Iliac Artery Intervention via Radial Access

Case report

A 55-year-old Caucasian farmer presented to our endovascular clinic with the chief complaints of bilateral hip and thigh claudication, limiting his ability to work on the farm. He had a past medical history of hypertension, ischemic cardiomyopathy, and chronic renal insufficiency. He is an active smoker with 60-pack year of smoking. On his physical exam, his bilateral lower extremity pulses were weak. The right femoral pulse was not palpable. Right leg ankle brachial index (ABI) at posterior tibial was 0.53 and left leg ABI at posterior tibial was 0.67. The pulse volume curve was blunted at every level and suggested iliofemoral disease. 

The initial angiogram was performed through the left common femoral artery (CFA). The right iliac angiogram was performed using a Rösch inferior mesenteric (RIM) catheter, which showed a heavily calcified tortuous artery with a sub-total proximal occlusion (Figure 1). We were unable to advance a 4 French (Fr) straight-tip Glide catheter (Terumo Corporation) or 0.035” Quick-Cross catheter (Spectranetics Corporation) after crossing the lesion with a 0.035” Glidewire (Terumo). Therefore, a right lower extremity run-off angiogram was performed, parking the RIM catheter in right iliac ostia. The right CFA was heavily calcified and totally occluded (Figure 2). The right superficial femoral artery and popliteal artery was patent with moderate calcified disease. There was three-vessel runoff in the right leg. The management plan was discussed with the vascular team at our institute. As the patient was a high-risk surgical candidate, we decided to treat the iliac artery (IA) disease percutaneously, followed by an endarterectomy of the right CFA.

The intervention was performed via the left radial approach using a 6 Fr sheath. After entering the descending thoracic aorta with a J wire, the short sheath was exchanged for a 90 cm Destination sheath (Terumo) and advanced into the distal abdominal aorta. A 125 cm multipurpose catheter was inserted in the right IA (Figure 3). The lesion was very easily crossed with a 0.035” angled Glidewire. The image overlay feature was used to position a balloon and a stent. After pre-dilation with 8 mm x 20 mm EverCross balloon (ev3), a 9 mm x 40 mm Cobalt balloon-expandable stent (Medtronic Corporation) was deployed in the right IA (Figure 4). An excellent angiographic result was noted (Figure 5). The sheath was removed slowly after giving additional intra-arterial nitroglycerine to avoid spasm and a hemostatic band was applied for two hours to achieve patent hemostasis (Figure 6). A total of 70 cc contrast was used and the patient was discharged home three hours post procedure.

Discussion

The use of radial access is expanding worldwide and data supports the use of radial access for peripheral vascular intervention.¹

Advantages

• Femoral access in presence of peripheral vascular disease (PVD) is associated with a higher incidence of complications.² The major bleeding rate of 2% to 6.1%, higher incidences of arteriovenous (AV) fistula, pseudoaneurysm rate of 0.1% to 1.5% in diagnostic procedures, and up to 7.7% in peripheral interventional procedures have been reported.³ Other complications like dissection and thromboembolism are also more likely in the presence of PVD.³
• Radial access is a better and safer alternative than brachial access in patients with occlusive aorto-iliac or femoral disease when the femoral pulse is not palpable.⁴ 
• Similar to the case discussed herein, the crossover through the distal aortic bifurcation is frequently hampered by severe tortuosity and calcification. 
• The radial approach facilitates early ambulation and same-day discharge. Patients with morbid obesity, severe chronic obstructive pulmonary disease (COPD), or spine diseases have the greatest advantage, as they can sit up immediately after the procedure. This also eliminates the need for pressure application in a diseased femoral artery.
• Although the distance from puncture to lesion site makes it look difficult, the geometry is a straight line from the sheath parked in the aorta or IA to a lesion in the Iliac/external iliac artery. This, in turn, provides sufficient support for introducing wire, balloon, and delivering stents. In the case we discuss, we could not advance any catheter after crossing the lesion with a wire through the contralateral femoral approach. 

Technique/recommendations

The following tips may help the reader to begin a transradial peripheral intervention program.

• Start with a diagnostic peripheral angiogram using a 5 Fr system from left radial access (as it saves 10-15 cm distance in comparison to the right radial). If there is difficulty entering the descending thoracic aorta, left anterior oblique (LAO) 40-degree view, a JR catheter, and an angled Glidewire will help.  After aortogram, a multipurpose or JR 4 catheter (110 or 125 cm) can be used for a selective lower extremity, renal or mesenteric angiogram. The down-facing origin of the renal and mesenteric artery makes it easier to get a coaxial engagement of the guide catheter from the radial artery. A quick outpatient (drive-through) procedure will define anatomy and you can plan disease-specific intervention with disease-specific access.
• Before initiating an intervention program, note the availability of equipments in your lab that has enough shaft length and 6 Fr compatibility. After accessing the descending thoracic aorta through a short radial sheath, exchange the catheter for a long sheath with a 300 cm 0.035” support wire (e.g. Supra Core, Abbott Vascular). For most patients shorter than 5 feet 10 inches, a 110 cm sheath (Cook Medical) will reach the IA. A device with a working length of 125 cm or more would reach up to CFA.  If the sheath does not reach to the Iliac, use a 125 cm guide through a long sheath to perform guide shots. Use image overlay or any radio-opaque landmark to deploy a balloon or stents. 
• Use a 5 Fr multipurpose catheter and telescope the sheath over when it is difficult to advance the sheath through tortuous subclavian anatomy.

Limitations

• Diameter and distance are the two major limitations. Most radial arteries will only allow use of a 6 French system. Newer Cobalt balloon expandable stents (Medtronic) up to 10 mm in diameter can be used through a 6 Fr sheath. To improve the efficacy of radial access, sheaths of at least 110–125 cm in length would be required to allow adequate guidance and better support during the intervention. This implies the availability of balloon and stent shafts of at least 135–150 cm.
• In the event of iliac perforation, a 6 Fr sheath will not allow deploying a covered stent. A balloon should be used to tamponade the perforation while femoral access is achieved and a covered stent is advanced. 
• Radial spasm is more likely with the long sheath, more so while withdrawing the sheath. Pretreatment with vasodilators, analgesics, and meticulous flushing of the sheath when it is withdrawn into the radial artery will reduce pain and radial occlusion rate.  
• Although feasibility studies exist, there is a lack of data support from case-controlled or randomized trials on radial use for peripheral interventions.

The authors can be contacted via Dr. Kintur Sanghvi at: SanghviK@Deborah.org.

References

1. Sanghvi K, Staniloae C, Coppola J. Transradial intervention of iliac and femoral artery: a case report study J Interv Cardiol 2008 Oct;21(5):385-387.
2. Judkins M, Gander M. Prevention of complications of coronary arteriography. Circulation 1974;49:599-602.
3. Samal AK, White CJ. Percutaneous management of access site complications. Catheter Cardiovasc Interv 2002 Sep;57(1):12-23.
4. Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol 1997 May;29(6):1269-1275.