Bilateral Trans-radial/ulnar Access for Percutaneous Recanalization of a Chronic Total Coronary Artery Occlusion using Antegrade Dissection and Re-entry

Percutaneous Coronary Intervention (PCI) for Chronic Total Occlusions (CTOs) necessitates dual arterial access to allow visualisation of the vessel both proximal and distal to the occlusion as well as the course of interventional collaterals. Potential access sites include bilateral femoral, combination of femoral and radial and bilateral radial arteries. Trans-ulnar access has been shown to be safe and feasible in patients with weak radial pulses and this is a further option. The advantages of radial/ulnar access relate to reduction in access site bleeding complications, which is particularly pertinent in CTO PCI where 7-8Fr guiding catheters are usually required. We describe a case of a patient undergoing repeat attempt at PCI of a Right Coronary Artery (RCA) CTO, the first attempt having been complicated by a life threatening retroperitoneal haemorrhage secondary to 8Fr femoral arterial access. Access was gained via the right ulnar artery and the left radial artery, a 7Fr JR4 guide catheter was used to intubate the RCA with a 5Fr EBU3.5 catheter in the left coronary artery providing contrast visualisation of the distal RCA. The CTO was successfully recanalized using antegrade dissection and re-entry technique with the StingrayTM catheter system without any access site complications. This case highlights the safety and feasibility of CTO PCI via bilateral trans-radial/ulnar access and this maybe the combination of choice in patients at high risk of access site bleeding. Bilateral Trans-radial/ulnar Access for Percutaneous Recanalization of a Chronic Total Coronary Artery Occlusion using Antegrade Dissection and Re-entry