Abdominal Infrarenal Aortic Stenosis Approached Through a Full Transradial Approach: A Case Series

Abstract: Six consecutive patients (3 men; mean age, 63 ± 14 years; age range, 38–81 years) with infrarenal abdominal aortic stenosis underwent unilateral or bilateral transradial approach for stenting of the aortic lesion. In 4 cases, isolated aortic stenting was performed through single transradial approach (in 2 cases with precise alignment to the proximal end of previously deployed iliac stents), whereas in the other 2 cases bilateral transradial approach was used for aortic stenting followed by bilateral stenting of the proximal iliac arteries. Either a “bare-on-the-wire” or a ”support-catheter” technique was used, according to patient anatomy and technical requirements. The median follow-up was 14.3 months, at which time all patients had relief of symptoms without thromboembolic or bleeding complications. In this performance and safety evaluation, full transradial approach was effective and safe for treating infrarenal aortic stenosis that is isolated or associated with iliac disease.

J INVASIVE CARDIOL 2017;29(7):227-231.

Key words: transradial approach, distal aortic stenosis, stent

Abdominal infrarenal aortic stenosis is an infrequent but challenging disease.^1,2 It can lead to claudication, lower-limb ischemia, emboli, aneurysm formation and rupture, renal ischemia, and hypertension.³ Although surgery has long been the approach of choice in this scenario, percutaneous intervention has also shown to be feasible.⁴ When a stent is implanted, a very good long-term patency is obtained, with a low complication rate.^5-7

Traditionally, infrarenal aortic stenosis stenting has been performed via the femoral artery,⁸ even though in the cardiology field it has been conclusively demonstrated that vascular and bleeding-related complications, in turn linked to excess morbidity and mortality, are increased with femoral access across the full spectrum of coronary syndromes.^9,10 Moreover, femoral access might be limited in these patients with severe peripheral arterial disease by important common femoral atheroma and vascular calcifications.

Whereas transradial access (TRA) has replaced femoral access as the dominant access site for percutaneous coronary interventions in many countries,^11,12 operators have only recently started to appreciate the usefulness of this access site for peripheral vascular interventions, in particular for the iliac-femoral district.^13,14 These large and rectilinear arteries, in fact, do not present many of the anatomic challenges that limit radial access in the treatment of lower-limb arteries.

The aim of this work is to report the effectiveness and safety of full TRA for the treatment of infrarenal aortic stenosis.  

Case Series

Patient selection and interventional procedure. At our center, the clinical, angiographic, and procedural data of patients undergoing percutaneous peripheral interventions are prospectively recorded into a dedicated electronic database previously used to assess the impact of systematic radial approach for coronary interventions.¹⁵ For the present study, we retrospectively identified all patients in whom endovascular treatment of infrarenal aortic stenosis was attempted through full TRA. Patients in whom other accesses were used, namely full transfemoral (n = 4) or combined TRA and transfemoral (n = 2), were excluded from this analysis.

Written informed consent was obtained from all patients. All patients were given aspirin (300 mg loading dose before the procedure, followed by 100 mg once daily indefinitely) and clopidogrel (300 mg loading dose and 75 mg daily for 1 month after the procedure).  

Radial approach, technique, and devices. Single or double TRA was used according to patient anatomy. In particular, double TRA was adopted for aortic disease involving the bifurcation, whereas single right or left TRA (according to operator preference) was used for the other patients. The diagnostic study was performed with standard 100/125 cm-long 5-6 Fr diagnostic catheters (Pigtail, Multipurpose, or Judkins right). Once the intervention was indicated, hydrophilic or standard wires (either 0.035˝ Glidewire or 0.018˝ V18 ControlWire) were used for lesion crossing. A multipurpose or Judkins right diagnostic catheter was used for support and for directing the guidewire tip. After crossing the intended lesion with wire and catheter, the wire was exchanged for a high-support 0.035˝ Supracore wire (Abbott Vascular). Then, two interventional techniques were utilized: (1) The “bare-on-the-wire” technique, consisting of standard 6 or 7 Fr Radifocus II (Terumo) introducers (6 Fr: 2.52 mm outer diameter and 0.079˝ inner diameter; 7 Fr: 2.85 mm outer diameter and 0.091˝ inner diameter) with the stent(s) pushed over the high-support wire(s). (2) The “support-catheter” technique, using either a 90 cm-long, 6 Fr Destination peripheral guiding sheath (Terumo) (2.82 mm outer diameter, 0.087˝ inner diameter) or a 90 cm PV 8.5 Fr sheathless guiding catheter (Asahi Intecc) (2.8 mm outer diameter, 0.090˝ inner diameter). 

Predilation with semicompliant balloons was performed at operator discretion. The balloons used were Admiral Xtreme (Invatec Medtronic), with shaft length of 130 cm, diameters of 3-7 mm, and lengths of 20-80 mm, or Renma 35 (Terumo), with shaft length of 135 cm, diameters of 4-10 mm, and lengths of 20-100 mm. Stents were: (1) self-expandable Smart Control stents (Cordis), with shaft length of 120 cm, diameters up to 14 mm (up to 10 mm compatible with 6 Fr, 12-14 mm compatible with 7 Fr sheaths) and lengths of 30-80 mm; and (2) self-expandable E-Luminexx vascular stents (Bard Peripheral Vascular), with shaft length of 135 cm, diameters up to 14 mm (all compatible with 6 Fr sheaths), and lengths of 20-120 mm. Additional stents used for treating the common iliac bifurcation were either self expandable (Smart) or balloon expandable (Scuba; Medtronic). Postdilation of the self-expandable stents was consistently performed. Roadmapping tool was commonly used for stent positioning. 

