Treating a Chronic Total Occlusion of the Iliac Artery via the Transradial Approach

“Orlando, we had a case that we were unable to do from the femoral approach. It was scheduled as a percutaneous transluminal angioplasty (PTA) of the iliac. Have you ever done an iliac from the radial approach?”

Excellent question, and the answer is yes. It is best to use the left arm, so all your equipment can reach. I have a case of a chronic total occlusion in the iliac artery for presentation.

Treating a Chronic Total Occlusion of the Iliac Artery via the Transradial Approach

Case performed by interventional cardiologist Zaheed Tai, DO, FACC, FSCAI, Winter Haven Hospital, Winter Haven, Florida, and presented by Orlando Marrero, RCIS, MBA, Tampa, Florida.

Case report

The patient is a 76-year-old female with history of peripheral vascular disease. She has bilateral superficial femoral artery (SFA) occlusions and had an occluded right external iliac and common femoral. She has atrial fibrillation, hypertension (HTN), dyslipidemia, carotid endarterectomy and recently had a ST-elevation myocardial infarction (STEMI) in September 2011 with successful revascularization of the right coronary artery (RCA). She is scheduled for surgical repair of her peripheral vascular disease for significant rest pain as well as questionable ischemia; however, in light of her recent MI, she is deemed a nonsurgical candidate and has been referred for percutaneous revascularization.

Procedure plan

Laser atherectomy, percutaneous transluminal angioplasty (PTA) and stenting of the right external Iliac and common femoral arteries, distal to proximal. Stents placed are a 5.0 x 60 mm Supera Veritas (IDEV Technologies) and an 8.0 x 80 mm EverFlex self-expanding stent (Covidien).

Description & process

The left radial artery was prepped and draped in sterile fashion. The left radial artery was accessed with a 5 French Glide sheath (Terumo).  A 100 cm internal mammary (IM) catheter was placed into the right iliac and selective angiography performed which demonstrated a 100% occlusion at the origin of the external iliac, with reconstitution just above the bifurcation in the distal common femoral artery (Figure 1).

We upsized to a 6 French 90 cm Pinnacle Destination sheath (Terumo), which was above the bifurcation. We advanced a .035” Quick-Cross catheter (Spectranetics) into the common iliac and performed selective angiography, then road mapping.

The angle that showed the origin of the external iliac was best viewed in a contralateral 30-degree angle (Figure 2). After anticoagulation was administered, we tried to cross with a .035” Glidewire and the Quick-Cross. We were unable to cross, so we switched out to an angled Quick-Cross, and were able to cross and pop through the cap into the distal common femoral, and into the profunda.

Selective angiography was then performed, showing that we were luminal and also that the SFA was occluded with some faint reconstitution at the adductor canal. We exchanged for a .014” wire and did laser atherectomy of the external iliac and common femoral with a 2.0 laser, making 2 passes at the 45-60 setting (Figure 3). This was followed by predilatation with 5.0 x 100 mm and 6.0 x 100 mm AngioSculpt balloons (AngioScore).

Given the patient’s advanced age and the extent of the disease, we elected to go ahead and a place a stent. Based on predilatation sizing, a 5.0 x 60 Supera stent was placed from the distal common femoral back to the origin. The Supera was then overlapped with an 8.0 x 80 mm EverFlex self-expanding stent. Following stent placement, we had excellent angiographic results. We then post-dilated both stents and had good flow into the produnda and distal reconstitution (Figure 4).

Conclusion

Peripheral vascular disease can be treated via the radial approach. In the future, we would like to see longer devices so we can reach the SFA and popliteal arteries.

Orlando Marrero can be contacted at orlm8597@yahoo.com.

Check out Orlando’s transradial blog at www.cathlabdigest.com/blogs (or scroll down to the bottom right for our blog section on the CLD homepage, www.cathlabdigest.com)

Disclosure: Orlando Marrero reports he is an independent consultant currently consulting as an endovascular specialist for IDEV Technologies.