Transradial artery access for iliac/SFA intervention - Zoltan Ruzsa

1. Zoltán Ruzsa MD PhD

2. Financial disclosures
No conflict of interest to declare

3. Access site selection for lower limb interventions
0
50
100
150
200
250
300
350
1 2 3 4 5 6
Femoral
Radial
Brachial
Dual- Radial + Femoral
Dual- Radial + Transpedal
Dual- Femoral + Transpedal

4. Access: Foundation of Complex Interventions
• Establish “in-line” flow from
aorta to foot…access is key!
– Retrograde access: Discrete
stenotic disease
– Antegrade CFA access:
Ideal for long occlusive disease; retained
‘pushability,’ torque
– Pedal access: Unsuccessful
antegrade approach (AT/PT)

5. Access sites for lower limb interventions
Conventional access
• Ad 1. Femoral
• Antegrade femoral
• Cross over
• Distal femoral retro
• Ad 2. Popliteal
• Ad 3. Brachial
• Ad 4. Transpedal
Slender technique
• Ad 5. Radial and Ulnar
• Ad 4. Transpedal

6. Transpedal punction- dist. ATA

7. Ultrasound guided puncture

8. Z. Ruzsa et al. Catheter Cardiovasc Interv. 2014 May 1;83(6):997-1007

9. Seems to be perfect technique, but…….
• High rate of vascular complications
• Femoral artery bleeding (Incidence ≤6%)
• Retroperitoneal haematoma (Incidence ≤3%)
• Pseudoaneurysm (Incidence by US ≤6%)
• AV fistula (Incidence ≤0.4%)
• Ischemia /emboli (Incidence ≤1%)
• Groin infection (Incidence ≤0.2%)
• Increased hospital stay
• The patients does not prefer the technique

10. Routine access site selection- iliac
- Multilevel disease
Iliac + Femoral + BTK
- Complex CTO
- Distal stenosis
- Non diseased
CFA
Retrograde
femoral
- EIA stenosis close
to the CFA
- Diseased CFA
Cross over Brachial or radial
access
- Scar
- Bypass
- Stents in the iliac
ostium
- Extreme
angulation
- Extreme
tortuosity
Is there a place for primary radial access for iliac artery intervention ???

11. Iliac artery intervention- Femoral
Advantages
• Easy
• Fast
• Unlimited use of 6-8F
compatible devices
• Good pushability
Disadvantages
• Vascular complications up to 1-5%
• Late mobilisation
• CFA too close to the lesion
• Cross over is sometimes impossible
• Limited use of closure devices
• Difficult reentry in CTO cases
A. B. C.

12. Transradial iliac intervention
Pts: 156 consecutive pts
Success: 155 (99.4%)
Cross over: 3.8%
Access site complications: 5.1%
Only minor !!
Learning curve: important role
Left or right side: not different

13. Sheathless guiding
Coronary SG 8.5 F 100 cm
Internal D: 2.28 mm
External D: 2.8 mm
Peripheral SG 6F 120 cm
Internal D: 2.29 mm
External D: 2.8 mm

14. Methods: Angioplasty technique
• Medical therapy
– Transradial cocktail (NaHeparin 5000 U and Verapamil
– Per os Aspirin and Clopidogrel
– Heparin up to 100 U/kg
• Punction
– Local anestesia and 5F TR sheath
• Diagnostic angiography
– 125 cm Pig tail catheter

15. Crossing the aortic arch
Easy aortic
arch
Difficult
aortic arch

16. Methods:
Angioplasty technique
Cannulation
-8.5 F 100 cm or 6F 120 cm Asahi sheathless
guiding over an long Starter or ES 0.035 GW
-Telescoping technique with a MP 125 cm 5F
catheter in CTO cases
Angioplasty
-„Road map imaging”
-Direct stenting with self expandable or balloon
expandable stent
-Pre and postdilatation
-Final angio
Postop treatment
-Non occlusive pressure bandage
-Immediate mobilisation

