Courtesy of Dr. Carlos Fava.

The transradial approach has been advanced in time, and is being increasingly used in more and more complex angioplasty procedures with the same benefit, compared to the classical femoral approach. As a result, in many high volume centers, this reality has demoted the femoral approach to a few particular procedures.

Chronic total occlusions (CTO) are a real challenge and the transradial approach could make them even more so, or it could make them safer. When it came to deciding on the most appropriate approach for CTO PCI, these questions remained unanswered. 

The study analyzed 585 CTO cases, 280 (47.8%) involving transradial access and 308 (52.1%) involving femoral access. Populations were similar, with the exception of patients in the femoral group, who more often presented a story of cardiac revascularization surgery. CTO was most frequent in the right coronary artery, followed by the anterior descending artery.

Severe calcification and ≥20 mm occlusion was more frequent in the femoral access group. Instead, the transradial group presented a lower J-CTO score. Technical success was similar (74% transradial and 72.5% femoral).

After propensity score matching of 187 patients in each group, no differences were found as regards procedural success, but less contrast was used in the femoral access group.

Failure was associated to:

• moderate or severe calcification
• >20 mm lesions
• absence of stump
• ≥3 J-CTO score

In patients presenting ≥3 J-CTO, the femoral approach was more successful, compared to the transradial (58.2% vs. 35.7% respectively).

The use of a guiding catheter <7F, calcification,>20 mm occlusion length and age were all associated to transradial recanalization failure.

Conclusion

CTO recanalization via transradial approach may be feasible in less complex cases. For more challenging complex cases, and especially with severe calcification, the femoral approach showed better results.

Editorial Comment

Chronic total occlusions are one of the greatest challenges we currently face. These procedures have been associated with higher complications rates, many of which are access site complications.

The transradial approach is a great alternative in some CTO cases, as it has been shown, but there is an important group of patients that still benefit from the femoral approach. We should develop new better devices to be able to use it in all CTO cases.

Courtesy of Dr. Carlos Fava. Favaloro Foundation, Buenos Aires, Argentina.

Original Title: Transradial Coronary Intervention for Complex Chronic Total Occlusions.

Reference: Yutaka Tanaka et al. J Am Coll cardiol Intv 2017;10:235-43.

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