Disclosure: Dr. Sangvhi reports he is a member of the speakers’ bureau for Medtronic. Dr. Pancholy reports he is a technical consultant for the transradial product line for Terumo and a speaker for Pfizer.
Dr. Sanghvi can be contacted at firstname.lastname@example.org.
A 65-year-old Caucasian male patient was referred to our endovascular clinic with the chief complaint of disabling left hip pain on minimal exertion. The left hip pain was progressively worse over 3 years. He was seen by two different orthopedic surgeons and was treated for arthritis and arthralgia. A first-year orthopedic resident, who on evaluation recognized poor peripheral pulsations, ordered an ankle-brachial index (ABI) and pulse volume ratio (PVR), and referred him to us. His past medical history included borderline hypertension. His past surgical history included laminectomy for cervical spine 3 years prior. He is an active smoker with 50-pack year of smoking. On his physical exam, his left lower extremity pulses at the dorsalis pedis were non-palpable and he had 1+ palpable pulses at the right dorsalis pedis. The left femoral pulse was weakly palpable. Right leg ABI at the posterior tibial was 0.91 and left leg ABI at the posterior tibial was 0.39 (Figure 1). The pulse volume curve was blunted at high thigh level on the left lower extremity, suggesting iliofemoral disease.
The diagnostic peripheral angiography procedure was performed via a left radial approach. Using a posterior wall puncture technique, a 6 French (Fr) Glide sheath (Terumo Corporation) was inserted over the wire. A 260 cm standard 0.035-inch J wire, along with a 110 cm long pigtail catheter, was advanced to the arch of the aorta. The pigtail catheter was rotated to face the pigtail towards the descending thoracic aorta. The 0.035-inch J wire was pushed to open the pigtail, and the guide wire was directed to the descending thoracic aorta and further into the abdominal aorta. We routinely administer 50 u/kg of heparin for every diagnostic procedure through radial access to prevent radial artery occlusion.
Using the pigtail catheter, distal abdominal aortography with peripheral runoff angiography was performed. An ostial left iliac artery chronic total occlusion (CTO) was identified (Figure 2). Collaterals from the right inferior hypogastric artery reconstituted the left common femoral artery (Figure 3). Further in the left superficial femoral artery, there was tubular, severe stenosis. The right lower extremity circulation was affected with mild to moderate non-obstructive atherosclerotic stenosis.
A hybrid approach to revascularize was planned with an initial attempt to cross the CTO via a retrograde approach from the left femoral access distal to the reconstitution. An additional 30u/kg heparin was given. Guided by the angiography, a micro-puncture needle was used to access the left common femoral artery and an 0.018-inch wire was inserted through a micro-dilator (0.018-inch). Wire escalation technique with an 0.018-inch V-18 Control wire (Boston Scientific) was attempted to cross the left iliac CTO unsuccessfully (Figure 1). At this point, the left radial short sheath was exchanged for a 90 cm Destination sheath (Terumo) and advanced into the distal abdominal aorta bifurcation (Figure 5). Wire escalation technique using an 0.018-inch V 18 control wire and an 0.018-inch Quick-Cross catheter (Spectranetics Corporation) was used to cross through the left iliac CTO successfully. The wire was initially inserted into the left profunda femoris artery (Figure 3). Subsequently, a 5.0mm x 100mm over-the-wire (OTW) balloon was inserted into the left external iliac artery (Figure 4). A 7.0mm x 100mm OTW balloon was inflated into the proximal left femoral artery and external iliac artery while removing the 0.018-inch wire from the femoral access. An 8mm x 150mm balloon was used to pre-dilate the left iliac and external iliac artery (Figure 5). Further 8mm x 80mm and 9mm x 120mm Protégé Everflex self-expanding stents (Medtronic) were deployed in an overlapping fashion. An optimal final angiographic result was obtained (Figure 6). The sheath was removed slowly after intra-arterial nitroglycerin was administered. A hemostatic band was applied using patent hemostasis technique. The patient was discharged home 4 hours after completing the procedure. At one-month follow-up, the patient had dramatically improved symptoms and capacity to ambulate.
With a clear understanding of the superiority of radial access in terms of safety, patient preference, early ambulation, early discharge, and cost savings, the use of radial access is expanding worldwide, beyond its use for cardiac catheterization and interventions. There are multiple case reports and registries supporting the feasibility of radial access for endovascular peripheral interventions.1 This case exemplifies the versatility added by multiple accesses to treat a very complex chronic total occlusion with hybrid antegrade and retrograde approaches.
The advantage of radial access for reducing access-related complications is pronounced in the presence of peripheral vascular disease (PVD). Femoral access in the presence of PVD is associated with a higher incidence of complications.2 A major bleeding rate of 2% to 6.1%, higher incidence of arteriovenous (AV) fistula, a 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 such as 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 Frequently, the crossover through the distal aortic bifurcation from the contralateral femoral access is hampered by severe tortuosity and calcification. A radial approach facilitates early ambulation and same-day discharge. Patients with morbid obesity, severe chronic obstructive pulmonary disease, 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 the puncture to the lesion site makes it appear difficult, the geometry of a straight line of the sheath parked in the aorta with a long vertical column provides good support, as in this case, while crossing a calcified CTO with a wire, balloon, and stents.
Diameter and distance are the two major limitations for radial access for endovascular intervention. Most radial arteries will only allow use of a 6 French system. The newer Assurant cobalt balloon-expandable stents (Medtronic), expandable up to a 10 mm diameter, can be used through a 6 Fr sheath. To improve the efficacy of radial access, sheaths of at least a 110-125cm length would be required to allow adequate guidance and better support during the intervention. This implies availability of balloon and stent shafts of at least 135-150 cm in length, preferably rapid-exchange shafts. In the event of iliac perforation, a 6 Fr sheath will not allow deploying a covered stent. A balloon should be used to tamponade the perforation while femoral access is achieved and a covered stent is advanced. Radial spasm is more likely with the long sheath, more so while withdrawing the sheath. Pretreatment with vasodilators, analgesics, and meticulous flushing of the sheath when it is withdrawn into the radial artery will reduce pain and the radial occlusion rate.
- Sanghvi K, Staniloae C, Coppola J. Transradial intervention of iliac and femoral artery: a case report study. J Interv Cardiol. 2008 Oct; 21(5): 385-387.
- Judkins M, Gander M. Prevention of complications of coronary arteriography. Circulation. 1974; 49: 599-602.
- Samal AK, White CJ. Percutaneous management of access site complications. Catheter Cardiovasc Interv. 2002 Sep; 57(1): 12-23.
- Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol. 1997 May; 29(6): 1269-1275.