17. CTO recanalisation- case 1
A. B. C.
D. E. F.

18. CTO recanalisation- case 2
A.
B.
C.
D.

20. Cross over cases
Subclavian artery CTO Failed reentry Failed reentry

21. Coronary and iliac lesion (CCS II angina, IC WD:50 m)

22. Borderline right iliac artery stenosis

23. Routine access site selection- femoral
- Multilevel disease
Iliac + Femoral + BTK
- Distal stenosis
- Non diseased
CFA
- Popliteal lesion
Anterograde
femoral
- SFA stenosis close
to the CFA
- Diseased CFA
Cross over
possible
Brachial or Radial
No cross over
- Scar
- Bypass
- Stents in the iliac ostium
- Extreme angulation
- Extreme tortuosity
Is there a place for primary radial access
for iliac artery intervention ???
Cross over
- Complex CTO
(failed antegrade)
Popliteal or Transpedal
yes
No
No No

24. Radial artery access for femoral interventions
Devices
- 6F Short Radial sheath
- Pig Tail catheter
- 300 cm long Starter GW
- 120 cm long Sheathless guiding
- 300 cm long 0.018 Steelcore GW (0.018)
- Balloon with long shaft (180 cm long shaft, long balloons – 5-6
mm x 120-250 mm)
Strategy
- Long balloons and long inflation time (2-3 min)
- Focal stenting (Optimed stent with 180 cm long)
- Stent only in flow limiting dissections
- Alternative access site is the popliteal or transpedal access for
stenting
- For DEB and DES
- Femoral access site only in bail out cases
Limitations
- No DEB available with this shaft size
- No DES available with this shaft size
CIRSE 2016 Abs No 467
PCR 2017
125 consecutive pts
Cross over to femoral 2.4%
Dual access 8%
Successful procedure 92.5%
CTO success 92.5%
Long term MAE: 3.2%
TLR : 1.6%

25. Femoral artery
intervention- CASE 1

26. Femoral artery
intervention- CASE 2

27. Access ??
- iliac stent
- diseases CFA
-Long SFA CTO
-Popliteal CTO
- ATA and ATP occl
TR access
- 6F SG
- V18 GW 300
- Treasure12 300
- Invatec 5x150 180
- Invatec 6x150 180
- Optimed 6x80 180
Peroneal access
- Cook 4F, Terumo 4F
- Progress40 300
- Fox 4x80
Femoropoliteal
intervention
CASE 3

28. Primary transpedal-
distal lesion, high patient, long arm

29. Below-the-knee and CLI
Anterograde BTK recanalisation-
wound releated artery
1. Inflow disease
2. Outflow disease
unsuccessful
Retrograde recanalisation
Transpedal access
(ATA, PTA, proneal)
unsuccessful
Kollateral dilatation
(malleolar)
Femoropopliteal
lesion-occlusion
present
Retrograde
recanalisation
Plantar loop technique
Paralell patent artery and plantar
arch present
Peroneal artery and malleolar
collaterals present
- Balloon angioplasty
- Stent in flow
limiting dissections
or recoil
Success
TCT 2011
Good distal run-off
Patent ATA or PTA

30. BTK and primary transpedal
(radial angio and TP PTA)
60/40 Hgmm 160/80 Hgmm

31. How to deal with complications ?
• Vascular
• Spasm
• RA perforation
• RA occlusion
• RA pseudoaneurysm
• Brachial artery dissection
• Non vascular
• Fibrous tissue formation
Kozak et. al. CCI 2003

32. Potential transpedal complications
• Early
• Dissection (Occlusion)
• Thrombosis (Occlusion)
• Vein puncture (AV fistula, vein closure)
• Later
• Athrosclerosis progression ???
• Pseudoaneurysm
• AV fistula

33. Angiography 2016.01 due to ALI (rad + ped)

36. Control angiography

38. Control retrograd angiograpy

41. Stent graft
3x24 mm

43. Conclusion
• Transradial iliac artery intervention is safe technique and can be
used as a primary access or secondary access when the femoral
access can not be obtained
• Transradial SFA intervention can be obtained when the femoral
access is not possible or risky. As a primary access site we need
more data…
• Ideal for restenosis and focal lesion
• For popliteal lesions the transradial technique can be used only
in limited cases, but possible from transpedal access
• For patients with multilevel disease and CLI can be used for
treating the inflow arteries with a combination of the transpedal
and popliteal approach
• For isolated BTK lesions the transpedal technique is optimal, but
for complex BTK lesions the antegrade femoral access is the
preferred technique