation PCI using a Radial
Approach
Carlos Cafri, MD
Department of Cardiology, Soroka University
Medical Center, Faculty of Health Sciences, Ben
Gurion University of the Negev, Beer Sheva ,
Israel

2. The Case
• Male, 59 years old
• Family history of CAD, HTN, type II DM
• Current presentation
– One month of exertional angina and
shortness of breath
– Admitted due to recurrent chest pain
and troponin elevation: NSTEMI

3. The Case
• Coronary angiography within 24 hours
of admission
– Right radial artery
– 6F universal diagnostic catheter
(Optitorque: 6F- BLK)
– Single vessel disease

4. The Bifurcation
n True Bifurcation: Medina 1.1.1
Large Diagonal Branch:
Large diameter: >2.5 mm
Large territory n 60 ° angle between branches

5. Possible Strategies
• Single Vessel Stenting/ Provisional
Stenting
• Two Vessel Stenting

6. Decision
• Data
– Randomized trials: Cactus,Nordic, BBC
– Observational trials
• Consensus
– European Bifurcation Club Meeting
• Feeling
– “Optical-Limbic Reflex”
• Access Site

7. The Decision : “Access Site”
– Paradigm:
• “It is really hard to perform two
vessel stenting via the transradial
approach”
• “Through the radial approach try to
do provisional stenting”

8. Why?
• Transradial PCI is performed with 6 F guiding
catheter
• A 6 French guide catheter allows simultaneous
crossing of:
• Two balloons
• Balloon and stent
• A 6 French guide catheter never allows
simultaneous crossing with two stents

9. Non Compatible Techniques with 6F
Guiding Catheter

10. Our case: What could do?
• Provisional Stenting
– Predilate both branches
– Stent implantation in the LAD
– Probably side branch compromise
– Stenting side branch if flow is reduced
or chest pain occurs

11. Our case: What could do?
• Change the access site :
– Femoral artery
– 7 French
– “Pay the price”
• New puncture
• Bleeding risk
• Discomfort

12. Our case: What could do?
– 7 French guiding catheter
• Possible
• Selective : Men, large radial, first radial
cath, no previous spasm
• Complicated: Spasm, bleeding and radial
occlusion

14. Our case. What could we do?
• Sheathless guiding catheter

16. Innovations in Guiding Catheters

17. Our case: What we did
• Exchange 6F sheath to 7.5 F sheathless guiding
• Heparin: 9000 U.
• Two wires: ATW- Whisper
• Kissing balloon: 2 x 15mm
• Two stents delivery: Promus 2.75 x 18mm; 2.5 x 12mm
• Mini-crush technique
• Diagonal stent deployment
• LAD stent deployment
• Final kissing balloon with a non compliant balloon

29. Conclusions
• Implementation of 7 F. Guiding catheters or sheath less
guiding catheters during transradial PCI allows
simultaneous delivery of two stents.
• All the existing strategies creates for the angioplasty
treatment of challenging bifurcation lesions can be
performed through the radial approach