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Robotic PCI Through the Distal Radial Artery

- How and Why? RI via Robotic

Karim Al-Azizi MD FACC

Structural Heart Disease Fellow
Interventional cardiology
The Heart Hospital – Plano
Baylor Scott & White

No disclosures

Why left distal radial artery?
Anatomy of the ”snuff box”

Why left distal radial?
Why left radial?

– Catheter cannulation simulates the femoral approach,

may reduce catheter exchanges and reduce procedure

– Cannulation of bypass grafts and especially the LIMA

graft (left internal mammary artery), that comes off the
left subclavian.

– Left radial access may be associated with a reduced

stroke risk, as compared to right, in a propensity
matched analysis*.
Incidence, Determinants, and Outcomes of Left and Right Radial Access Use in Patients Undergoing Percutaneous Coronary Intervention in the
United Kingdom: A National Perspective Using the BCIS Dataset. Rashid, Mamas et al. JACC Cardiovasc Interv. 2018 May 11. pii: S1936-
#ldtra 8798(18)30419-9. doi: 10.1016/j.jcin.2018.01.252.
Why left distal radial ?

– Improved patient ergonomics, more natural pronation

vs supination..

– Improved operator ergonomics, pronated hand,

provides more length.

– Easier and more predictable hemostasis, with shorter

hemostasis times.

– Ability to flex the wrist, and ability to use the right hand
after the procedure with no risk of hematoma.

– Preserve the proximal left radial and right radial for

future procedures.

EuroIntervention. 2017 Sep 20;13(7):851-857. doi: 10.4244/EIJ-D-17-00079.
#ldtra Left distal transradial access in the anatomical snuffbox for coronary angiography (ldTRA) and interventions (ldTRI).
Cardiovasc Revasc Med. 2018 Oct 25. pii: S1553-8389(18)30463-9. doi: 10.1016/j.carrev.2018.10.023. [Epub Cardiovasc Revasc Med. 2018 Mar 26. pii: S1553-8389(18)30123-4. doi: 10.1016/j.carrev.2018.03.020. The
ahead of print]. The left distal trans-radial artery access for coronary angiography and intervention: A US distal left radial artery access for coronary angiography and intervention: A new era.
The distal left radial artery for coronary angiography and intervention: A US experience
Karim Al-Azizi, MD1, Kyle Gobeil, DO2, Vikram Grewal, MD2, Khawar Maqsood, MD2, Ali Haider, MD2, Amir Mohani, MD2, Gregory Giugliano, MD2, Amir Lotfi, MD2
1 The Heart Hospital, Plano – Baylor Scott & White, 2 Baystate Medical Center – University of Massachusetts Medical School

