Ad hoc PCI via the transradial approach: how to achieve success

1. Ajay J. Kirtane, MD, SMAjay J. Kirtane, MD, SM
CenterCenter for Interventional Vascular Therapyfor Interventional Vascular Therapy
Columbia University Medical Center /Columbia University Medical Center /
New York Presbyterian HospitalNew York Presbyterian Hospital
Ad Hoc PCI via theAd Hoc PCI via the
Transradial Approach:Transradial Approach:
How to Achieve SuccessHow to Achieve Success

2. ConflictConflict of Interest Disclosureof Interest Disclosure
•• Ajay J. KirtaneAjay J. Kirtane
¡¡ NoneNone
¡¡ Off-label use will be discussedOff-label use will be discussed

3. Basic Principles of Transradial PCI:Basic Principles of Transradial PCI:
Debunking the MythsDebunking the Myths
•• Back to basics: standard and essential PCIBack to basics: standard and essential PCI
principles apply!principles apply!
•• Pre-cath evaluationPre-cath evaluation
¡¡ Evaluate the hand and pulses (all) yourselfEvaluate the hand and pulses (all) yourself
•• In-lab procedureIn-lab procedure
¡¡ PCI success depends on ability to access thePCI success depends on ability to access the
artery selectively, cross with wire, and deliverartery selectively, cross with wire, and deliver
devices, which is dependent upon support ofdevices, which is dependent upon support of
the guide/wire (coaxial system)the guide/wire (coaxial system)
•• Post-cath access / carePost-cath access / care

4. Setup / Operator / Lab ComfortSetup / Operator / Lab Comfort
Radial site
R Groin site

5. Basic Principles of Transradial PCI:Basic Principles of Transradial PCI:
Debunking the MythsDebunking the Myths
•• Hemodynamic assessments are possible!Hemodynamic assessments are possible!
¡¡ LV can be accessedLV can be accessed
•• Wire-facilitated catheter crossingWire-facilitated catheter crossing
•• Stiffer diagnostic catheters can helpStiffer diagnostic catheters can help
¡¡ RHC can be performed from the armRHC can be performed from the arm
•• Brachial vein approach with 5 FrenchBrachial vein approach with 5 French
SwanSwan
¡¡ Venous sheath in neck or groinVenous sheath in neck or groin

6. How to do a RHC from the ArmHow to do a RHC from the Arm
•• Brachial vein accessBrachial vein access
¡¡ Re-wire existing antecubital i.v.Re-wire existing antecubital i.v.
¡¡ Insert new iv/sheathInsert new iv/sheath
¡¡ Ultrasound-guided brachial vein accessUltrasound-guided brachial vein access
•• 5 French Swan-Ganz Catheter5 French Swan-Ganz Catheter
•• BMW or workhorse wire (to direct the swanBMW or workhorse wire (to direct the swan
through smaller arm vessels)through smaller arm vessels)
•• 14 Guage Angiocath to exchange for sheath14 Guage Angiocath to exchange for sheath
at end of caseat end of case

7. Exchanging antecubital i.v. for SheathExchanging antecubital i.v. for Sheath

8. Antecubital Vein AnatomyAntecubital Vein Anatomy

9. Try to Avoid the Cephalic (Lateral AC Access)Try to Avoid the Cephalic (Lateral AC Access)

10. Glidesheath Dilator into 14 Gauge AngiocathGlidesheath Dilator into 14 Gauge Angiocath

11. After sheath removed over 0.021” wireAfter sheath removed over 0.021” wire

12. Upfront Choice #1Upfront Choice #1
Radial sheath size: 6 French vs. SmallerRadial sheath size: 6 French vs. Smaller
6 Fr Standard Sheath 0.038” wire
6 Fr Glidesheath 0.021” wire
5 Fr Glidesheath 0.021” wire

13. Upfront Choice #1Upfront Choice #1
Radial sheath sizeRadial sheath size
•• Things you can do with a 6 French Guide:Things you can do with a 6 French Guide:
¡¡ Multiple wire casesMultiple wire cases
¡¡ IVUS / FFR / OCTIVUS / FFR / OCT
¡¡ Bifurcation lesions including kissing balloonsBifurcation lesions including kissing balloons
(as long as balloons are not BOTH 3.5-4.0 NC)(as long as balloons are not BOTH 3.5-4.0 NC)
¡¡ Guideliner casesGuideliner cases
¡¡ Thrombectomy cases (but 2Thrombectomy cases (but 2ndnd
wire might not bewire might not be
possible)possible)
¡¡ Rotational atherectomy (1.25, 1.5 mm burrs)Rotational atherectomy (1.25, 1.5 mm burrs)
¡¡ Embolic protectionEmbolic protection
5 French too

14. Going from 5 French to 6 French:Going from 5 French to 6 French:
How to Upsize a Tapered Hydrophilic SheathHow to Upsize a Tapered Hydrophilic Sheath
(0.035”
exchange kit
exists and
Slender sheath
coming 7/13)

15. Down
Sizing
Equivalent
Diameter6Fr GSS6Fr Sheath 5Fr Sheath
Gray on strain relief
(Indicates O.D. of 5Fr)
Green on valve and dilator
(Indicates I.D. of 6Fr)
Thin-walled Sheath (Slender)Thin-walled Sheath (Slender)

