8/25/2014 TRANSRADIAL ILIAC INTERVENTIONS. disclosure. Why Radial. Speaker for Medtronics Consultant for Terumo Speaker for Boston Scientific

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1 John Coppola MD FACC NYU Langone Medical Center TRANSRADIAL ILIAC INTERVENTIONS disclosure Speaker for Medtronics Consultant for Terumo Speaker for Boston Scientific Why Radial Difficult access can t feel the pulse Compression of artery distal to a fresh stent Early ambulation and discharge 1

2 Iliac Difficult groins prior surgery Ca+ with difficult angles to cross over Contralateral disease making cross over more of a problem Ostial disease No need to close or compress after intervention in setting of PVD External iliac disease introducer half in lesion Avoid complications 1996 DeBelder et. Al. retrospective review of 75 cases done via radial for diagnostic coronary or intervention in patients with CAD 97% success rate 2000 Hildick-Smith 297 patients with aorto iliac disease Femoral 79% success radial 91% vascular complications 9/154 femoral 0/143 radial 2008 Garcia reviewed CARP data small # radial no complications overall 1.7% access complications Anthropometric measurements R Wrist - R Carotid = 55-65cm R Wrist - L Carotid (bovine arch) = 55-65cm 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 2

3 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) 1. Shorter time to discharge (14.4 vs 20.9 hrs) 2. Lower access-site complications (0 vs 7.2%) Staniloae et al. Cath Cardiovasc interv 2009 Iliac Artery Stenting L radial is preferred (gain aprox 10 cm) 5-6 Fr / 110 cm introducers Any unilateral angioplasty and stenting can be performed either with 5Fr compatible selfexpandable stents (Cook Medical), or balloon expandable stents Iliac Artery Stenting 6 Fr 110cm sheath Post Stenting 330 cm Viper wire 3

4 Case Type 2 diabetes hyperlipidemia and hypertension Rutherford Class III claudication Non invasive data high grade rt iliac lesion The patient BMI 1.3 procedure Will use the left wrist for iliac procedures avoids the arch and allows for 6-8 cm more working length. Set up to allow for arm to be moved. Short 5 Fr introducer Standard IMA diagnostic catheter 260 cm wire follow passage to avoid spinal braches 4

5 equipment Standard 5 Fr short introducer 5 Fr IMA diagnostic catheter 260 cm guide wire 6Fr 90 cm coated introducer (110 cm most often used) 300 cm guide wire 5x80 balloon shaft 135cm 6x80 Zilver stent Control angiogram Can get distal vessels Decrease frame rate 5

6 Post PTA Positioning of stent 6

7 Post stenting 7

8 Transradial Approaches to Peripheral Intervention Douglas E. Drachman, M.D., F.A.C.C. Division of Cardiology Vascular Medicine Section August 26, 2014 Disclosure Information Douglas E. Drachman, M.D. Abbott Vascular, Inc.: Advisory Board Atrium Medical Corporation: Research Grant Support idev Technologies, Inc.: Research Grant Support Lutonix/BARD: Research Grant Support PLC Medical Systems, Inc.: Clinical Events Committee Prairie Education & Research Cooperative: Data Safety & Monitoring Board Off-label use of products will be discussed in this presentation as indicated. Many stents used in the peripherial arterial circulation are indicated for biliary or tracheal application. Objectives Transradial access benefit Vascular complication avoidance Strategic access Parallels, differences compared with coronary Logistical considerations Example cases 1

9 Transradial access benefit Reduced bleeding risk Patient comfort Early ambulation Same day discharge is feasible Vascular Access Bleeding Risk Aortoiliac Issues (AAA, sev athero, tortuosity) Equipment options Backup support Downgoing artery Radial Brachial Femoral Courtesy of H. Arnonow Logistical considerations Length of catheter systems and distance to lesion 135cm baloon/shaft measures from tip to hub e.g. a 10cm balloon on a 135cm shaft will not extend out of a 125cm long guide Length of Tuohy-Borst affects length of system 2

10 Logistical considerations Caliber of sheath/guide necessary to accommodate stent 6F guide has larger lumen and smaller OD than 5F sheath Consider sheathless insertion Use the left wrist Shorter distance to target Avoid traversing the arch/vessels Example opportunities for transradial peripheral intervention: Carotid/vertebral Subclavian Renal Mesenteric Iliac CFA/PFA SFA A recent consult for ARF,CHF, malignant HTN Our clinical dx: renal artery stenosis Our plan: renal intervention Multiple exams documented palpable but diminished distal pulses and femoral bruits To our exam: no palpable leg pulses Monophasic doppler at femorals 3

11 We found an I+ CT scan from prior admission We used radial access Special Circumstances: Morbid Obesity We used radial access 4

12 Be aware of vascular tortuosity/redundancy Guide may lack longitudinal stability Left subclavian stenting from the wrist 5F HC 90 cm sheath 5

13 Left subclavian stenting from the wrist 5F HC 90 cm sheath Arch aortagram Left subclavian stenting from the wrist 5F HC 90 cm sheath Arch aortagram Baseline subclavian angiogram Left subclavian stenting from the wrist 5F HC 90 cm sheath Arch aortagram Baseline subclavian angiogram Balloon/stent 6

