Cath Lab Digest

Case report

A 55-year-old Caucasian farmer presented to our endovascular clinic with the chief complaints of bilateral hip and thigh claudication, limiting his ability to work on the farm. He had a past medical history of hypertension, ischemic cardiomyopathy, and chronic renal insufficiency. He is an active smoker with 60-pack year of smoking. On his physical exam, his bilateral lower extremity pulses were weak. The right femoral pulse was not palpable. Right leg ankle brachial index (ABI) at posterior tibial was 0.53 and left leg ABI at posterior tibial was 0.67. The pulse volume curve was blunted at every level and suggested iliofemoral disease. 

The initial angiogram was performed through the left common femoral artery (CFA). The right iliac angiogram was performed using a Rösch inferior mesenteric (RIM) catheter, which showed a heavily calcified tortuous artery with a sub-total proximal occlusion (Figure 1). We were unable to advance a 4 French (Fr) straight-tip Glide catheter (Terumo Corporation) or 0.035” Quick-Cross catheter (Spectranetics Corporation) after crossing the lesion with a 0.035” Glidewire (Terumo). Therefore, a right lower extremity run-off angiogram was performed, parking the RIM catheter in right iliac ostia. The right CFA was heavily calcified and totally occluded (Figure 2). The right superficial femoral artery and popliteal artery was patent with moderate calcified disease. There was three-vessel runoff in the right leg. The management plan was discussed with the vascular team at our institute. As the patient was a high-risk surgical candidate, we decided to treat the iliac artery (IA) disease percutaneously, followed by an endarterectomy of the right CFA.

The intervention was performed via the left radial approach using a 6 Fr sheath. After entering the descending thoracic aorta with a J wire, the short sheath was exchanged for a 90 cm Destination sheath (Terumo) and advanced into the distal abdominal aorta. A 125 cm multipurpose catheter was inserted in the right IA (Figure 3). The lesion was very easily crossed with a 0.035” angled Glidewire. The image overlay feature was used to position a balloon and a stent. After pre-dilation with 8 mm x 20 mm EverCross balloon (ev3), a 9 mm x 40 mm Cobalt balloon-expandable stent (Medtronic Corporation) was deployed in the right IA (Figure 4). An excellent angiographic result was noted (Figure 5). The sheath was removed slowly after giving additional intra-arterial nitroglycerine to avoid spasm and a hemostatic band was applied for two hours to achieve patent hemostasis (Figure 6). A total of 70 cc contrast was used and the patient was discharged home three hours post procedure.

Discussion

The use of radial access is expanding worldwide and data supports the use of radial access for peripheral vascular intervention.¹

Advantages

• Femoral access in presence of peripheral vascular disease (PVD) is associated with a higher incidence of complications.² The major bleeding rate of 2% to 6.1%, higher incidences of arteriovenous (AV) fistula, pseudoaneurysm rate of 0.1% to 1.5% in diagnostic procedures, and up to 7.7% in peripheral interventional procedures have been reported.³ Other complications like dissection and thromboembolism are also more likely in the presence of PVD.³
• Radial access is a better and safer alternative than brachial access in patients with occlusive aorto-iliac or femoral disease when the femoral pulse is not palpable.⁴ 
• Similar to the case discussed herein, the crossover through the distal aortic bifurcation is frequently hampered by severe tortuosity and calcification. 
• The radial approach facilitates early ambulation and same-day discharge. Patients with morbid obesity, severe chronic obstructive pulmonary disease (COPD), or spine diseases have the greatest advantage, as they can sit up immediately after the procedure. This also eliminates the need for pressure application in a diseased femoral artery.
• Although the distance from puncture to lesion site makes it look difficult, the geometry is a straight line from the sheath parked in the aorta or IA to a lesion in the Iliac/external iliac artery. This, in turn, provides sufficient support for introducing wire, balloon, and delivering stents. In the case we discuss, we could not advance any catheter after crossing the lesion with a wire through the contralateral femoral approach. 

Technique/recommendations

The following tips may help the reader to begin a transradial peripheral intervention program.