16. Radial PharmacologyRadial Pharmacology
•• Preloading withPreloading with
antiplatelet agentsantiplatelet agents
¡¡ AspirinAspirin
¡¡ P2Y12 inhibitorP2Y12 inhibitor
•• AnticoagulantAnticoagulant
¡¡ HeparinHeparin
¡¡ BivalirudinBivalirudin
¡¡ Can do radial casesCan do radial cases
on therapeutic oralon therapeutic oral
agents!!agents!!
•• Agents for spasmAgents for spasm
¡¡ Sedation!Sedation!
¡¡ Topical (not i.a.) lidocaineTopical (not i.a.) lidocaine
¡¡ Topical or sq NTGTopical or sq NTG
¡¡ Calcium Channel blockerCalcium Channel blocker
•• Nicardipine 200 mcgNicardipine 200 mcg
•• Verapamil 250-500 mcgVerapamil 250-500 mcg
¡¡ NTG 200NTG 200-400 mcg-400 mcg

17. Administering the Radial CocktailAdministering the Radial Cocktail

18. Wire for Traversing the ArmWire for Traversing the Arm
Rosen
Standard J
•• Standard Approach:Standard Approach:
¡¡ Exchange Rosen WireExchange Rosen Wire
¡¡ Also “Baby J”Also “Baby J”
•• For tortuous anatomy:For tortuous anatomy:
¡¡ BMW or non-hydrophilicBMW or non-hydrophilic
workhorse wireworkhorse wire
•• (Glidewires)(Glidewires)

19. Navigating Tortuous AnatomyNavigating Tortuous Anatomy

20. Getting the Guide to the AortaGetting the Guide to the Aorta
Patel, Shah, Pancholy, CCI 2013
Balloon-assisted tracking of the guide catheter
(to minimize the effect of the guide-wire transition point)

21. What Guides Should I Use forWhat Guides Should I Use for
Transradial PCI?Transradial PCI?
•• Start with guides you are familiar with:Start with guides you are familiar with:
•• Left Coronary Artery:Left Coronary Artery:
¡¡ EBU 3.5, XB 3.5EBU 3.5, XB 3.5
•• Right Coronary Artery:Right Coronary Artery:
¡¡ JR4, Hockeystick, AL 0.75 or AL 1JR4, Hockeystick, AL 0.75 or AL 1
¡¡ Typically with sideholesTypically with sideholes
•• You can experiement with specialty guides,You can experiement with specialty guides,
but these are not a necessitybut these are not a necessity

22. Specialty Guide ShapesSpecialty Guide Shapes
Ikari and Tig
“Easy Radial”

23. Getting the Guide to the Ascending Aorta:Getting the Guide to the Ascending Aorta:
Effect of a Deep BreathEffect of a Deep Breath

24. Engagement: The Wire is Your FriendEngagement: The Wire is Your Friend

25. “Flipping Down” the Guide“Flipping Down” the Guide

26. Finding the Left CuspFinding the Left Cusp

27. Left Guide AdventuresLeft Guide Adventures

28. Common Myth:Common Myth:
Complex PCI Can’tComplex PCI Can’t
Be Done RadiallyBe Done Radially

29. 1.5 mm Rotational Atherectomy1.5 mm Rotational Atherectomy

30. Guideliner case (Difficult RCA)Guideliner case (Difficult RCA)

31. Stent with Multiple Wires (jailed wires)Stent with Multiple Wires (jailed wires)

32. Implications of Radial sheath sizesImplications of Radial sheath sizes
•• When do youWhen do you reallyreally need a guide bigger thanneed a guide bigger than
6 French?6 French?
¡¡ *Perforation to facilitate placement of a Jo-*Perforation to facilitate placement of a Jo-
Med Graftmaster StentMed Graftmaster Stent
¡¡ Simultaneous 2 or 3 stent case that can’t beSimultaneous 2 or 3 stent case that can’t be
done sequentiallydone sequentially
•• Minicrush, SKSMinicrush, SKS
¡¡ IVUS-guided CTOIVUS-guided CTO
¡¡ Lost device retrievalLost device retrieval
¡¡ Lack of supportLack of support

33. Can you use guides bigger than 6 French inCan you use guides bigger than 6 French in
the Radial Artery?the Radial Artery?
•• Yes!Yes!
•• Men: most can tolerate 7 Fr, some even 8 FrMen: most can tolerate 7 Fr, some even 8 Fr
•• Women: some can tolerate 7 FrWomen: some can tolerate 7 Fr
¡¡ But radial artery occlusion may become anBut radial artery occlusion may become an
issue with either of these approachesissue with either of these approaches
•• Sheathless guide techniquesSheathless guide techniques

34. Sheathless Guide Technique (7 French)Sheathless Guide Technique (7 French)
•• Using 5 Fr Dilator orUsing 5 Fr Dilator or
long multipurposelong multipurpose
diagnostic for thediagnostic for the
transition pointtransition point
T. Kwan et al, CCI 2012

35. ConclusionsConclusions
•• Basic principles: a PCI is a PCI, and accessBasic principles: a PCI is a PCI, and access
is just a part of the caseis just a part of the case
•• Knowing just a few basic techniques willKnowing just a few basic techniques will
dramatically impact your learning curvedramatically impact your learning curve
•• Transradial PCI is not only doable, but inTransradial PCI is not only doable, but in
many cases preferred, especiallymany cases preferred, especially ad hocad hoc
•• My advice: start with minimal changes toMy advice: start with minimal changes to
equipment (use what’s familiar to you) andequipment (use what’s familiar to you) and
then start to try other equipment once you’vethen start to try other equipment once you’ve
mastered the basicsmastered the basics
Ajay J. Kirtane:
akirtane@columbia.edu