14 Left subclavian stenting from the wrist 5F HC 90 cm sheath Arch aortagram Baseline subclavian angiogram Balloon/stent Final angio (restoration of antegrade flow) Simultaneous radial and femoral access: A hostile left subclavian lesion Baseline (groin sheath) EPD from wrist PTA/stent Simultaneous radial access: adjunct Final angio Debris in EPD 7

15 Abdominal aortic intervention 64yo F with claudication Prior ABF for AAA CTA at OSH: Severe stenosis graft proximal anastomosis Plan: L radial access (ideally 6F sheath) to permit PTA/stent of aorta Avoid ABF access L radial access unsuitable anatomy Aortagram 8

16 Crossed antegrade, snared retrograde PTA/stent from the leg CAN get there from here! Transradial access and benefits Solitary kidney, EVAR, severe EIA/CFA/RSFA PAD 9

17 CAN get there from here! Transradial access and benefits CAN get there from here! Transradial access and benefits Transradial access is not infallible Aseptic granuloma vs. abscess I & D and abx 10

18 Conclusions Transradial access Vascular complication avoidance Strategic access Parallels, differences compared with coronary Logistical considerations Tailor approach to suit patient/lesion 11

19 Advanced Challenges with Transradial Access and Hemostasis Samir B. Pancholy, MD Anterior puncture Radial Artery Access Counterpuncture Disclosures Teaching honoraria: Medtronic Terumo 1

20 Radial Artery Access TR vs. TF access smaller needle (20 or 16 ) bare-needle vs. teflon-sheathed needle or guidewire Puncture techniques Anterior puncture technique femoral access similar to Anterior puncture technique 2

21 Anterior puncture technique Counterpuncture technique RATE trial Pancholy SB, SanghviKA, Patel TM. Catheter Cardiovasc Interv Aug 1;80(2):

22 Technical tips Immobilize the radial artery to prevent rolling Technical tips Immobilize the radial artery to prevent rolling Using counterpuncture technique using a teflon-sheathed needle, a steep angle entry in the artery may be more successful Technical tips Immobilize the radial artery to prevent rolling Using counterpuncture technique using a teflon-sheathed needle, a steep angle entry in the artery may be more successful After removal of metallic stylet, flattening the teflon cannula in the process of withdrawing it, makes it co-axialize with the radial lumen 4

23 Counterpuncture 5

24 Withdraw Teflon cannula parallel to skin 6

25 Kinking is prevented by constant pull Upon entry into lumen from posterior wall, cannula straightens out Upon entry into lumen from posterior wall, cannula straightens out 7

26 Upon entry into lumen from posterior wall, cannula straightens out Anterior puncture / metallic needle users, enter at shallow angle Anterior puncture / metallic needle users, enter at shallow angle 8

27 Anterior puncture / metallic needle users, enter at shallow angle Modified Counterpuncture technique Hydrophilic sheath Less spasm (Saito et al, Rathore et al), Increased comfort? Less entrapment? Less RAO 9

28 Radial Cocktail Vasodilators (prevent spasm) mcg IA) Calcium channel blockers 5 mg, Verapamil 2.5 mg IA Nitrates (200 Diltiazem Anticoagulants Prevent radial artery occlusion Anticoagulants Unfractionated heparin at least 50 U/Kg (Spaulding et al, Leipzig study, Bernat et al) systemic effect, IA vs IV (Pancholy et al) 10

29 Anticoagulation Effect probably related to degree of anticoagulation Seen with Bivalirudin (Plante et al) Summary Use dedicated access equipment?counterpuncture faster, first-attempt success Hydrophilic introducer sheath Spasmolytic cocktail Anticoagulation Summary Use dedicated access equipment?counterpuncture faster, first-attempt success Hydrophilic introducer sheath Spasmolytic cocktail Anticoagulation Prevent the urge to re-invent the wheel for the first 1000 cases 11

30 Radial hemostasis The easiest part of the procedure. The main reason for attractiveness of TRA Radial artery hemostasis Radial artery lies on the flat portion of radius No major neurovascular structures Ulnar collateralization prevents ischemia Well tolerated Distal forearm anatomy 12

31 Common Methods Sheath is removed and Hemoband / TR band is applied Patient can sit up immediately after the procedure Ambulation can occur as soon as patient steady. Radial artery hemostasis Most significantly affects radial artery outcomes Radial artery hemostasis Most significantly affecting radial artery outcomes Most CAD patients will need more than one procedure 13

32 % 8/25/2014 Radial artery occlusion Asymptomatic Symptomatic Inflammatory (radial arteritis) Ischemic (embolic) Limits future ipsilateral TRA Radial Artery Occlusion Rates Early Late Pre-Patent hemostasis NR NR Sanmartin Rathore Plante Pancholy UFH u/kg UFH 70 u/kg UFH 70 u/kg UFH 50u/kg Anticoagulation Or Bivalirudin Coutesy of SV Rao, MD Heparin and RAO Incidence of RAO (%) No I.U 2000 I.U 5000 I.U Heparin I.U Spaulding et al Bernat et al Incidence of RAO (%) 14

