This document discusses the use of transradial approach for carotid artery stenting (CAS) in Japan. It presents two case studies where transradial IVUS-guided CAS was performed successfully despite complex aortic arch anatomy. The document also provides data on 15 patients who underwent transradial CAS. It finds that aortic arch type does not significantly impact the technical difficulty of transradial CAS. It concludes that transradial CAS is safe, feasible, and well-tolerated by patients due to reduced bleeding risks and lumbar pain compared to transfemoral CAS.

1. TRA and CarotidStenting
Experience from Japan
Yuji Ikari, MD, PhD, FESC, FACC
Tokai University, School of Medicine
Japan

2. Background
• Transradial approach intervention has been applied
to peripheral approach.
• Initial results of transradial iliac artery stenting.
Shinozaki N, Ogata N, Ikari Y. Vasc Endovascular Surg.
2014 Jan;48(1):51-4
• Our basic approach for carotid stenting is IVUS-
guidance
• Plaque protrusion detected by intravascular ultrasound
during carotid artery stenting. Shinozaki N, Ogata
N, Ikari Y. J Stroke Cerebrovasc Dis. 2014;23(10):2622-5.

3. IVUS

4. Transradial CAS
• We perform transradial approach IVUS-guided CAS
• Benefits
• Low bleeding complication rate
• QOL
• Technically easy in case of complex arch type
• Disadvantage
• 6F sheath is sometimes too big for Japanese patients
• Different technique for guiding catheter engagement

5. ８４ year old Male
• AAA surgery five years ago
• He had a plan to undergo TAA stent graft, however,
right carotid artery stenosis was found

8. 6F Long sheath, Fubuki 90cm (Asahi Intech)
6F Diasgnostic catheter, Simmonds 130 cm (Asahi Intech)

9. IVUS Pre dilatation

10. Precise stent

11. Stent placement Post dilatation IVUS
Plaque protrusion

12. Plaque protrusion

13. Post dilatation again However, plaque protrusion
remained

14. Another precise stent 6mm X 20 mm
Stent in stent
Post dilatation again
IVUS showed plaque protrusion became minimum

15. There is still plaque protrusion angiographically.
But significant improvement was observed with IVUS.
So, We finished the procedure.

17. 86 year old male
• PCI 3 years ago
• Left carotid artery stenosis with TIA

19. Type III or more

20. 6F Long sheath, Fubuki 90cm (Asahi Intech)
6F Diasgnostic catheter, Simmonds 130 cm (Asahi Intech)
The guiding sheath was impossible to insert up

21. The Guiding sheath was bended!
A 035 inch wire was inserted while the guiding sheath was pulled a little
What
happened?

22. Cruise guidewire (Asahi Intech) Gaia 3rd (Asahi Intech)

23. Cruise guidewire (Asahi)
With a micro catheter

24. Pre dilatation with a 1.5mm balloon without protection

25. We need a protection device
• Two EZ filter wires were broken at the bended
point even with the 035 inch wire was placed
parallelly.
• An angioguard could pass the bended point. After
placement of the angioguard, we thought of
removing 035 inch wire to pass a stent.
• Then, we made parallel wires with three 014 inch
GW (Cruise, Grandslam and angioguard)

26. Predilatation with a 3.5 mm balloon
IVUS
Stent pass at the bended point
With three wires

31. Patient / Lesion Characteristics N=15
Symptomatic 20 %
age, 74 ± 8
Male 93 %
Height 163 ± 7 cm
Weight 60 ± 7 kg
Smoker 47 %
Hypertension 80 %
Dyslipidemia 93 %
Diabetes mellitus 27 %
insulin 13 %
Old MI 7 %
Prior PCI 33 %
Prior CABG 0 %
Prior Stroke 27 %
Hemodialysis 0 %
Arch type Ⅰ/Ⅱ/Ⅲ, % 53/20/27
Bovine arch, % 27
Stenosis location L/R, % 47/53

32. Procedure
Guiding Fubuki/Destination/SheathlessPV 33/40/27 %
Procedure time 56 (40-82) min
Fluoroscopy time 14 (14-23) min
Contrast volume 130 (112-155) ml
Stent Precise/Wall 87/13 %
Stent size 8.7 ± 1.0 mm
Stent length 36.3 ± 5.6 mm
Distal protection 100 %
IVUS 100 %

33. 30 days Outcome
Death 0
Myocardial infarction 0
Stroke 0
TIA 1
Major / Minor bleeding 0

34. Type 1-2
n=7
Type 3
n=5
Bovine
n=3
p
puncture to GC
engagement
32 (23-42) 33 (31-60) 41 (16-52) 0.6
Fluoroscopy
time
14 (13-20) 14 (13-27) 23 (18-82) 0.1

35. 69 year old male
70mm AAA
Prior CABG
Tight stenosis at right carotid artery
Aortic arcy type III or more
Right radial approach。
Guiding sheath 6F Fubuki （Asahi）
Simmonds 6F (Asahi)
Radifocus Stiff （Terumo）
Procedure 40 minutes
Distance from arch top to brachiocephalic
Is 5 times of left common carotid artery

36. 75 year old male
Coronary artery disease
Right carotid stenosis
shaggy aorta。
Right radial approach。
Guiding sheath 6F Fubuki （Asahi）
Simmonds 6F(Asahi)
Radifocus Stiff （Terumo）
Procedure 42 min

37. Discussion
• Aortic arch type strongly correlates with
technical difficulty of CAS.
• However, difficulty of transradial CAS does not
have any association with the aortic arch type.

38. Conclusion
• Transradial CAS is safe and feasible.
• Transradial CAS does not be affected by the
aortic arch type.
• Patient likes transradial approach because of
low lumber pain or no urine problem
• Bleeding complications are almost none.
• Further technical advancement is necessary
for quick procedure.