lDTRA Results:
Procedure related data (n=61) dLTRA was attempted in 61 patients. Access was
Background: Indication for cardiac catheterization successful in 60 patients (98.4%) with one patient
The radial artery is the access of choice in many Unstable angina 18 (29.5) failed cannulation of distal left radial. Conversion
catheterization labs around the world due to its proven NSTEMI 26 (42.6) occurred in 1 patient (1.7%), requiring an additional
benefits over the femoral artery access. Though the right STEMI 1 (1.6) arterial access to complete the coronary
radial artery is the preferred side, there has been growing Non ACS 16 (26.2) angiography. 34 patients (55.7%) required
interest in utilizing the left radial especially in patients with Sheath size percutaneous coronary intervention (PCI).There
bypass grafts. It has been widely criticized due to the lack 5 8 (13.1) were no access site bleeds post procedure, no
of good ergonomics and patient comfort during the 6 53 (86.9) hematomas, with 100% successful hemostasis with
procedure. The distal left radial artery access (dltra) has Diagnostic catheters per case (mean) 2.09 a radial band. There were 2 cases requiring re-
helped resolve these issues. We sought to evaluate the Guiding catheters per case (mean) 1.1 access of the distal left radial artery access for
feasibility, safety and complication rates of the distal left FFR 12 (19.7) repeat revascularization, with procedure success
radial artery access for coronary angiography and PCI 34 (55.7) and good left radial artery patency
intervention. IVUS 6 (9.8)
Coronary artery treated
Left Main 1 (1.6) Conclusion:
Left Anterior Descending Artery 12 (19.7) dLTRA is a safe and feasible arterial access in a
Left Circumflex 10 (16.4) radial experienced catheterization lab. dLTRA
Right Coronary Artery 16 (26.2) provides improved operator ergonomics and
Methods: Mean contrast volume (cc) 126.7 patient’s comfort, in addition to the advantage of
This is a single arm cohort evaluating patients who 4.32 able to cannulate the bypass grafts and with
underwent dlTRA attempt. Patients were consented Mean Lido stick to sheath time minutes very low risk of vascular complications.
for a cardiac catheterization with possible coronary Mean Flouro time (hh:mm:ss) 0:18:18
intervention. The distal left radial artery is accessed Mean Procedure time (hh:mm) 1:34
in the anatomical snuff box, and the sheath is
inserted carefully. The procedure was completed References
using standard diagnostic and guiding catheters.
Hemostasis was achieved with a radial band. Outcomes 1. Kiemeneij F, Laarman GJ (1993) Percutaneous trans-radial artery
approach for coronary stent implantation. Cathet Cardiovasc
Procedure success was defined as ability to Successful completion of the 59/61 Diagn. 30: 173-8.
complete the procedure without conversion to a cardiac catheterization (96.7%) 2. Kiemeneij F, Laarman GJ, Odekerken D (1997) A randomized
comparison of percutaneous transluminal coronary angioplasty by
different access site due to failure of coronary artery Successful cannulation and the radial, brachial and femoral approaches: the access study. J
cannulation. We evaluated the rates of procedure insertion of the sheath through the 60/61 Am Coll Cardiol. 29: 1269-75.
3. Kiemeneij F (2017) Left distal transradial access in the anatomical
success, complication rates and failure of distal left radial artery (98.4%) snuffbox for coronary angiography (ldTRA) and interventions
hemostasis. Conversion rate 1/60 (1.7) (ldTRI). EuroIntervention. 13: 851-857.
4. Al-Azizi KM, Lotfi AS. (2018) The distal left radial artery access for
Major bleeding 0 coronary angiography and intervention: A new era. Cardiovasc
Post-procedure radial band Revasc Med. 2018 Mar 26. pii:S1553-8389(18)30123-4.doi:
hematoma 0 5. Davies RE, Gilchrist IC. Back hand approach to radial access: the
snuff box
Why Robotic PCI?


More data….

Robotic and radial…

Ronald Caputo, Alexander Lesser, Michael Fischi and Alan Simons, ACC15

Madder R, Campbell PT, Caputo R, Kasi V, Mahmud E, Manish P, Marshall JJ, Stys T, Wohns D, Weisz G. TCT conference,
October 13, 2015; San Francisco, CA

Real world data and Cost

Courtesy of Mohanad Hamandi and Srini Potluri

Technique and Cases
Soft wrist restraint Soft wrist restraint

Clip to tie wrist restraint




Courtesy of Prof. Kiemeneij

• Not a “one size fits all”…..radial artery size, hand size, reported complications.

• Patients with large abdominal girth or severe left shoulder arthritis, may not be
good candidates for this access.

• Not an ideal access for an unstable patient.

• Requires radial artery access skillset and experience.

• Tortuous course of the radial artery may be challenging.

• Cost of cassette, expertise in operating the robot, and time consumption in

• Distal left trans-radial artery (snuff box) access for coronary angiography and interventions
is feasible and safe in patients that are carefully selected and are deemed good

• May have further advantages over the traditional right radial access.

• Is not a radial artery access eccentricity…thinking outside the box…

• Left distal radial Robotic PCI adds the advantage of improved guide support and faster
patient recovery with reduced radiation to the operator.

• There is a learning curve for developing such program from a radial and a robotic PCI

• More studies are needed to understand the impact of such alternative upper extremity
arterial access on patient’s outcomes and hand function.
Reduce the Door-to-Phone time

Courtesy of Dr. Kim

Thank you!

Karim Al-Azizi, MD #ldtra
@kalazizimd #RadialFirst