Transradial Peripheral Interventions: Two Cases

Question: Do you do peripheral cases utilizing the radial approach?

Answer: We do. We have used the radial approach for a variety of non-coronary cases. Following are two examples.

Case 1

The first case involves an 84-year-old female with hypertension on multiple medications (>3 antihypertensives) that had fluctuations in her blood pressure and even had admission for reported “flash” pulmonary edema at another institution. She had an initial ultrasound, which was inconclusive, but computed tomography angiography (CTA) suggested high-grade stenosis of the left renal artery. Given her issues with controlling blood pressure, it was recommended she undergo angiography and stent of the left renal artery.

Utilizing the left radial artery, a hybrid 5/6 sheath [5 French (Fr) outer diameter, 6 Fr inner diameter, (Terumo)] was placed (Figure 1). A pigtail catheter was placed in the distal aorta and an aortogram was performed, revealing a napkin ring lesion of 50-60% on the left, with a >20 mm gradient demonstrated with a multipurpose catheter (Figures 2-3). Using a diagnostic multipurpose catheter, a 0.018” 300 cm SurePath wire (IDEV Technologies) was advanced in the renal and a second 300 cm, 0.014” Ironman wire (Abbott Vascular) was placed in the aorta. Utilizing the two wires, a 6 Fr multipurpose guide was advanced into the renal with the “no touch” technique (removing the Ironman to allow cannulation). A 5.0 x 19 mm Express stent (Boston Scientific) was deployed at nominal pressure (Figure 4) and then the balloon was withdrawn slightly and then taken to high pressure. The wire was removed and final angiography demonstrated good flow (Figure 5). The guide was removed, a TR Band (Terumo) was placed, and the patient discharged later that day.

Case 2 

The second case involves a 60-year-old male with coronary artery disease, atrial fibrillation, and peripheral vascular disease. Non-invasive studies suggested right-sided inflow disease confirmed by magnetic resonance angiography (MRA), with high-grade stenosis of the right iliac as well as some common femoral disease. He was referred for lower extremity angiography and revascularization.

The left radial artery was accessed with a 5 French Glidesheath (Terumo). A 125 cm pigtail was passed distally and a distal aortogram was performed, demonstrating mild ectasia of the distal aorta and a high-grade stenosis of the right common iliac (Figure 6). The remainder of the vasculature did not demonstrate any critical disease. Following diagnostic angiography, the radial sheath was upsized to a 6 Fr, 90 cm Pinnacle Destination sheath (Terumo), placed in the distal aorta (Figure 7). We marked the location of the iliac artery on digital subtraction angiography, and then advanced a Runthrough wire (Terumo) distally. A 6 x 20 mm AngioSculpt balloon (AngioScore) was used to predilate the lesion (Figure 8), which did not involve the ostium. We stayed just below the ostium and deployed an 8 x 29 mm Genesis stent at nominal pressure (Figure 9). Final angiography revealed a brisk flow without dissection, perforation or embolization, and an angiographically well-sized lumen. The patient tolerated the procedure well. The sheath was removed, a TR Band was placed over the radial artery and he was discharged later that day.

Discussion

Currently, most peripheral interventions are performed using the transfemoral approach. Patients often have bilateral disease and the presence of diffuse atherosclerosis may preclude contra lateral or ipsilateral femoral artery cannulation. Alternatively, the brachial artery is then used for access; however, this can be associated with an increased risk of access site complications. The coronary literature has demonstrated a reduction in bleeding and access site complications with the transradial approach over the transfemoral approach.^1,2 The increased utility of transradial access (TRA) in the coronaries has led to dedicated radial equipment for the coronaries, and the development of longer shaft balloons and stents that has made the radial approach more feasible for an increasing number of peripheral procedures.

A detailed discussion of the TRA approach is beyond the scope of this article. A basic knowledge of radial artery caliber and anatomical considerations (hypoplasia, spasm, loops, etc.) is essential to avoid complications, save time, and select appropriate equipment. Although the right radial is more comfortable for most operators, left radial access will allow one to reach more distally, and avoid tortuosity of the supraortic vessels and the aortic arch. The use of longer sheaths may induce spasm; however, in most cases, this can be treated with additional sedation and/or vasodilators. With the exception of some devices (JetStream, Fox Hollow, larger size Viabahn and iCast stents), the majority of peripheral equipment will fit through a 6 Fr sheath, obviating the need for larger sheath sizes. Although body weight dose not necessarily correlate to radial artery caliber, it has been our experience that patients over 180 lbs will accommodate a 7 Fr sheath. One should also be familiar with the anthropomorphic measurements to understand potential limitations and chose the correct length equipment. 

Renal arteries 

The renal arteries generally have a downward oriented take-off, which makes for more direct cannulation with radial access as well as good support. They are well oriented for a Judkins right (JR)4 or multipurpose catheter. In patients taller than 5 ft 9 in (> 180 cm), a 125 cm guide may be required to allow direct cannulation. Longer shaft stents and balloons will be required (135 cm shaft minimum) in this instance. Studies have not demonstrated a difference in success between TRA and TFA for renal arteries.^3,4

Above-the-knee arteries (ATK arteries)

Use of the TRA for ATK arteries is feasible, but may have some limitations, particularly in taller patients (> 180 cm). In the taller patients, a 90 cm Destination sheath will not selectively cannulate the iliac and may result in loss of support. Longer guides can be considered in this instance. Atherectomy may be feasible in the iliac, but at this time, the shaft length is not long enough to utilize in the superficial femoral arteries (SFAs) or more distal. Stents will usually be able to reach suprainguinal anatomy, but not infrainguinal should a dissection occur. Also, if distal embolization occurs, it likely cannot be treated from the same access site. In our lab, it is mostly used for treating iliac disease, ostial iliac disease, and common femoral disease (particularly if there is bilateral disease). Often a 90 cm Destination sheath can be placed above the bifurcation, and using DSA with road mapping, the case can be completed without moving the camera. Occasionally, selective shots can be done via a crossing catheter (QuickCross, Spectranetics or CXI, Cook). Bard and eV3 both have long shaft balloons to allow treatment further down if necessary.

Transradial treatment of peripheral vascular disease is feasible in most instances, limited mostly by equipment length and occasionally size. As transradial access continues to grow, there is increasing demand for more dedicated equipment. Perhaps the armentarium will continue to grow. There is a growing body of literature utilizing this approach for a variety of complicated cases. It is important to note that the majority are observation studies, case reports, and include few patients. In addition, in most cases, the operator is an experienced radialist, so there may be some selection bias. More clinical trials will be needed to prove the safety and efficacy of this approach in various non-coronary interventions.

Disclosure: Orlando Marrero reports no conflicts of interest regarding the content herein. Dr. Zaheed Tai reports the following: Terumo (proctor for transradial course), Spectranetics (proctor for laser course, speaker, advisory board), Medicines Company (speakers bureau).

Orlando Marrero can be contacted at orlm8597@yahoo.com. Dr. Zaheed Tai can be contacted at zaheedtai@gmail.com.

References 

1. Gostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004; 44: 349–356.
2. Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: A systematic review and meta-analysis of randomized trials. Am Heart J. 2009; 157: 132–140.
3. Trani C, Tommasina A, Burzotta F. Transradial renal stenting: why and how. Catheter Cardivasc Interv. 2009; 74(6): 951-956.
4. Scheinert D. Braunlich S. Nonnast-Daniel B, et al. Transradial approach for renal artery stenting. Catheter Cardivasc Interv. 2001; 54(4): 442-447.