Iliac and femoral intervention by radial artery approach: what do we need

1. TRANSRADIAL
ENDOVASCULAR Iliac and
Femoral INTERVENTIONS
Chicago AIM R a d i a l 2014
John Coppola
NYU Langone Medical Center

2. Overview
 1. Why TRA for Endovascular Iliac Interventions?
 2. Anthropometric Measurements
 Limitations and needs

3. Bleeding
2004-2011 3,386,688 PCIs
1.7% bleeding episodes
Increased risk for mortality of 12.1%
Chhatriwella JAMA 3/13/2013

4. Radial Artery-Ideal Access
Site
 Easily accessible even in subjects with severe PVD
 Cannulation benefit for most arterial beds (natural blood flow)
 Major advantage in terms of bleeding complications1,2
 Improved quality of life3
 Time-sparing hemostasis
 Same-day discharge
Kiemeneij F, et al. ACCESS Trial. JACC, 1997
RIVAL Trial. Lancet 2011
Cooper CJ, et al. Am Heart J, 1999

5. ACCUITY - Access
Radial (798) Femoral (11988)

6. advantages
 Absent or markedly decreased pulse
 Difficult to crossover in calcified vessels
 “ upside down “V”
 Ostial disease on contralateral side
 Low external iliac disease
 Avoid closure device or compression distal to
fresh stent

7. Most patients making radial
first
My practice

8. How
 Use left radial saves crossing arch
 Start with short introducer give cocktail
 LIMA if wire does not go right into DA always
follow passage of wire down to avoid damage
to branch vessels of aorta
 With exchange wire in DA exchange for long
sheath Cook 110 or Terumo 90 cm
 Self expanding 5Fr or 6Fr balloon expandable
many need 7Fr of “free wire”

9. How
 Use long wire for exchange
 If 0.014” system viper wire from CSI 360cm
can usually use 0.14 exchange wirers
 Super core 0.035 300 cm wire

10. Anthropometric measurements
Wrist - Subclavian = 50-
65cm
L Wrist - Renal A = 90cm
L Wrist - Common Iliac = 105-115cm
R Wrist - R Carotid = 55-65cm
R Wrist - L Carotid (bovine arch) =
55-65cm
L Wrist - CFA = 125-
135 cm
L Wrist - Popliteal A= 155-
170 cm
L Wrist - Foot= 200-230
cm

11. Left Radial Artery
vs R-Radial
 1. Gain about 5-8 cm
 2. Avoid the innominate a. tortuosity
 3. Avoid catheter manipulation in the aortic arch

12. TRANSRADIAL
for Endovascular Interventions
BASIC EQUIPMENT
Introducer Sheaths: 5 and 6 Fr 90 cm (Terumo); 110 cm (Cook)
Wires: 0.014 / 330 Viper (CSI); 0.035 / 300 Supracor (Abbott); 0.035 hydrophilic coating (Terumo; Cordis)
Balloons:
up to 5.0 mm diameter - 150 cm shaft (most balloons)
5.5mm and up - longest shaft 135 (Abbott, EV3)
Scoring Balloons:
Angiosculpt - 5 Fr - up to 6.0 - 137-139cm shaft
Cutting Ballons - 6 Fr - 137 cm
Stents:
the only 5 Fr platform - Zilver stent (Cook) -125cm
6 Fr platform - longest shaft 135 (Abbott)

13. TRANSRADIAL
for Endovascular
Interventions ADVANCED EQUIPMENT
 CTO Devices:
 CROSSER (Bard) - 146 cm shaft - 6Fr (14S)
 Wildcat (Avinger) 6Fr - 110 cm; 5Fr - 140 cm
 Frontrunner (Cordis) - 140 cm
 Reentry Devices:
 Outback (Cordis) - 6 Fr - 120 cm
 Pioneer (Medtronic) - 6 Fr - 120cm
 Atherectomy:
 DB 360 (CSI) - 146 cm shaft - all crowns fit in 6 Fr (except 2.25mm)
 IVUS:
 Volcano - 150 cm
 Atlantis (Boston Scientific) - 135 cm

14. Iliac Artery Stenting
 L radial is preferred (gain aprox 10
cm)
 5-6 Fr / 110 cm introducers
 Any unilateral angioplasty and
stenting can be performed either
with 5Fr compatible self-expandable
stents (Cook
Medical), or balloon expandable
stents

15. Iliac Artery Stenting
6 Fr 110cm sheath
Post Stenting
330 cm 0.014” Viper wire

16. Transradial Iliac
Stenting
 80 iliac lesions treated via TRA (28%CTO) or TFA (9% CTO)
Conclusions:
1. Similar contrast use (238 vs 213 ml)
2. Similar fluoroscopy time (30 vs 27 min)
1. Shorter time to discharge (14.4 vs 20.9 hrs)
2. Lower access-site complications (0 vs 7.2%)
Staniloae et al. Cath Cardiovasc interv 2009

17. CFA Interventions
 No stent zone
 Frequently - atherectomy + PTA
 Most atherectomy devices require 7 Fr
introducer sheaths
 DB360 - CSI - the only atherectomy
device 6 Fr compatible

18. CFA Interventions
Left radial access
Right CFA occlusion Left CFA occlusion

19. CFA Interventions
Shuttle sheath, 6Fr/ 110cm/ 0.087” via left radial access
CROSSER 14S
Calcified CFA, SFA, PFA

20. CFA Interventions
DB 360 - 2.0 SC 30
PTA 6.0 mm balloon

21. CFA Interventions
Post PTA 6.0 at 4 atm
Residual Calcified
Eccentric Stenosis
Residual calcified plaque at the bifurcation

22. CFA Interventions
Wire in PFA DB 360 SC
Final result

23. New Frontiers
SFA / Popliteal
 Currently - severe limitations do to lack of
adequate equipment
 Proximal SFA:
 PTA
 Atherectomy with DB 360 - shaft length 146 cm
 Occasionally - stenting (135 cm)

24. Proximal SFA
5 Fr 110 cm sheath
Edge restenosis post
Viabahn stent
Angioscupt 5.0/40

25. Limitations of TRA for
Endovascular Interventions
 Lack of adequate transradial training
 Limited equipment
 Paucity of clinical studies

26. Equipment Shortage
There is a need for:
1. Larger variety of introducer sheaths (90 / 100 / 110 / 125 cm)
2. Ballon catheters with shaft lenghts up to 170-180 cm
3. Longer Guidewires (360-380cm)
4. Stents with shaft lenghts up to 170-180cm
5. CTO / Reentry devices longer and lower profile

27. SFA
 Same procedure as iliac
 Devices limited to balloon 150 length but only
up to 4mm
 CSI diamond back has 137-143 working length
 Unless working on Mickey and Minnie limited