33 Heparin and RAO Incidence of RAO (%) Non-pharmacologic strategies No I.U 2000 I.U 5000 I.U Heparin I.U Spaulding et al Bernat et al Incidence of RAO (%) Radial artery Hemostasis PREVENTION OF RADIAL ARTERY OCCLUSION Mechanism of RAO Flow cessation During procedure: Caused by hardware 15

34 Mechanism of RAO Flow cessation During procedure: Caused by hardware Caused by spasm Mechanism of RAO Flow cessation During procedure: Caused by hardware Caused by spasm After procedure: Mechanism of RAO Flow cessation During procedure: Caused by hardware Caused by spasm After procedure: Caused by compression 16

35 Mechanism of RAO Flow cessation During procedure: Caused by hardware Caused by spasm After procedure: Caused by compression Caused by residual spasm Mechanism of RAO Mechanism of RAO Thrombosis (acute) Rapid organization with fibrotic lumen obliteration 17

36 Mechanism of RAO Mechanism of RAO Mechanism of RAO 18

37 Mechanism of RAO Mechanism of RAO Mechanism of RAO Flow cessation During procedure: Caused by hardware Caused by spasm After procedure: Caused by compression Caused by residual spasm 19

38 Prevention of RAO During the procedure Use lowest profile hardware Systemic anticoagulation Radial artery hemostasis Absent radial flow At applica on At removal Sanmartin et al CCI 2007; 70: Radial artery hemostasis Interruption of radial flow highly predictive of subsequent radial artery occlusion Sanmartin et al CCI 2007; 70: RAO No RAO 20

39 Active radial hemostasis Attention to hemostasis Attention to radial artery patency Periodic monitoring of radial artery patency Patent Hemostasis P < 0.05 % Pancholy S et al, CCI 2008;72: Patent Hemostasis 21

40 Patent Hemostasis Patent Hemostasis Patent Hemostasis 22

41 Patent Hemostasis Patent Hemostasis Patent Hemostasis 23

42 Patent Hemostasis Ideal Hemostasis Have we made a difference? 24

43 % 8/25/2014 Radial Artery Occlusion Rates 12 Early Late 10.5 Pre-Patent hemostasis Post-Patent hemostasis NR NR Sanmartin Rathore Plante Pancholy Cubero Bernat Anticoagulation UFH u/kg UFH 70 u/kg UFH 70 u/kg UFH 50u/kg UFH u/kg UFH 5000 u Or Bivalirudin Patent hemostasis No No No Yes Yes Yes + Ulnar compression Summary Use lowest profile hardware Use systemic anticoagulation Use patent hemostasis technique New ideas? Thank you 25

44 8/21/2014 Jeffrey M. Schussler, MD, FACC, FSCAI Baylor University Medical Center, Dallas, Tx I have no financial relationships with any medical company or any conflicts of interest. A society with so many disclaimers has too many lawyers. 51 year old man, presented to a satellite hospital (no PCI capabilities) with 2 hours SSCP EKG showed ST elevation, inferior / lateral leads 1

45 8/21/2014 Given potential prolonged transfer / d2b time, lytics (Retavase) were given, along with aspirin and clopidogrel He was transferred to our facility within 60 minutes. EKG was improved, but he continued to have chest pain. Given ongoing (albeit improved) chest pain, he was taken to the cath lab. 2

46 8/21/2014 6Fr, right radial approach, 5 mg verapamil Bivalirudin used Jacky diagnostic catheter 3

47 8/21/2014 EBU 3.75 Guide 3mm x 23 mm Promus 3.5 post dilation balloon Complete resolution of symptoms EF 50%, without residual cardiomyopathy Peak troponin ~4 Discharged at 48 hour mark (on aspirin, clopidogrel, carvedilol, lisinopril, and atorvastatin). 4

48 8/21/2014 High Volume Radial Operators Low use of bivalirudin High use of 2b/3a antagonists (>60 %) Conclusion: The reduction in bleeding events / mortality of transradial approach for STEMI may be over-stated, or just may not reflect what we do in the US in clinical practice. Lower fear of bleeding despite additional anti-coagulation / antiplatelet Earlier ambulation Lower risk of morbidity in obese patients and groin complications Learning curve Guide sizing inability to use >6Fr guides What if we need to place a balloon pump or impella? New equipment? Radial access and door to balloon times 5

49 8/21/2014 The fundamental mechanics of PCI through transradial approach are the same. Once the guide is engaged, it s pretty much business as usual. Most PCI (even complex) can be done through 6Fr Learning Curve: Get some cases under your belt doing elective cases before trying STEMIs. The lowest hanging fruit are the highest risk for bleeding: already on anti-coagulation, lytics. Little old ladies are the hardest radial cases, but may gain the most. Avoid at first. Left system: use slightly shorter guides, and engage with wire in the catheter. D2B times awareness of door-time, and not try to attempt radial PCI Impella / IABP Transradial approaches for STEMI do not handicap an operator once over the learning curve hump, and can afford a safer route for PCI in the highest risk patients. 6