8/25/2014 · 8/25/2014 1 TRANSRADIAL ILIAC ... with 5Fr compatible self-expandable stents (Cook ... •Our clinical dx: renal artery stenosis •Our plan:

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TRANSRADIAL ILIAC INTERVENTIONS

John Coppola MD FACCNYU Langone Medical Center

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

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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

Wrist - Subclavian = 50-

65cm

L Wrist - Renal A = 90cm

L Wrist - Common Iliac = 105-115cm

L Wrist - CFA = 125-

135 cm

R Wrist - R Carotid = 55-65cm

R Wrist - L Carotid (bovine arch) =

55-65cm

L Wrist - Popliteal A= 155-

170 cm

Anthropometric measurements

L Wrist - Foot= 200-230 cm

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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 self-expandable stents (Cook Medical), or balloon expandable stents

Iliac Artery Stenting

6 Fr 110cm sheath

Post Stenting

330 cm 0.014” Viper wire

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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 0.035” wire follow passage to avoid spinal braches

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equipment

Standard 5 Fr short introducer

5 Fr IMA diagnostic catheter

260 cm 0.035 guide wire

6Fr 90 cm coated introducer (110 cm most often used)

300 cm 0.014 guide wire

5x80 balloon shaft 135cm

6x80 Zilver stent

Control angiogram

Can get distal vessels

Decrease frame rate

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Post PTA

Positioning of stent

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Post stenting

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Transradial Approaches to

Peripheral Intervention

Douglas E. Drachman, M.D., F.A.C.C.

Division of Cardiology

Vascular Medicine Section

August 26, 2014

Drachman 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.

Drachman 2014

Objectives

• Transradial access benefit

– Vascular complication avoidance

– Strategic access

– Parallels, differences compared with coronary

• Logistical considerations

• Example cases

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Drachman 2014

Transradial access benefit

• Reduced bleeding risk

• Patient comfort

• Early ambulation

• Same day discharge is feasible

Drachman 2014

Bleeding Risk Aortoiliac Issues

(AAA, sev athero,

tortuosity)

Equipment

options

Backup

support

Downgoing

artery

Radial ↑ +++ + ++ +++

Brachial ↑↑↑ +++ ++ +++ +++

Femoral ↑↑ + +++ + +

Courtesy of H. Arnonow

Vascular Access

Drachman 2014

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

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Drachman 2014

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

Drachman 2014

Example opportunities for transradial

peripheral intervention:

• Carotid/vertebral

• Subclavian

• Renal

• Mesenteric

• Iliac

• CFA/PFA

• SFA

Drachman 2014

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

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Drachman 2014

We found an I+ CT scan from prior admission

Drachman 2014

We used radial access

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Special Circumstances: Morbid Obesity

We used radial access

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Be aware of vascular tortuosity/redundancy

Drachman 2014

Guide may lack longitudinal stability

Drachman 2014

Left subclavian stenting from the wrist

• 5F HC 90 cm sheath

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Drachman 2014



• Arch aortagram

Drachman 2014



• Arch aortagram

• Baseline subclavian

angiogram

Drachman 2014



• Arch aortagram


angiogram

• Balloon/stent

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Drachman 2014



• Arch aortagram


angiogram

• Balloon/stent

• Final angio (restoration of

antegrade flow)

Drachman 2014

EPD from wrist

Simultaneous radial and femoral access:

A “hostile” left subclavian lesion

Baseline

(groin sheath) PTA/stent

Drachman 2014

Simultaneous radial access: adjunct

• Final angio

• Debris in EPD

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Drachman 2014

• 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

64yo F with claudication

Abdominal aortic intervention

Drachman 2014

L radial access… unsuitable anatomy

Drachman 2014

Aortagram

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Drachman 2014

Crossed antegrade, snared retrograde

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PTA/stent from the leg

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CAN get there from here!

Transradial access and benefits

Solitary kidney, EVAR, severe EIA/CFA/RSFA PAD

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Drachman 2014



Drachman 2014



Drachman 2014

Transradial access is not infallible

Aseptic granuloma vs. abscess

I & D and abx

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Drachman 2014

Conclusions

• Transradial access

– Vascular complication avoidance

– Strategic access

– Parallels, differences compared with coronary

• Logistical considerations

• Tailor approach to suit patient/lesion

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Advanced Challenges with Transradial Access and Hemostasis

Samir B. Pancholy, MD

Radial Artery Access

• Anterior puncture

• Counterpuncture

Disclosures

• Teaching honoraria:MedtronicTerumo

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Radial Artery Access

• TR vs. TF accesssmaller needle (20” or 16”)

bare-needle vs. teflon-sheathed needle

0.018” or 0.021” guidewire

Puncture techniques

• Anterior puncture technique similar to

femoral access

Anterior puncture technique

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Anterior puncture technique

Counterpuncture technique

RATE trial

Pancholy SB, Sanghvi KA, Patel TM. Catheter Cardiovasc Interv. 2012 Aug 1;80(2):288-91

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Technical tips

• Immobilize the radial artery to prevent “rolling”

Technical tips


• Using counterpuncture technique using a teflon-sheathed needle, a “steep” angle entry in the artery may be more “successful”

