Transradial Bilateral Iliac Stenting

Use of the radial artery for coronary angiography was first reported by Campeau in 1989.¹ Since then, this approach has become more popular and has been extended to coronary interventions, particularly with the use of aggressive antithrombotic therapy. Although coronary interventions are performed via the radial approach with increasing frequency, peripheral interventions using this approach have been rarely described. There are presently only limited reports of renal and iliac artery interventions performed via the transradial approach.^2,3Case Report. A 65-year-old female patient was admitted for percutaneous angioplasty and stenting of both common iliac arteries. The patient had known nonobstructive coronary artery disease, hypertension and dyslipidemia. She had limiting claudications bilaterally. She was recently diagnosed with bilateral iliac artery stenosis. Her ankle-brachial index (ABI) was 0.56 on the left side and 0.67 on the right side; her bilateral severe common iliac stenoses were suggested by arterial duplex studies. The patient was overweight, and the common femoral pulses were not palpable bilaterally. She was 63 inches tall and weighed 230 pounds. In view of the potential femoral access problems, we decided to perform bilateral common iliac artery stent placement via the radial route. A 6 Fr 90 cm-long Pinnacle Destination introducer sheath (Terumo, Somerset, New Jersey) was placed via the left radial artery into the descending aorta. A long (125 cm) 6 Fr Multipurpose diagnostic catheter (Boston Scientific Corp., Natick, Massachusetts) was advanced into the right and subsequently into the left common iliac artery. Selective angiographies confirmed significant stenoses in both common iliac arteries just after their origin (Figure 1). The distal vessels showed only mild, diffuse narrowing, without critical stenoses. The Multipurpose catheter was then removed and the left common iliac artery stenosis was crossed with a 0.014 inch (300 cm) BMW guidewire (Guidant Corp., Indianapolis, Indiana). A 0.014 inch wire was chosen because it adds 40 cm to the longest available 0.035 inch wire. A self-expandable 10 x 60 mm Absolute stent (Guidant) was delivered in the left iliac artery lesion. The stent was then dilated with a 7 x 20 mm Agiltrac peripheral dilatation balloon (Guidant) that was inflated at 12 atm, with good angiographic result (Figure 2). The guidewire was removed from the left iliac artery and placed across the lesion in the right common iliac artery. A self-expandable 10 x 30 mm Absolute stent was delivered in the right iliac artery lesion. The stent was postdilated with the same 7 x 20 mm Agiltrac peripheral dilatation balloon. The final result is shown in Figure 2. The procedure was terminated, the radial sheath removed immediately and a pressure dressing was applied. During the intervention, the patient received unfractionated heparin, and the ACT was kept between 250–300 seconds. The patient was discharged on the same day on 75 mg/day clopidogrel and 81 mg aspirin. At 1-month follow up, the patient reported complete resolution of her symptoms, and her ABI improved to 0.9, bilaterally. Discussion. To our knowledge, this is the first report of bilateral iliac artery stenting via the transradial approach performed in the same procedure. Transradial access, adapted for therapeutic procedures by Kiemeneij and Laarman,⁴ has increased in popularity due to technological advances in sheath and catheter design, miniaturization of the interventional equipment and improved physician experience with this approach. Due to rapid ambulation postprocedure, radial access became particularly attractive for patients undergoing coronary interventions. This approach should be particularly beneficial for patients undergoing peripheral interventions for several reasons. First, these patients frequently present with bilateral disease that makes them more susceptible to local vascular complications. Not infrequently, the crossover technique is hampered by severe tortuosity, and therefore bilateral percutaneous stenting is rarely performed in the same procedure. Second, it eliminates compressing the common femoral artery after the procedure, which in the presence of occlusive disease, may lead to ischemia or thrombosis. Third, this approach facilitates same-day discharge, even in the presence of aggressive antithrombotic treatment. Although lower extremity interventions via the brachial artery approach have been reported,⁵ they could be accompanied by major complications such as false aneurysms, large brachial hematomas requiring surgical exploration and arterial repair, and hematomas with clinical median nerve dysfunction.⁶ These complications resemble those encountered during the femoral approach, and therefore make the radial artery interventions safer. Nevertheless, there are significant limitations to the radial artery technique. These are related particularly to the lack of adequate equipment. The current introducer sheaths extend to a maximum of 90 cm; in the majority of cases this brings the sheath only to the renal artery level. Sheaths of at least 110–125 cm length would be required to allow angiography to be performed, as well as adequate guidance during the intervention. This implies availability of exchange wires of at least 300 cm and balloon and stent shafts of at least 135–150 cm. Furthermore, use of the radial artery could limit the size of introducer sheath to 6 Fr, which can be a limiting factor when larger devices are required. Should “kissing stents” be needed, a bilateral radial approach could be used. Radiation exposure is another concern when using radial artery access. A recent study demonstrated that the radial approach is burdened with a 100% increase in operator radiation exposure during diagnostic coronary catheterization procedures, and a 50% increase during coronary interventions, provided that no special devices for radiation protection are used.⁷ Although there are current limitations to the radial artery technique, the potential benefits outlined above should justify the development of specific devices designed for this purpose. The radial artery is an excellent conduit for performing vascular interventions and is particularly attractive due to the ability to contain any potential local complications.

References 1. Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn 1989;16:3–7. 2. Flachskampf FA, Wolf T, Daniel WG, Ludwig J. Transradial stenting of the iliac artery: A case report. Catheter Cardiovasc Interv 2005;65:193–195. 3. Shiraishi J, Higaki Y, Oguni A, et al. Transradial renal artery angioplasty and stenting in a patient with Leriche syndrome. Int Heart J 2005;46:557–562. 4. Kiemeneij F, Laarman GJ, de Melker E. Transradial artery coronary angioplasty. Am Heart J 1995;129:1–7. 5. Ernst S, Fischbach R, Brochhagen HG, et al. Transbrachial thrombolysis, PTA and stenting in the lower extremities. Cardiovasc Intervent Radiol 2003;26:516–521. 6. Hildick-Smith DJ, Khan ZI, Shapiro LM, Petch MC. Occasional-operator percutaneous brachial coronary angiography: First, do no arm. Catheter Cardiovasc Interv 2002;57:161–165; Discussion p. 166 7. Lange HW, von Boetticher H. Randomized comparison of operator radiation exposure during coronary angiography and intervention by radial or femoral approach. Catheter Cardiovasc Interv 2006;67:12–16.