Case details. The details of the patients and procedures are shown in Tables 1 and 2. Briefly, 6 patients (3 females; age range, 38-81 years) were included. Preoperative assessment was carried out by angiography and/or computed tomography in all cases. Indication for percutaneous transluminal angioplasty was clinical, and included moderate-to-severe intermittent claudication (Rutherford classification types 2-4) or critical limb ischemia (Rutherford classification types 5-6). 

In 4 patients (cases #1-#4), the disease did not involve the aortoiliac bifurcation and was successfully treated using a single TRA (3 right and 1 left). Three of those patients had severe claudication. Case #1 was referred for severe bilateral thigh and calf pain on exertion, and an ulcerated complex severe stenosis of the aorta was detected. Case #2 presented with a history of angina abdominis plus recurring exertional bilateral thigh and buttock pain, as he had been already treated with simultaneous kissing stenting of the common iliac arteries. He underwent distal aorta single-stent implantation, which was precisely released to obtain alignment with the previously implanted iliac stents. Case #3 was a young, male, non-diabetic, heavy smoker who presented with ischemic ulceration of the left foot and was found to have only a very severe ulcerated lesion of the infrarenal aorta. A diagnosis of Buerger’s disease was later made. One patient (case #4) presented with critical limb ischemia with ischemic ulcerations of the digits. He had previously undergone simultaneous kissing stenting of the iliac common arteries for claudication. Distal aorta single-stent implantation was performed during the index procedure. Severe bilateral downstream lesions involving the tibial vessels were also present, which were subsequently treated using the antegrade approach. As shown in Table 1, all patients received a single, appropriately sized, self-expandable stent followed by balloon postdilation. The bare-on-the-wire technique was used in 3 cases and the support-catheter technique (using a PV 8.5 Fr sheathless guiding catheter) was used in 1 patient. An example of isolated aortic stenting (case #1) is reported in Figure 1.

In the other 2 patients (cases #5 and #6), who both presented with exertional bilateral thigh and buttock pain after less than 200 m of walking, the disease involved the aortoiliac bifurcation and the procedure was successfully performed using a double-TRA approach. In 1 patient (case #5), a support-catheter technique using two 90 cm-long 6 Fr Destination peripheral guiding sheaths was employed and aortic stenting was followed by simultaneous kissing stent using balloon-expandable stents of the common iliac arteries. In case #6, a bare-on-the-wire technique was adopted and self-expanding stents were used to treat the ostial common iliac arteries. Case #6 is illustrated in Figure 2.

All patients were clinically followed at 6-24 months. None of them showed recurrence of symptoms. Doppler examination confirmed patency of aortic/iliac stents in all patients at a median of 12 months follow-up. 

Discussion

Aortoiliac stenotic disease is commonly associated with severe, diffuse atherosclerosis and often presents with claudication, which can potentially progress to critical limb ischemia. Open surgical bypass grafting using aortobifemoral grafts has long been the established treatment, with good long-term patency of 80% and 60% at 5 and 10 years, respectively, albeit with a relevant operative mortality of 4%-5%.¹⁶ Over the last decade, endovascular treatment has emerged as an alternative to open surgery because of the avoidance of general anesthesia and the inherent risks of open abdominal surgery; it also allows a shorter postoperative hospital stay.¹⁶ The long-term results of endovascular stenting of the infrarenal aorta also seem comparable to open surgery, with primary patency of 80%-100% at 3-10 years.^17-19 These good results also extend to angioplasty of the infrarenal aorta plus angioplasty of the bifurcation, albeit with increased restenosis rates.⁸

Our case series shows, for the first time, that infrarenal aortic stenosis, even with bifurcation involvement, can be treated using full TRA, and allows some insights regarding this technique. First, procedural and technical success was achieved in all patients, and contrast use, fluoroscopy times, and radiation doses were acceptable. Moreover, and consistent with the reported safety of transradial interventions,^9-11,20 we did not register bleeding, stroke, or other complications related to the procedure. 

Second, some technical points deserve specific clarification. A general limitation of TRA in this setting is related to the well-known small caliber of radial arteries. In the majority of cases, only 6-Fr compatible equipment may be used. The bare-on-the-wire technique allowed us to treat small-to-medium sized aortas, up to 14 mm in diameter, with low risk of damage to the radial artery because 6 Fr sheaths were used. This simpler technique is further limited by the need for roadmapping guidance and can only be applied with self-expandable stents, which are protected by their sleeve. If treatment of the aortoiliac bifurcation is also required, this must be accomplished with self-expandable stents, sacrificing radial strength, as advancing unprotected balloon-expandable stents without catheters might not be safe.  

Conversely, the support-catheter technique might be more suitable for cases with important subclavian or aortic tortuosity, and also allows treatment of a severely calcified aortoiliac bifurcation with balloon-expandable stents, if needed. The increased back-up of this approach is coupled with the possibility of real-time contrast injection guidance. The most important drawback of this technique, however, is that 7 Fr access is required, as the outer size of both the 6 Fr long peripheral supporting sheath and the dedicated 8.5 PV sheathless catheter approaches the 2.85 mm outer diameter of regular 7 Fr sheaths.

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From the Department of Cardiovascular and Thoracic Sciences, Gemelli Foundation Hospital, Catholic University of the Sacred Heart, Rome, Italy.

Disclosure. The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted February 10, 2017, final version accepted February 17, 2017.

Address for correspondence: Italo Porto, MD, PhD, Department of Cardiovascular and Thoracic Sciences, Gemelli Foundation Hospital, Catholic University of the Sacred Heart, Largo A. Gemelli 00168, Rome, Italy. Email: italo.porto@gmail.com