Technical tips


• 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

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Counterpuncture

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Withdraw Teflon cannula parallel to skin

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Kinking is prevented by constant pull

Upon entry into lumen from posterior wall, cannula “straightens” out


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Anterior puncture / metallic needle users, enter at “shallow” angle


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Modified Counterpuncture technique

Hydrophilic sheath

• Less spasm (Saito et al, Rathore et al),

• Increased comfort

• ? Less entrapment

• ? Less RAO

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Radial Cocktail

• Vasodilators (prevent spasm)Nitrates (200

mcg IA) Calcium channel blockers

Diltiazem 5 mg, Verapamil 2.5 mg IA

Anticoagulants

• Prevent radial artery occlusion

Anticoagulants

• Unfractionated heparinat least 50 U/Kg (Spaulding et al,

Leipzig study, Bernat et al)systemic effect, IA vs

IV (Pancholy et al)

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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

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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

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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.


• Most significantly affects radial artery outcomes


• Most significantly affecting radial artery outcomes

• Most CAD patients will need more than one procedure

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Radial artery occlusion

• Asymptomatic

• Symptomatic Inflammatory (radial arteritis)Ischemic (embolic)

• Limits future ipsilateral TRA

10.5

9.0

5.0

6.9

5.3

1.8

0

2

4

6

8

10

12

Sanmartin Rathore Plante Pancholy

%

Radial Artery Occlusion Rates

Early Late

NRNR

Anticoagulation UFH 70-100 u/kg UFH 70 u/kgOr Bivalirudin

UFH 70 u/kg UFH 50u/kg

Pre-Patent hemostasis

Coutesy of SV Rao, MD

Heparin and RAO

0

10

20

30

40

50

60

70

80

NoHeparin

2000-3000I.U

5000 I.U 2000 I.U 5000 I.U

Incidence of RAO (%)


Spaulding et al Bernat et al

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Heparin and RAO

0

10

20

30

40

50

60

70

80

NoHeparin

2000-3000I.U

5000 I.U 2000 I.U 5000 I.U



Spaulding et al Bernat et al

Non-pharmacologic strategies

Radial artery Hemostasis

PREVENTION OF RADIAL ARTERY OCCLUSION

Mechanism of RAO

• Flow cessationDuring procedure:

Caused by hardware

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Mechanism of RAO


Caused by hardware Caused by spasm

Mechanism of RAO



After procedure:

Mechanism of RAO



After procedure: Caused by compression

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Mechanism of RAO



After procedure:Caused by compression Caused by residual spasm

Mechanism of RAO

Mechanism of RAO

• Thrombosis (acute)

• Rapid organization with fibrotic lumen obliteration

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Mechanism of RAO

Mechanism of RAO

Mechanism of RAO

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Mechanism of RAO

Mechanism of RAO

Mechanism of RAO



After procedure: Caused by compression Caused by residual spasm

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Prevention of RAO

• During the procedure Use lowest profile hardware Systemic anticoagulation

Radial artery hemostasisAbsent radial flow

0

10

20

30

40

50

60

70

Atapplica on Atremoval

Sanmartin et al CCI 2007; 70: 185-9


• Interruption of radial flow highly predictive of subsequent radial artery occlusion.

0

10

20

30

40

50

60

70

80

90

100

RAO NoRAO

Sanmartin et al CCI 2007; 70: 185-9

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Active radial hemostasis

Attention to hemostasis

Attention to radial artery patency

Periodic monitoring of radial artery patency

Patent Hemostasis

%

Pancholy S et al, CCI 2008;72:335-40

P < 0.05

Patent Hemostasis

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Patent Hemostasis

Patent Hemostasis

Patent Hemostasis

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Patent Hemostasis

Patent Hemostasis

Patent Hemostasis

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Patent Hemostasis

Ideal Hemostasis

Have we made a difference?

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10.5

9.0

5.0

1.1 0.8

6.9

5.3

1.8

0

2

4

6

8

10

12

Sanmartin Rathore Plante Pancholy Cubero Bernat

%

Radial Artery Occlusion Rates

Early Late

NRNR

Anticoagulation

Patent hemostasis

UFH 70-100 u/kg

No

UFH 70 u/kgOr Bivalirudin

No

UFH 70 u/kg

No

UFH 50u/kg

Yes

UFH 70-100 u/kg

Yes

UFH 5000 u

Yes +Ulnar compression

Pre-Patent hemostasis Post-Patent hemostasis

Summary

• Use lowest profile hardware

• Use systemic anticoagulation

• Use patent hemostasis technique

• New ideas?

Thank you

8/21/2014

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Jeffrey M. Schussler, MD, FACC, FSCAI

Baylor University Medical Center, Dallas, Tx

[email protected]

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

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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.

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6Fr, right radial approach, 5 mg verapamilBivalirudin usedJacky diagnostic catheter

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EBU 3.75 Guide3mm x 23 mm Promus3.5 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).

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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 / anti-platelet

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

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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.

Documents

8/25/2014 · 8/25/2014 1 TRANSRADIAL ILIAC ... with 5Fr compatible self-expandable stents (Cook ... •Our clinical dx: renal artery stenosis •Our plan: