8/25/2014
1
TRANSRADIAL ILIAC INTERVENTIONS
John Coppola MD FACCNYU Langone Medical Center
disclosure
Speaker for Medtronics
Consultant for Terumo
Speaker for Boston Scientific
Why Radial
Difficult access “can’t feel the pulse”
Compression of artery distal to a fresh stent
Early ambulation and discharge
8/25/2014
2
Iliac
Difficult groins prior surgery
Ca+ with difficult angles to cross over
Contralateral disease making cross over more of a problem
Ostial disease
No need to close or compress after intervention in setting of PVD
External iliac disease introducer half in lesion
Avoid complications
1996 DeBelder et. Al. retrospective review of 75 cases done via radial for diagnostic coronary or intervention in patients with CAD
97% success rate
2000 Hildick-Smith 297 patients with aorto iliac disease Femoral 79% success radial 91% vascular complications 9/154 femoral 0/143 radial
2008 Garcia reviewed CARP data small # radial no complications overall 1.7% access complications
Wrist - Subclavian = 50-
65cm
L Wrist - Renal A = 90cm
L Wrist - Common Iliac = 105-115cm
L Wrist - CFA = 125-
135 cm
R Wrist - R Carotid = 55-65cm
R Wrist - L Carotid (bovine arch) =
55-65cm
L Wrist - Popliteal A= 155-
170 cm
Anthropometric measurements
L Wrist - Foot= 200-230 cm
8/25/2014
3
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
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
Iliac Artery Stenting
6 Fr 110cm sheath
Post Stenting
330 cm 0.014” Viper wire
8/25/2014
4
Case
Type 2 diabetes hyperlipidemia and hypertension
Rutherford Class III claudication
Non invasive data high grade rt iliac lesion
The patient
BMI 1.3
procedure
Will use the left wrist for iliac procedures avoids the arch and allows for 6-8 cm more working length.
Set up to allow for arm to be moved.
Short 5 Fr introducer
Standard IMA diagnostic catheter
260 cm 0.035” wire follow passage to avoid spinal braches
8/25/2014
5
equipment
Standard 5 Fr short introducer
5 Fr IMA diagnostic catheter
260 cm 0.035 guide wire
6Fr 90 cm coated introducer (110 cm most often used)
300 cm 0.014 guide wire
5x80 balloon shaft 135cm
6x80 Zilver stent
Control angiogram
Can get distal vessels
Decrease frame rate
8/25/2014
6
Post PTA
Positioning of stent
8/25/2014
7
Post stenting
8/25/2014
1
Transradial Approaches to
Peripheral Intervention
Douglas E. Drachman, M.D., F.A.C.C.
Division of Cardiology
Vascular Medicine Section
August 26, 2014
Drachman 2014
Disclosure Information
Douglas E. Drachman, M.D.
Abbott Vascular, Inc.: Advisory Board
Atrium Medical Corporation: Research Grant Support
iDEV Technologies, Inc.: Research Grant Support
Lutonix/BARD: Research Grant Support
PLC Medical Systems, Inc.: Clinical Events Committee
Prairie Education & Research Cooperative: Data Safety & Monitoring Board
Off-label use of products will be discussed in this presentation as indicated. Many stents used in the peripherial arterial circulation are indicated for biliary or tracheal application.
Drachman 2014
Objectives
• Transradial access benefit
– Vascular complication avoidance
– Strategic access
– Parallels, differences compared with coronary
• Logistical considerations
• Example cases
8/25/2014
2
Drachman 2014
Transradial access benefit
• Reduced bleeding risk
• Patient comfort
• Early ambulation
• Same day discharge is feasible
Drachman 2014
Bleeding Risk Aortoiliac Issues
(AAA, sev athero,
tortuosity)
Equipment
options
Backup
support
Downgoing
artery
Radial ↑ +++ + ++ +++
Brachial ↑↑↑ +++ ++ +++ +++
Femoral ↑↑ + +++ + +
Courtesy of H. Arnonow
Vascular Access
Drachman 2014
Logistical considerations
• Length of catheter systems and distance to lesion
• 135cm baloon/shaft measures from tip to hub
– e.g. a 10cm balloon on a 135cm shaft will not
extend out of a 125cm long guide
• Length of Tuohy-Borst affects length of system
8/25/2014
3
Drachman 2014
Logistical considerations
• Caliber of sheath/guide necessary to
accommodate stent
– 6F guide has larger lumen and smaller OD than
5F sheath
– Consider “sheathless” insertion
• Use the left wrist
– Shorter distance to target
– Avoid traversing the arch/vessels
Drachman 2014
Example opportunities for transradial
peripheral intervention:
• Carotid/vertebral
• Subclavian
• Renal
• Mesenteric
• Iliac
• CFA/PFA
• SFA
Drachman 2014
A recent consult for ARF,CHF, malignant HTN
• Our clinical dx: renal artery stenosis
• Our plan: renal intervention
• Multiple exams documented palpable but
diminished distal pulses and femoral bruits
• To our exam: no palpable leg pulses
• Monophasic doppler at femorals
8/25/2014
4
Drachman 2014
We found an I+ CT scan from prior admission
Drachman 2014
We used radial access
Drachman 2014
Special Circumstances: Morbid Obesity
We used radial access
8/25/2014
5
Drachman 2014
Be aware of vascular tortuosity/redundancy
Drachman 2014
Guide may lack longitudinal stability
Drachman 2014
Left subclavian stenting from the wrist
• 5F HC 90 cm sheath
8/25/2014
6
Drachman 2014
Left subclavian stenting from the wrist
• 5F HC 90 cm sheath
• Arch aortagram
Drachman 2014
Left subclavian stenting from the wrist
• 5F HC 90 cm sheath
• Arch aortagram
• Baseline subclavian
angiogram
Drachman 2014
Left subclavian stenting from the wrist
• 5F HC 90 cm sheath
• Arch aortagram
• Baseline subclavian
angiogram
• Balloon/stent
8/25/2014
7
Drachman 2014
Left subclavian stenting from the wrist
• 5F HC 90 cm sheath
• Arch aortagram
• Baseline subclavian
angiogram
• Balloon/stent
• Final angio (restoration of
antegrade flow)
Drachman 2014
EPD from wrist
Simultaneous radial and femoral access:
A “hostile” left subclavian lesion
Baseline
(groin sheath) PTA/stent
Drachman 2014
Simultaneous radial access: adjunct
• Final angio
• Debris in EPD
8/25/2014
8
Drachman 2014
• Prior ABF for AAA
• CTA at OSH: Severe stenosis graft proximal
anastomosis
• Plan: L radial access (ideally 6F sheath) to permit
PTA/stent of aorta
• Avoid ABF access
64yo F with claudication
Abdominal aortic intervention
Drachman 2014
L radial access… unsuitable anatomy
Drachman 2014
Aortagram
8/25/2014
9
Drachman 2014
Crossed antegrade, snared retrograde
Drachman 2014
PTA/stent from the leg
Drachman 2014
CAN get there from here!
Transradial access and benefits
Solitary kidney, EVAR, severe EIA/CFA/RSFA PAD
8/25/2014
10
Drachman 2014
CAN get there from here!
Transradial access and benefits
Drachman 2014
CAN get there from here!
Transradial access and benefits
Drachman 2014
Transradial access is not infallible
Aseptic granuloma vs. abscess
I & D and abx
8/25/2014
11
Drachman 2014
Conclusions
• Transradial access
– Vascular complication avoidance
– Strategic access
– Parallels, differences compared with coronary
• Logistical considerations
• Tailor approach to suit patient/lesion
8/25/2014
1
Advanced Challenges with Transradial Access and Hemostasis
Samir B. Pancholy, MD
Radial Artery Access
• Anterior puncture
• Counterpuncture
Disclosures
• Teaching honoraria:MedtronicTerumo
8/25/2014
2
Radial Artery Access
• TR vs. TF accesssmaller needle (20” or 16”)
bare-needle vs. teflon-sheathed needle
0.018” or 0.021” guidewire
Puncture techniques
• Anterior puncture technique similar to
femoral access
Anterior puncture technique
8/25/2014
3
Anterior puncture technique
Counterpuncture technique
RATE trial
Pancholy SB, Sanghvi KA, Patel TM. Catheter Cardiovasc Interv. 2012 Aug 1;80(2):288-91
8/25/2014
4
Technical tips
• Immobilize the radial artery to prevent “rolling”
Technical tips
• Immobilize the radial artery to prevent “rolling”
• Using counterpuncture technique using a teflon-sheathed needle, a “steep” angle entry in the artery may be more “successful”
Technical tips
• Immobilize the radial artery to prevent “rolling”
• Using counterpuncture technique using a teflon-sheathed needle, a “steep” angle entry in the artery may be more “successful”
• After removal of metallic stylet, “flattening” the teflon cannula in the process of withdrawing it, makes it co-axialize with the radial lumen
8/25/2014
5
Counterpuncture
8/25/2014
6
Withdraw Teflon cannula parallel to skin
8/25/2014
7
Kinking is prevented by constant pull
Upon entry into lumen from posterior wall, cannula “straightens” out
Upon entry into lumen from posterior wall, cannula “straightens” out
8/25/2014
8
Upon entry into lumen from posterior wall, cannula “straightens” out
Anterior puncture / metallic needle users, enter at “shallow” angle
Anterior puncture / metallic needle users, enter at “shallow” angle
8/25/2014
9
Anterior puncture / metallic needle users, enter at “shallow” angle
Modified Counterpuncture technique
Hydrophilic sheath
• Less spasm (Saito et al, Rathore et al),
• Increased comfort
• ? Less entrapment
• ? Less RAO
8/25/2014
10
Radial Cocktail
• Vasodilators (prevent spasm)Nitrates (200
mcg IA) Calcium channel blockers
Diltiazem 5 mg, Verapamil 2.5 mg IA
Anticoagulants
• Prevent radial artery occlusion
Anticoagulants
• Unfractionated heparinat least 50 U/Kg (Spaulding et al,
Leipzig study, Bernat et al)systemic effect, IA vs
IV (Pancholy et al)
8/25/2014
11
Anticoagulation
• Effect probably related to degree of anticoagulation
• Seen with Bivalirudin (Plante et al)
Summary
• Use dedicated access equipment
• ?Counterpuncture faster, first-attempt success
• Hydrophilic introducer sheath
• Spasmolytic cocktail
• Anticoagulation
Summary
• Use dedicated access equipment
• ?Counterpuncture faster, first-attempt success
• Hydrophilic introducer sheath
• Spasmolytic cocktail
• Anticoagulation
Prevent the urge to “re-invent” the wheel for the first 1000 cases
8/25/2014
12
Radial hemostasis
• The easiest part of the procedure.
• The main reason for attractiveness of TRA
Radial artery hemostasis
• Radial artery lies on the flat portion of radius
• No major neurovascular structures
• Ulnar collateralization prevents ischemia
• Well tolerated
Distal forearm anatomy
8/25/2014
13
Common Methods
Sheath is removed and Hemoband / TR band is applied
Patient can sit up immediately after the procedure
Ambulation can occur as soon as patient steady.
Radial artery hemostasis
• Most significantly affects radial artery outcomes
Radial artery hemostasis
• Most significantly affecting radial artery outcomes
• Most CAD patients will need more than one procedure
8/25/2014
14
Radial artery occlusion
• Asymptomatic
• Symptomatic Inflammatory (radial arteritis)Ischemic (embolic)
• Limits future ipsilateral TRA
10.5
9.0
5.0
6.9
5.3
1.8
0
2
4
6
8
10
12
Sanmartin Rathore Plante Pancholy
%
Radial Artery Occlusion Rates
Early Late
NRNR
Anticoagulation UFH 70-100 u/kg UFH 70 u/kgOr Bivalirudin
UFH 70 u/kg UFH 50u/kg
Pre-Patent hemostasis
Coutesy of SV Rao, MD
Heparin and RAO
0
10
20
30
40
50
60
70
80
NoHeparin
2000-3000I.U
5000 I.U 2000 I.U 5000 I.U
Incidence of RAO (%)
Incidence of RAO (%)
Spaulding et al Bernat et al
8/25/2014
15
Heparin and RAO
0
10
20
30
40
50
60
70
80
NoHeparin
2000-3000I.U
5000 I.U 2000 I.U 5000 I.U
Incidence of RAO (%)
Incidence of RAO (%)
Spaulding et al Bernat et al
Non-pharmacologic strategies
Radial artery Hemostasis
PREVENTION OF RADIAL ARTERY OCCLUSION
Mechanism of RAO
• Flow cessationDuring procedure:
Caused by hardware
8/25/2014
16
Mechanism of RAO
• Flow cessationDuring procedure:
Caused by hardware Caused by spasm
Mechanism of RAO
• Flow cessationDuring procedure:
Caused by hardware Caused by spasm
After procedure:
Mechanism of RAO
• Flow cessationDuring procedure:
Caused by hardware Caused by spasm
After procedure: Caused by compression
8/25/2014
17
Mechanism of RAO
• Flow cessationDuring procedure:
Caused by hardware Caused by spasm
After procedure:Caused by compression Caused by residual spasm
Mechanism of RAO
Mechanism of RAO
• Thrombosis (acute)
• Rapid organization with fibrotic lumen obliteration
8/25/2014
18
Mechanism of RAO
Mechanism of RAO
Mechanism of RAO
8/25/2014
19
Mechanism of RAO
Mechanism of RAO
Mechanism of RAO
• Flow cessationDuring procedure:
Caused by hardware Caused by spasm
After procedure: Caused by compression Caused by residual spasm
8/25/2014
20
Prevention of RAO
• During the procedure Use lowest profile hardware Systemic anticoagulation
Radial artery hemostasisAbsent radial flow
0
10
20
30
40
50
60
70
Atapplica on Atremoval
Sanmartin et al CCI 2007; 70: 185-9
Radial artery hemostasis
• Interruption of radial flow highly predictive of subsequent radial artery occlusion.
0
10
20
30
40
50
60
70
80
90
100
RAO NoRAO
Sanmartin et al CCI 2007; 70: 185-9
8/25/2014
21
Active radial hemostasis
Attention to hemostasis
Attention to radial artery patency
Periodic monitoring of radial artery patency
Patent Hemostasis
%
Pancholy S et al, CCI 2008;72:335-40
P < 0.05
Patent Hemostasis
8/25/2014
22
Patent Hemostasis
Patent Hemostasis
Patent Hemostasis
8/25/2014
23
Patent Hemostasis
Patent Hemostasis
Patent Hemostasis
8/25/2014
24
Patent Hemostasis
Ideal Hemostasis
Have we made a difference?
8/25/2014
25
10.5
9.0
5.0
1.1 0.8
6.9
5.3
1.8
0
2
4
6
8
10
12
Sanmartin Rathore Plante Pancholy Cubero Bernat
%
Radial Artery Occlusion Rates
Early Late
NRNR
Anticoagulation
Patent hemostasis
UFH 70-100 u/kg
No
UFH 70 u/kgOr Bivalirudin
No
UFH 70 u/kg
No
UFH 50u/kg
Yes
UFH 70-100 u/kg
Yes
UFH 5000 u
Yes +Ulnar compression
Pre-Patent hemostasis Post-Patent hemostasis
Summary
• Use lowest profile hardware
• Use systemic anticoagulation
• Use patent hemostasis technique
• New ideas?
Thank you
8/21/2014
1
Jeffrey M. Schussler, MD, FACC, FSCAI
Baylor University Medical Center, Dallas, Tx
I have no financial relationships with any medical company or any conflicts of interest.
A society with so many disclaimers has too many lawyers.
51 year old man, presented to a satellite hospital (no PCI capabilities) with 2 hours SSCP
EKG showed ST elevation, inferior / lateral leads
8/21/2014
2
Given potential prolonged transfer / d2b time, lytics (Retavase) were given, along with aspirin and clopidogrel
He was transferred to our facility within 60 minutes. EKG was improved, but he continued to have chest pain.
Given ongoing (albeit improved) chest pain, he was taken to the cath lab.
8/21/2014
3
6Fr, right radial approach, 5 mg verapamilBivalirudin usedJacky diagnostic catheter
8/21/2014
4
EBU 3.75 Guide3mm x 23 mm Promus3.5 post dilation balloon
Complete resolution of symptoms
EF 50%, without residual cardiomyopathy
Peak troponin ~4
Discharged at 48 hour mark (on aspirin, clopidogrel, carvedilol, lisinopril, and atorvastatin).
8/21/2014
5
High Volume Radial Operators Low use of bivalirudin High use of 2b/3a antagonists (>60 %) Conclusion: The reduction in bleeding events
/ mortality of transradial approach for STEMI may be over-stated, or just may not reflect what we do in the US in clinical practice.
Lower “fear” of bleeding despite additional anti-coagulation / anti-platelet
Earlier ambulation
Lower risk of morbidity in obese patients and groin complications
Learning curve
Guide sizing – inability to use >6Fr guides
What if we need to place a balloon pump or impella?
New equipment?
Radial access and door to balloon times
8/21/2014
6
The fundamental mechanics of PCI through transradial approach are the same. Once the guide is engaged, it’s pretty much “business as usual.” Most PCI (even complex) can be done through 6Fr
Learning Curve: Get some cases under your belt doing elective cases before trying STEMIs. The lowest hanging fruit are the highest risk for bleeding: already on anti-coagulation, lytics.
Little old ladies are the hardest radial cases, but may gain the most. Avoid at first.
Left system: use slightly shorter guides, and engage with wire in the catheter.
D2B times – awareness of door-time, and not try to attempt radial PCI
Impella / IABP
Transradial approaches for STEMI do not handicap an operator once over the learning curve “hump,” and can afford a safer route for PCI in the highest risk patients.