Interventional Round Direct Coronary Stenting by Transradial Approach: Rationale and Technical Issues Francesco Burzotta, 1 * MD, PhD, Martial Hamon, 2 MD, Carlo Trani, 1 MD, and Ferdinand Kiemeneij, 3 MD Direct stent implantation using radial approach represents to date the less invasive, less traumatic strategy to perform a percutaneous coronary intervention, rendering its adop- tion an attraction for many interventional cardiologists. A growing series of reports suggests the feasibility of transradial direct stenting in a variety of clinical situations. Here we discuss the main advantages of the adoption of this technique. Moreover, a detailed analysis of the technical issues specifically related with each phase of transra- dial direct stenting procedures is reported. Catheter Cardiovasc Interv 2004;63:215–219. © 2004 Wiley-Liss, Inc. Key words: percutaneous coronary interventions; direct stenting; radial approach TECHNICAL FEASIBILITY OF DIRECT STENT IMPLANTATION Direct stent implantation (direct stenting, DS) consists of the implantation of stent without predilation of the lesion with the balloon (conventional stenting, CS). Its affirmation in the common practice has been related to the improvement in stent’s technical characteristics (crimping on the balloon, low profile, pushability, etc.). The feasibility of the DS technique in selected coro- nary lesions has been suggested by some authors in the late 1990s and then assessed in a series of subsequent randomized trials [1]. The coronary lesions that have been considered eligible for DS in such studies were constantly short, nonocclusive, noncalcified, nonbifur- cated, and localized in vessels without relevant tortuosity and were mainly approached by the femoral artery. The first important message arising from such trials [2] is that, in selected lesions, DS, compared to CS, warrants the same angiographic success rates. In the randomized studies, despite the exclusion criteria adopted, DS failed in an overall rate of 6% of the cases requiring crossover to predilation. A series of preprocedural characteristics has been associated with failure of DS: the circumflex artery location, the distal location, the lesion complexity, the stent length, the presence of visible calcifications, and older age of patients. However, if carefully done, the attempt to direct implant a stent has been found not to be associated with stent loss or any specific adverse event [2]. Recent reports have suggested the safety and feasibil- ity of DS also in more anatomically complex lesions such as the long ones (requiring  18 mm stents) [3] and in those with relevant side branches ( 1 mm) [4], thus extending the field of application for this technique. A series of advantages may be associated with the adoption of DS technique. The first evident advantage is related with the optimization of the resources of the catheterization laboratory: a meta-analysis of 10 random- ized trials comparing DS with CS reported an overall 17% procedural time, 18% fluoroscopy time, 11% con- trast volume, and 22% cost reduction with DS [2]. More- over, the DS technique implies a modification in the approach to coronary lesion dilation, potentially reducing vessel trauma and plaque embolization. The possible beneficial clinical consequences have not been clearly stated. Nonrandomized data suggest a reduction in the 1 Institute of Cardiology, Catholic University, Rome, Italy 2 Department of Cardiology, University Hospital of Caen, Caen, France 3 Amsterdam Department of Interventional Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands *Correspondence to: Dr. Francesco Burzotta, Via Prati Fiscali 158, 00141 Rome, Italy. E-mail: f.burzotta@eudoramail.com Received 23 October 2003; Revision accepted 15 April 2004 DOI 10.1002/ccd.20126 Published online in Wiley InterScience (www.interscience.wiley.com). Catheterization and Cardiovascular Interventions 63:215–219 (2004) © 2004 Wiley-Liss, Inc.