How can we manage radial artery late occlusion: recanalization of occlusion or proximal 'high' puncture of radial artery

1. HOW CAN WE MANAGE RADIAL ARTERY
LATE OCCLUSION: RECANALIZATION OF
OCCLUSION OR PROXIMAL “HIGH”
PUNCTURE OF RADIAL ARTERY
Avtandil M. Babunashvili
Center of Endosurgery, Moscow, Russia

2. Disclosure: Avtandil M. Babunashvili, MD
I have no relevant financial interests to disclose

3. Background:
_______________________________________________
Transradial interventions (TRI) are associated
with certain risk of radial artery (RA) occlusion, limiting
The possibility of re-intervention through the same
access site.

4. Study population
Occlusion of the RA/UA was detected in 72 cases (3.7%)
of the 1972 repeat transradial or transulnar interventions
for
diagnostic
and
interventional
procedures
from
January 2005 to November 2012.
Methods
In case of late RA/UA occlusion if the distal stump was
palpable
pulse,
puncture
and
cannulation
of
the
postocclusion segment, retrograde RA/UA recanalization
and angioplasty was performed using the "Dottertechnique” or plain balloon dilatation or mixed technique.

5. 1
2
Schematic image and angiogram of previous (1) and repeat (2)
puncture for recanalization of RA

6. Radial artery late occlusion recanalization
Instruments
Same as used for CTO coronary
or tibial arteries
(Fielder, Miracle series etc)
Wire strategy
● escalation
● penetration
Recanalization technique
● True lumen
● Subintimal
(Bolia technique)
Final lumen formation
● “Dotter” technique
● Balloon angioplasty
● Mixed

7. Combined (Dotter+balloon) technique for
RA recanalization

8. various grade Dissections are common after procedure …

9. Long balloon (220cm) for tibial angioplasty for
dissection sealing

10. Sheath as a temporary stent . . .

11. PROCEDURAL AND DEMOGRAPHIC DATA OF 72 PATIENTS WITH
RADIAL ARTERY LATE OCCLUSION
Patient or procedure related factors
Number of patients, (%)
woman
10 (13,9%)
22 (36,1%)
Age > 65
5
Previous TRI
6
48 (66,7%)
7
Sheath used, F
18 (25%)
6 (8,3%)
<15
Duration of TRI,
min
9 (12,5%)
15-60
40 (55,6%)
>60
23 (31,9%)
Multiple previous punctions (2 or more
TRI through the same RA)
CAG
Type of
procedure
24 (33,3%)
34 (65,4%)
Procedure
details
9 (17,3%)
PCI bifurcation
(including LM)
Present TRI*
PCI CTO
7 (13,5%)
PCI as a second
stage
6 (11,5%)
Ad-hoc PCI after
control CAG
12 (23%)
Control CAG
24 (46,2%)

12. Immediate results of RA/UA recanalization
Type of occlusion
artery
Subacute
(<2 week)
radial
ulnar
CTO
(> 3 months)
radial
ulnar
success
Technical
failure
Complication
10
1
1
1
40
6
2
1
52
7
3
(85,2%) (11,5%) (4,9%)
12
49
61

13. RECANALIZATION TECHNIQUES USED IN OCCLUDED
RADIAL/ULNAR ARTERIES
Type of
occlusion
artery
Balloon
angioplasty
“Dotter”technique
combined
technique
thrombus
aspiration+
Balloon
Subacute
(<2 week)
radial
4
3
3
-
ulnar
-
-
-
1
CTO
(> 3 months)
radial
17
13
10
-
ulnar
1
-
-
-
22
(42,3%)
16
(30,8%)
13 (25%)
1 (1,9%)
11
41
52

14. Ulnar artery subacute (6 days) thrombosis recanalization

16. Thrombus dislocation during subacute
Radial artery recanalization

17. RA perforation after successful puncture of distal stump

18. Factors influencing on immediate success of recanalization
Factors
OR
p
Duration of occlusion
OR = 0.97
(95% CI 0.94-1.01)
0,269
Length of stump
OR = 1.94
(95% CI 1.17-3.21)
0.010
OR = 0.98
95% CI 0.97-1.02
0.039
Length of occlusion

19. DEPENDENCE OF DOSE AND DURATION OF RECANALIZATION
RADIAL / ULNAR ARTERY FROM TYPE OF CORONARY INTERVENTION
Mean ±
SD
CAG (n= 34)
Control CAG+ad hoc Planned PCI (n= 6)
PCI (n=12)
Total
RA/UA
recanaliza
tion
Total
RA/UA
recanaliza
tion
Total
RA/UA
recanali
zation
Radiation
Dose,
µGy/m2
2705.6 ±
2160.1
21.8 ±
32.3
12014.1 ±
8932.6
122.7 ±
265.7
5274 ±
4052.9
70.1 ±
48.3
Time, min
26 ±
15.8
15.2 ± 9.7
69.9
±29.1
19.1 ±
10.8
68.7 ±
30.2
18 ±
10.1

20. Follow-up (1 week-3 year) results of RA/UA
recanalization
Type of occlusion
Subacute
(<2 week)
artery
radial
ulnar
CTO
(> 3 months)
radial
ulnar
Patent
(angio or US)
reocclusion
6
4
1
20
20
1
28
24
(53,8%) (46,2%)
Successfully
reopened
2
2
11
41
52

21. Immediate and follow-up (8 months) result of
Right RA recanalization

22. Proximal (“high”) puncture of
occluded radial artery

24. Proximal Radial artery puncture under US guidance
Bifurcation point
Previous Puncture site

25. Proximal RA puncture and 7F sheath inserted before PCI

26. Proximal puncture of high take-off Radial artery

27. ► “High” puncture sucessfully performed in 5
patients (3 –control angio, 2 – PCI);
► in one case proximal punction was performed in
RA with high take-off from brachial artery;
► Only one small haematoma (< 5X5cm) was occured

28. CONCLUSIONS
► Recanalization of late radial/ulnar artery occlusion for repeat arterial
access is technically feasible and safe with acceptable success rate;
► There is more benefit than harm in this technique taking in
consideration the difficulties of puncture and catheterization of distal
postocclusion segment;
► Despite the high risk of reocclusion this technique allows to solve the
problem of access in Patients with challenging approach;
► Proximal RA catheterization under US control is feasible and safe in
certain case of retrograde recanalization failure.