TRANSRADIAL PERIPHERAL VASCULAR INTERVENTIONS
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1 TRANSRADIAL PERIPHERAL VASCULAR INTERVENTIONS Cezar Staniloae NYU Heart and Vascular Institute May 27, 2015
2 Radial Artery is an Ideal Acess Site Easily accessible even in subjects with severe PVD Major advantage in terms of bleeding complications 1,2 Cannulation benefit for most arterial beds Improved quality of life 3 Time-sparing hemostasis Same-day discharge 1. Kiemeneij F, et al. ACCESS Trial. JACC, RIVAL Trial. Lancet Cooper CJ, et al. Am Heart J, 1999
3 ACCUITY - Access Radial (798) Femoral (11988) Stone G et al. N Engl J Med 2006
4 Anthropometric measurements R Wrist - R Carotid = cm R Wrist - L Carotid (bovine arch) = 65-70cm Wrist - Subclavian = 50-65cm L Wrist - Renal A = 90cm L Wrist - Common Iliac = cm L Wrist - CFA = cm L Wrist - Popliteal A= cm L Wrist - Foot= cm
5 Subclavian Artery Stenting Technique 1. Access: 5 Fr short sheath (occasional US guidance) 2. Diagnostic imaging: 5Fr MP 2. Exchange for 5-6 Fr cm sheath 3. Image either retrograde or antergrade 4. Stable position of the camera landmarks 5. PTA / Stenting 6. Final imaging: via sheath or pigtail
6 Subclavian Artery Stenting Ideal guide support Useless femoral access
7 Subclavian Artery Stenting Catheter in the Aorta Stenting Useless catheter from the groin
8 Subclavian Artery Stenting Advantages of Radial Approach 1. Excellent guide support 2. Prevent excessive guide manipulation in the aortic arch 3. Limited contrast use 4. Absent access-site bleeding complications 5. Immediate ambulation 6. Early discharge
9 Carotid Artery Stenting TRA IS the preferred access site for: 1. RICA in the presence of type III aortic arch, or severely disease arch 2. LICA - when it arises from the innominate artery (bovine arch)
10 Carotid Artery Stenting RICA in presence of type III aortic arch, or severely diseased aortic arch
11 LICA in Bovine Arch Technique
12 Carotid Artery Stenting TRA IS NOT the preferred access site for: 1. LICA - lack of support and potential for guide prolapse in the aortic arch
13 Carotid Artery Stenting Technical considerations 1. Advance the 6Fr Shuttle sheath in the subclavian a. 2. Cannulate the R-CCA (or the L-CCA when arising from the innominate artery) using a 5Fr IM / AR-2 catheter 3. Wire the ECA 4. Telescope SS over the 5fr IM
14 Carotid Artery Stenting TRA 2-center report: CAS - attempted from TR in 382 patients Procedural success: 347/382 (91%) patients 201/216 (93%) right CA, 14/16 (88%) bovine left CA 132/150 (88%) left CA. Etxegoien et al. Cath Cardiovasc Interv 2012
15 Carotid Artery Stenting TRA Adverse events at 30 days: 2 major strokes (0.6%) / 1 Death 3 minor strokes (1%) No myocardial infarction No bleeding Etxegoien et al. Cath Cardiovasc Interv 2012
16 Abdominal vessels
17 Renal Artery Stenting Anatomically, the renal arteries take off in a downward fashion - therefore, cannulation is easier from above
18 Renal Artery Stenting Technique: L Radial Access Either 5 Fr / 90 cm Ansel 1 sheath, or 6 fr guiding catheter MP / AR2 / HS
19 Renal Artery Stenting TRA approach - better than femoral: In general Special circumstances: AAA Severe PVD Steeply angulated renal arteries
20 Iliac Artery Stenting L radial is preferred (gain aprox 5-10 cm) IM catheter to direct a 260cm wire in the descending aorta 5 Fr / 110 cm introducer sheaths 5Fr compatible self-expandable stents (Zilver 518 -Cook Medical), or balloon expandable stents
21 Iliac Artery Stenting 5 Fr 110cm sheath Post Stenting 330 cm Viper wire
22 Transradial Iliac Stenting 80 iliac lesions treated via TRA (28%CTO) or TFA (9% CTO) Conclusions: 1. Similar contrast use (238 vs 213 ml) 2. Similar fluoroscopy time (30 vs 27 min) 3. Shorter time to discharge (14.4 vs 20.9 hrs) 4. Lower access-site complications (0 vs 7.2%) Staniloae et al. Cath Cardiovasc interv 2009
23 CFA Interventions No stent zone Frequently - atherectomy + PTA Most atherectomy devices require 7 Fr introducer sheaths DB360 - CSI - the only atherectomy device 5-6 Fr compatible
24 CFA Interventions Left radial access Right CFA occlusion Left CFA occlusion
25 CFA Interventions Shuttle sheath, 6Fr/ 110cm/ via left radial access CROSSER 14S Calcified CFA, SFA, PFA
26 CFA Interventions DB SC 30 PTA 6.0 mm balloon
27 CFA Interventions Post PTA 6.0 at 4 atm Residual Calcified Eccentric Stenosis Residual calcified plaque at the bifurcation
28 CFA Interventions Wire in PFA DB 360 SC Final result
29 New Frontiers SFA / Popliteal Currently - severe limitations do to lack of adequate equipment Atherectomy with DB shaft length 145 cm + 15cm PTA of the SFA with 170/180mm shaft balloons
30 TRA is the approach of choice for stenting of the: 1. Subclavian artery 2. Right Carotid Artery type 3 / diseased arch 3. Left Carotid Artery arising from the innominate a 4. Renal and mesenteric arteries 5. Iliac Arteries
31 Limitations of TRA for Peripheral Interventions Lack of adequate transradial training Limited equipment Paucity of clinical studies
32 Equipment Shortage There is an immediate need for: 1. Larger variety of introducer sheaths (90 / 110 / 125 cm) 2. Longer Guidewires ( cm) 3. Stents with shaft length up to cm 4. CTO / Reentry devices with longer shaft and lower profile
33 TRANSRADIAL for Vascular Interventions BASIC EQUIPMENT Introducer Sheaths: 5 and 6 Fr 90 cm (Terumo); (4-6Fr) 110 cm (Cook) Wires: / 330 Viper (CSI); / 300 Supracor (Abbott); hydrophilic coating (Terumo; Cordis) Balloons: -longest shaft 170/180mm (Cook, Medtronic) Scoring Balloons: Angiosculpt - 5 Fr - up to cm shaft Cutting Ballons - 6 Fr cm Chocolate Balloons: 6 Fr 140 cm lenght Stents: the only 5 Fr platform - Zilver stent (Cook) -125cm 6 Fr platform - longest shaft 135 (Abbott)
34 TRANSRADIAL for Vascular Interventions ADVANCED EQUIPMENT CTO Devices: CROSSER (Bard) cm shaft - 6Fr (14S) Wildcat (Avinger) 6Fr cm; 5Fr cm Frontrunner (Cordis) cm TruePath (Boston Sci) 140cm Reentry Devices: Outback (Cordis) - 6 Fr cm Pioneer (Volcano) - 6 Fr - 120cm Enteer (EV3) 5Fr cm OffRoad (Boston Sci) 5-6 Fr 100cm
35 TRANSRADIAL for Vascular Interventions ADVANCED EQUIPMENT Atherectomy: DB cm reach (145 cm shaft + 15cm though) - all crowns fit in 5 Fr (except 2.0 mm) TurboHawk, JetStream, Laser large profile IVUS: Volcano cm Atlantis (Boston Scientific) cm
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