Transradial CAS

Transradial and Transulnar
Access for Carotid Artery
Stenting Using Deep Loop
Retrograde Cannulation
Sasko Kedev MD
University Clinic of Cardiology
Skopje, Republic of Macedonia
e-mail: [email protected]
Disclosure Statement of Financial Interest
I, Sasko Kedev DO NOT have a financial
interest/arrangement or affiliation with
one or more organizations that could be
perceived as a real or apparent conflict of
interest in the context of the subject of
this presentation.
Why Radial or Ulnar
Access for
CAS?
Access Site Complications I
The most common adverse event after CAS
from the femoral approach
MOST TECHNICAL FAILURES ARE
RELATED TO A COMPLEX ARCH
Femoral Approach Limitations I
• Aorto-iliac disease or occlusion
• Previous surgical bypass at this level
• Diseased and Complex aortic arch with
• Tortuous SAA originating from elongated,
or type II, III, or bovine aortic arch
Aorto-Iliac Disease or Occlusion
Severe Peripheral Vascular Disease
Previous surgical bypass at this level
Diseased and Complex Aortic Arch
Tortuous SAA Originating from Elongated or
Bovine Aortic Arch
Access Site Complications II
Vascular access is 1st reason of bleeding
complications & MACE after PCI
BLEEDING INCREASES MORTALITY ! ! !
38,872 PCI procedures
Radial Artery Access halved
 transfusion rate
 one year mortality
Meta-analysis: Radial vs Femoral Access
7020 pts enrolled in 23 randomized trials:
• 73 % reduction in major bleeding
• 29 % reduction in death, MI, and stroke
Jolly SS. Am Heart J 2009;157(1):132–140.
Femoral Approach Limitations II
• Increased back pain
• Urinary retention
• Delayed ambulation
• Neuropathy
Alternatives to Femoral Approach
• Brachial
• Radial / Ulnar
• Direct puncture
Brachial Approach
ADVANTAGE
• Larger artery
• Shorter distance
• Spasm is not significant issue
Brachial Approach
LIMITATIONS - COMPLICATIONS
• End blood supply to the forearm
and hand
• Hand ischemia
• Brachial sheath hematoma
• Compartment syndrome
• Median nerve injury
• Higher operator radiation
Radial Approach
• Widespread use by
cardiologist
• Rarely used in the SA field
• Promising technique
to solve access problems
Ulnar Approach
• Alternative of TRA
• Larger diameter and
straighter course
• More deeply seated
• Near the ulnar nerve
Transradial CAS
” Walk In, Walk Out “
Benefit !!!
Transradial CAS
IMPORTANCE OF EARLY AMBULATION
• Patient comfort and satisfaction
• Reduced nursing cost
• Reduced vagal reaction
• Reduced hypotensive response
• Reduced bleeding complications
Transradial CAS
ANCHORING TECHNIQUE
• SIM 1-3 in CCA
• Long hydrophilic GW in ECA
• Exchange with transfer catheter
• Exchange with extra stiff GW in ECA
• Advance 6F GS in CCA
Case 1.
5F JR GC in LECA and Supper stiff GW .035” in LECA
Simple Loop Cannulation - 6F GS in LCCA, with
DPD and Stent Deployment
Case 2. Severe
Angulations at the Origin of Innominate Artery
5F JR GC in Right ECA and Stent Deployment
(Xact 8.0/30mm) Through 6F GS
TRA CAS of RICA - Final Result
Transradial CAS
TELESCOPIC APPROACH
• SIM 1-3 in CCA
• Long J shaped GW in CCA bellow bifurcation
• Advance “mother and child” system in CCA
5-6F GS or 7F GC with long 5F cath
Case 3.
TRA CAS of LICA
Case 4.
TRA CAS of LICA
Case 5.
Ulcerated Lesion of LICA in Symptomatic pt
Indicated for CABG
Direct LCCA Cannulation - Stent Deployment and
Final Result
Case 6.
TRA CAS of LICA – Simple Loop Cannulation
Transradial CAS
DEEP LOOP RETROGRADE CANNULATION
• Soft GW with loop at the aortic valve
• Exchange with stiff GW over transfer cath
• Advance 5F GC bellow SAA and enter CCA with
GW (.14” - .25”)
• “Mother and Child” system (5-6F GS or 7F GC
with long 5F cath) in CCA
Case 7.
