Within the past 12 months, the author has received consulting fees or honoraria from Boston Scientific, Medtronic, and Terumo. The document discusses the advantages of radial artery access over femoral artery access for carotid artery stenting (CAS), including reduced risk of emboli in patients with aortic atherosclerosis, lower rates of access site complications and bleeding, earlier ambulation for patients, and improved patient comfort and satisfaction. Several cases demonstrating transradial CAS procedures are presented. Both radial and ulnar arteries can be used for access. While there is a learning curve for new operators and some procedures may take longer, radial access allows for CAS in complex aortic arch anatomies and avoids complications associated with femoral access

1. Ø Consulting Fees/Honoraria
Ø Boston Scientific
Ø Medtronic
Ø Terumo
Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below:
Affiliation/Financial Relationship Company
Disclosure Statement

2. Why Radial Artery Access for CAS ?

3. Femoral approach limitations
Ø Aorto-iliac disease or occlusion
Ø Previous surgical bypass at this level
Ø Diseased and Complex aortic arch with
Ø Tortuous SAA originating from elongated,
or type II, III, or bovine aortic arch

4. Risk of catheter-related emboli in patients with
atherosclerotic debris in the thoracic aorta
Karalis DG et al. Am Heart J. 1996 Jun;131(6):1149-55.
Courtesy of Dr. A. Pacchioni

6. Femoral approach limitations II
Ø Increased back pain
Ø Urinary retention
Ø Delayed ambulation
Ø Neuropathy

7. The most common adverse event after CAS
from the femoral approach
MOST TECHNICAL FAILURES ARE
RELATED TO A COMPLEX ARCH
Access site complications

8. Vascular access is 1st reason of bleeding
complications & MACE after PCI
BLEEDING INCREASES MORTALITY ! ! !
Access site complications ll

9. Radial access - alternatives
Ø Right Radial Artery is
1st choice !
Ø Right Ulnar Artery
Ø Left Radial Artery
Ø Left Ulnar Artery

10. Ø Patient comfort and satisfaction
Ø Reduced nursing cost
Ø Reduced vagal reaction
Ø Reduced hypotensive response
Ø Reduced bleeding complications
Transradial CAS
IMPORTANCE OF EARLY AMBULATION

11. Ø Anchoring technique
Ø Telescopic approach
Transradial CAS

12. Left ACC 100%Case 1.

13. RICA

14. Terumo advantage wire in RECA

15. Amplatz stiff wire in RECA

16. Destination sheath 6Fr

17. Destination sheath 6Fr

18. Final result

19. Before / After

20. Ø Anchoring technique
Ø Telescopic approach
Transradial CAS

21. RRA CAS of LICA in highly symptomatic
patient with amaurosis fugax
Male
K. G.
64 y.o
Case 2.

22. LICA 99%+Thrombus

23. “Wireless” Telescopic Aproach

24. Shuttle Sheath 5F

25. Final result

26. Before/After

27. 1 Month Follow up

28.
Ø Right Wrist Access
Ø Left Wrist Access
Transradial CAS

29. Left TRA CAS of RICA – Simple loop
cannulation
Case 3.

30. Left TRA CAS of RICA – Final result

31. Before / After

32.
Ø Tortuous Internal Carotid Artery
Ø String Sign
Ø Contralateral Occlusion
Ø Acute Carotid Syndrome
Wrist access (radial & ulnar) for CAS

33. TRA for CAS of
Tortuous LICA
Male
S. M.
86 y.o.
Case 4.

34. LICA 90%

35. GC MP 7F

36. Result

37. Balloon post dilatation

40. Final result

41. Final result

42. Male
J. B.
71 y.o.
TRA CAS of RICA
Case 5.

43. TRA

44. RICA 99%

45. RICA 99%

46. DPD Emboshield NAV 6

47. Balloon pre-dilatation 2.5/12mm

48. Stent Xact 8.0/40mm

49. Final result

50. Final result

51. Female
S. I.
61 y.o.
TRA CAS of LICA in symptomatic patient
Case 6.

52. TRA

53. LICA 99%

58. Мale
Ј. М.
61 y.o.
TRA CAS of LICA in
symptomatic patient
Case 7.

59. Right RA: high take-off

61. LICA 99%

62. Stent deployment: Xact 8.0/40mm

63. Final result

64. TUA for CAS of LICA with
contralateral occlusion
Male
J. A.
66 y.o.
Case 8.

65. RICA 100%

66. Destination sheath 6Fr

67. Final result

68. Before / After

69. Before / After

70. Male
K. A.
58 y.o.
TRA CAS of LICA in patient with Acute
Carotid Syndrome
Case 9.

71. Right TRA

72. After additional vasodilators

73. Thrombotic subocclusion of LICA

74. Destination 5F

75. Final result

76. Final result

77. Before / After

78. Stent deployment
Cristallo ideale

79. Final result

80. TRA CAS of LICA in highly
symptomatic patient
M.V.
76 y.o.
Female
Case 10.

81. Right RA: high take-off

83. LICA 99%

85. Asachi sheathless 7.5F

86. NAV 6 & Wallstent 7.0/30mm

91. TRA CAS of RICA
in a patient with
Acute Carotid Syndrome
M.P.
Male
68 y.o
Case 11.

92. TRA

93. LICA 90%

94. LICA 90%

95. RICA 99%

96. RICA 99%

97. Asahi sheathless 7.5F

99. Stent: Roadsaver 7.0/25mm

100. Balloon post-dilatation

101. Final result

102. Final result

103. Case 12.
Male
D. G.

116. TUA CAS of RICA
in Acute Carotid Syndrome
G.I.
Male
73 y.o
Case 13.

117. RICA 99%

118. RICA 99%

119. Roadsaver 7.0/30mm

122. TRA CAS of LICA
and
J. L.
Female
50 y.o
Case 14.

125. LICA 95%

127. Wallstent 7.0/30mm

128. Result

129. Result

130. A subclavia lat sin 95%

131. Stent: Bridge X3 7.0/15

132. Stent deployment

133. Final result

134. Male
G. D.
59 y.o.
TRA CAS of LICA with
MoMa proximal protection
Case 15.

135. TRA

136. LICA 95%

137. LICA 95%

138. MoMa proximal protection device

141. Male
D. L.
74 y.o.
TRA CAS of RICA with
MoMa proximal protection
Case 17.

142. 8F: MoMa PPD

143. RICA 95%

144. MoMa proximal protection device

145. Final result

146. Hemostasis

147. Patent hemostasis

150. A randomised comparison of TRA and TFA for CAS:
RADCAR (RADial access for CARotid artery stenting) study
Ruzsa Z et al. EuroIntervention 2014;10:381-391

151. Ø Easy access in otherwise very complex aortic arcs
Ø Immediate patient mobilisation
Ø Reduced hypotensive response
Ø No bleeding
Ø Anticoagulation is not an issue
Ø Reduced nursing cost
Ø Outpatient performance in selected cases
Wrist access (radial & ulnar) CAS
ADVANTAGE

152. Ø Significant learning curve for new TRA operators
Ø Sometimes longer procedure for easy case
with type I aortic arch
Ø Proximal PD and larger devices could not
be used freely in all cases
Ø Radial artery occlusion ≈ 10 %
Wrist access (radial & ulnar) CAS
DISADVANTAGE

153. MISTAKE:
Ø Perform TRA only when FA is not possible !!!
Wrist access (radial & ulnar) CAS

154. Conclusions
Ø TRA for CAS is feasible and safe when performed
by experienced TRA operator
Ø Easy access for CAS in difficult anatomies
(bovine arch LCCA and most of the innominate
artery take offs)
Ø Allows early patient mobilization
Ø Eliminates bleeding complications
Ø Further studies are needed before recommending
wrist access for endovascular procedures as
primary approach over femoral access