Transradial approach for carotid artery stenting - Sasko Kedev

1. Sasko Kedev
Skopje, Macedonia
Radial access for
carotid artery stenting

2. I have no conflict of interest to declare
Disclosures

3. Why radial access for CAS ?

4. Femoral environment

5. Aorto-iliac disease or occlusion

6. Tortuous SAA originating from
elongated or bovine aortic arch

7. 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

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

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

11.  Radial artery
 Aortic arch, CCA takeoff
 Carotid lesion
Tailored Approach
Transradial CAS

12. Methods
 953 consecutive pts with CA stenosis >80%
 Age 66 ± 8 years
 659 Male / 251 female

13. Demographics of study population
 Octogenerians 390 (38%)
 Hypertension 840 (87%)
 Diabetes 390 (38%)
 Hyperlipidemia 480 (50%)
 Smoking 403 (42%)

14. Demographics of study population
 Previous myocardial infarction 360 (37%)
 Previous PCI 193 (20%)
 ≥ 2 vessel CAD 190(19.2%)
 Bilateral carotid disease 232 (24%)
 Contralateral carotid occlusion 80 (8%)

15. Demographics of study population
 Symptomatic 700 (73%)
 Asymptomatic 253 (27%)
Neurological status before CAS

16.  5F Guiding sheath 169 (18%)
 6F Guiding sheath 490 (51%)
 6F Guiding catheter 90 (9.4%)
 7F Guiding catheter 120 (12%)
 8F Guiding catheter 63 (6,6%)
 Sheathless Asahi 7.5 51 (5%)
Procedural data

17. Target CCA cannulation
 Anchoring technique 813 (86%)
 Telescopic approach 140 (14%)

18. Procedural results
 LICA 468 (49%)
 RICA 442 (51%)

19. Results
 Primary success 952 (99.8%)
 Switch to femoral access 11 (1.1%)
 Simultaneous PCI 29 (3%)
 Interventional time (min) 8 -120min
 Hospital stay (days) 1 ± 1.3

20. Complications at 30 Days
 Death 4/953 (0.4%)
 Major stroke 4/953 (0.4%)
 Minor stroke 4/953 (0.4%)
 Intraprocedural TIA 7/953 (0.7%)
 Radial artery occlusion 80/953 (8.3%)
 Major vascular complications 1/953 (0.1%)

21. RRA CAS of RICA in
highly symptomatic patient
Male
S. S.
82 y.o
Case 1.

22. RCCA 99% stenosis

23. 8F MP GC

25. NAV 6 + Xact 8-6/40

26. Final result

27. Final result

28. LRA CAS of RICA
Male
T. B.
80 y.o
Case 2.

29. RRA

31. LRA

32. RICA 99% stenosis

33. RICA 99% stenosis

35. Wallstent 7.0/30mm

36. Final result

37. RRA CAS of RICA
Female
T. T.
73 y.o
Case 3.

38. RICA 99%

39. Stent: Roadsaver deployment

40. Paladin system
Post dilation balloon with integrated embolic protection
40-micron pore size

41. Paladin system

42. Paladin system

43. Final result

44. Before

45. After

46. RRA CAS of LICA in highly symptomatic
patient with Amaurosis Fugax
Male
K. G.
64 y.o
Case 4.

47. Right TRA

48. After additional vasodilators

49. LICA 99%+thrombus

50. ‘’ Wireless’’ telescopic approach

51. Shuttle sheath 5F

52. Final result

53. Before/after

54. 1 Month Follow up

55. Male
J. B.
71 y.o.
Right RA CAS of RICA
in patient with Acute carotid syndrome
Case 5.

56. RICA subocclusion

57. RICA 99%

58. DPD - Emboshield NAV 6

59. Final result

60. TRA CAS of LICA in patient
with acute stroke
Male
I. V.
62 y.o.
Case 6.

61. 5FSS: LICA 99%+thrombus

62. Adapt 4/9/40mm

63. Final result

64. TRA CAS RICA with
contralateral occlusion
M.Sh
Male
80 y.o
Case 7.

65. High takeoff of RRA

66. LICA occluded

67. RICA high grade stenosis

68. 8F MPGC

69. Xact 8-6/40

70. Final result

71. Right RA CAS of LICA in
highly symptomatic patient
M.V.
76 y.o.
Female
Case 8.

72. Right RA: high take-off

74. LICA 99%

75. Asachi sheathless 7.5F

76. NAV 6 & Wallstent 7.0/30mm

77. Final result

78. Final result

80. Right UA CAS of RICA
in Acute Carotid Syndrome
G.I.
Male
73 y.o
Case 9.

81. RUА & RAO

82. 5F Shuttle sheath

83. RICA 99%

84. Roadsaver 7.0/30mm

85. Final result

86. Male
D. L.
74 y.o.
TRA CAS of RICA with
MoMa proximal protection
Case 10.

87. 8F - MoMa PPD

88. RICA 95%

89. MoMa proximal protection device

90. Final result

91. Male
S. P.
59 y.o.
Right RA CAS of LICA with
MoMa proximal protection
Case 11.

92. Right RA

93. LICA 95%

96. MoMa PPD

99. Final result

100. Female
P. G.
49 y.o
Case 12.
RRA CAS of bovine arch LICA &
ipsilateral IC aneurysm

103. 6F Shuttle sheath

105. Xact 8-6/30

107. 6F soft GC

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