Transradial approach for structural intervention - Kintur Sanghvi

1. Kintur Sanghvi MD FACC FSCAI
Associate Medical Director of Cathlab
Director of Radial & Mitral Valve Program
Associate Professor of Medicine
Deborah Heart & Lung Center
Philadelphia School of Osteopathic Medicine
Radial Approach For Structural
Interventions

2. Disclosure
No relevant conflict of interest for this presentation

3. Present & Future of Radial Access for
Structural Endovascular Interventions
§ Use as primary access:
§ Alcohol Septal Ablation
§ Paravalvular Leak Closure
§ VSD closure
§ RV Biopsy
§ Balloon Vavuloplasty
§ IVC Revascularization & IVC Filter retrieval
§ Use as ancillary access:
§ TAVR
§ PDA closure
§ EVAR & TVAR
§ CTO

4. Systemic Literature Review:
Eur J Clin Invest. 2015 Feb;45(2):215-25. doi: 10.1111/eci.12398
§ There were 18 reports or studies (2002-14) evaluating the
utility of TR access in transcatheter structural interventions
(ASA: 3; VSD: 1; RD: 3; PVL closure: 1; TAVI: 7, ERAC: 3)
§ Femoral access complications ranged from 0.16% to 40%,
with an overall incidence of 2.2% (56/2521).
§ The overall incidence of access-site complications following a
TR approach was 0.5% (2/406 patients), with no major
vascular or bleeding complications.
§ The use of TR access either as primary or secondary access
site was feasible and allowed the completion of the procedure
in all cases.

5. Transradial versus transfemoral ancillary approach in complex structural, coronary, and
peripheral interventions. Results from the multicenter ancillary registry: A study of the
Italian Radial Club
B Cortese et.al. Catheterization and Cardiovascular Interventions 2 MAY 2017

6. Procedural & In-hospital outcome based on ancillary access
Predictors of BARC grade 3-5 bleeding
B Cortese et.al. Catheterization and Cardiovascular Interventions 2 MAY 2017

7. Alcohol Septal Ablation

8. Alcohol Septal Ablation
§ Alcohol septal ablation from the radial approach could be
performed with similar acute and long-term success, but with
lower vascular complications compared to the femoral
approach. (0.58% vs. 7.3%; p = 0.002)
International Journal of Cardio 2016 Oct; 220(1):7-13

9. Symptomatic IHSS

10. EBU 3.5 guide: 2.0 OTW balloon

11. Most Basal branch ablated with echo guidance

12. First septa branch ablation

13. Post-Ablation , LVOT gradient reduced

14. Post-ablation Follow-up echo

15. Alcohol Septal Ablation
Sanghvi et al. Journal of Invasive Cardiology. 2014 Apr;26(4):E37-9

16. VSD Closure

17. Perimembranous VSD
Sanghvi at el. J Interv.Cardiol. 2014 Apr;27(2):199-203

18. Right Radial & Right Basilic Vein Access
VSD closure
Sanghvi at el. J Interv.Cardiol. 2014 Apr;27(2):199-203

19. Right Radial & Right Basilic Vein Access
VSD closure
Sanghvi at el. J Interv.Cardiol. 2014 Apr;27(2):199-203

20. AV loop formed with a sheath & Device loaded
Sanghvi at el. J Interv.Cardiol. 2014 Apr;27(2):199-203

21. LV disc deployed
Tug test
Sanghvi at el. J Interv.Cardiol. 2014 Apr;27(2):199-203

22. Right Radial & Right Basilic Vein Access
VSD closure
Sanghvi at el. J Interv.Cardiol. 2014 Apr;27(2):199-203

23. Device Flat Just Below AV

24. No shunt by TEE

25. VSD size: Compatibility from basilic vein for
Amplatzer Muscular VSD occluder
Device size Disc Diameter Waist Length Min Sheath Size
4 9 7 5 Fr/ 90 cm
6 14 7 6 Fr/ 90 cm
8 16 7 6 Fr/ 90 cm
10 18 7 6 Fr/ 90 cm
12 20 7 7 Fr/ 90 cm

26. Very high membraneous VSD by TEE

27. Complex VSD with Pseudo aneurysm
PSA directed to toward FV & Easy to cross from RA
AV Rail between RA & FV

28. Femoral vein approach was used because of the direction of the
opening in the pseudoaneurysm Delivery of 10mm VSD device
(note inferior aspect of pseudoaneurysm)

29. Final LVG

30. Final LVG

31. Device tucked into PA just below AV with minimal residual shunting (angio
shows we’re clearly below the aortic valve)

32. Structural: Paravalvular Leak Closure

33. Severe PVL

34. PV Leak on TEE & Size measurement

35. 10 mm plug deployed 6 Fr 90 cm Sheath

36. Posterior leak with 8 mm Vacular plug III

37. 83 year old male with 19 yr old prosthetic AV

38. Paravalvular Leak

39. PVL crossed with JR 4 & Glide wire
Sheath exchanged over J wire

40. Paravalvular leak (Pigtail LR)
8 mm Vascular plug 4

41. Tug test & released

44. RV Biopsy

45. RV Biopsy

46. A B

47. Acute Pulmonary Embolism

48. Bilateral Saddle Pulmonary Embolus with
impending Right Heart Failure
Sanghvi K et. al. catheterization and Cariovascular Intervention.2017 July 22

49. Sanghvi K et. al. catheterization and Cariovascular Intervention.2017 July 22

50. Basilic & Cephilic Vein Access With Ekos
Catheter
Sanghvi K et. al. catheterization and Cariovascular Intervention.2017 July 22

51. TAVR

52. S III Deployment
MP catheter inserted in the right IA

53. 14 Fr Sheath pulled back &
Balloon from Radial Inflated

54. Pre-close method with Prostar & Sutures tied
while balloon inflated & final dry Seal

55. EVAR & TVAR

56. AAA of 7 cm size with wide neck at Renal
origin

57. Bilateral Radial access with 110 cm 6 Fr
sheath and 6.0 Atrium covered stents

58. After final graft deployment no endoleak

59. TVAR with Renal insufficiency

60. After the graft deployment repeat IVUS is
performed

61. PDA closure

62. PDA with severe Pulmonary HTN

63. Effect on hemodynamics with sizing balloon

64. Final Result

65. Conclusion
§ Radial artery or Basilic vein access are safe and feasible as
either a primary or secondary(ancillary) access for
endovascular treatment of structural cardiovascular
interventions.