TRA CAS of LICA – DLRC – Transfer Catheter
TRA CAS of LICA – DLRC – 5F JR GC
TRA CAS of LICA – DLRC – Stiff GW in LECA
TRA CAS of LICA – DLRC – 7F MP GC
TRA CAS of LICA – DLRC – Final Result
TRA CAS of LICA – DLRC - GC Retrieval
Case 8.
TRA CAS of LICA - DLRC
TRA CAS of LICA - DLRC
Methods
• 145 consecutive pts with CA stenosis >80%
• Age 68 ± 7.8 years
• 112 male / 33 female
Baseline Characteristics I
• Octogenerians
18 (12 %)
• Hypertension
58 (40 %)
• Diabetes
42 (29 %)
• Hyperlipidemia
101 (70 %)
• Smoking
61 (42 %)
• Oral anticoagulation
23 (16 %)
Baseline Characteristics II
• Previous myocardial infarction
38 (26 %)
• Previous PCI
47 (32 %)
• Previous CEA
22 (15 %)
• Previous CABG
27 (17 %)
• Indication for CABG
30 (21 %)
• Contralateral occlusion
29 (20 %)
Procedural Characteristics
• Symptomatic
49 (34 %)
• Asymptomatic
96 (66 %)
Procedural Characteristics
• Left Internal Carotid Artery
81 (56 %)
• Right Internal Carotid Artery
64 (44 %)
• Bilateral CAS
7 (5 %)
Procedural Characteristics
• Right Radial artery
126 (87 %)
• Right Ulnar artery
13 (9 %)
• Left Radial artery
6
(4 %)
Procedural Characteristics
• 5F Guiding sheath
20 (14 %)
• 6F Guiding sheath
108 (75 %)
• 7F Guiding catheter
17 (11 %)
Target CCA Cannulation
• Direct CCA Cannulation
• Simple Loop CCA Cannulation
• Deep Loop Retrograde
Cannulation
10 (7 %)
113 (78 %)
22 (15 %)
Device Used
Distal protection device
136 (94%)
• Emboshield Pro (Abbott)
98 (72 %)
• FilterWire EZ(Boston Sci)
36 (26 %)
• Angiogard (J & J)
2 (1.5 %)
Device Used
Carotid stent (Rx)
• Xact (Abbott)
103 (71%)
• Wallstent (Boston Sci)
23 (16 %)
• Precise (J & J)
12 (8 %)
• Crystallo ideale (Invatec)
7 (5 %)
Case 9.
TRA CAS of RICA - 6F GS in RCCA – Direct Cannulation
TRA CAS of RICA - Final Result
Case 10.
TRA CAS of LICA – Direct Cannulation
TRA CAS of LICA – Final Result
Case 11.
TRA CAS of RICA – Severe Angulations of IA
TRA CAS of RICA – Simple Loop Cannulation
TRA CAS of RICA - Final Result
Case 12.
TRA and TUA CAS of Bilateral CAD
TRA CAS of LICA – Simple Loop Cannulation
One Month Later - TUA for CAS of RICA
TUA CAS of RICA
Case 13.
Left TRA CAS of RICA – Simple Loop Cannulation
Left TRA CAS of RICA – Final Result
Case 14.Left
TRA CAS of RICA – Mother and Child with DLRC
Left TRA CAS of RICA – DLRC with 7F GC
Left TRA CAS of RICA – DLRC
Case 15.
TRA CAS of RICA - String Sign
TRA CAS of RICA – Final Result
One Hour After TRA CAS of RICA
Case 16.
Tortuous LICA Subocclusion in Octogenarian
Tortuous LICA Subocclusion in Octogenarian
TRA CAS of LICA – Precise 7.0/40
TRA CAS of LICA – Final Result
Case 17.
LICA Occlusion - RICA Complex Lesion
6F GS in RCCA
TRA CAS of RICA – Final Result
TRA CAS of RICA (Xact 9/7 30 mm)
Results
• Primary success
• Switch to femoral access
• Direct stenting
• Simultaneous PCI
• Interventional time (min)
• Hospital stay (days)
140 (97%)
4 ( 3%)
130 (90%)
3 (21%)
42 ± 26
1 ± 1.3
Complications at 30 days
• Death
• Major stroke
• Minor stroke
• Intraprocedural TIA
• Myocardial infarction
• Severe hypotension
• Bleeding
• RA occlusion
0
0
0
4 ( 3 %)
0
0
0
9 ( 6 %)
Radial Approach - Hemostasis
Radial Approach - Hemostasis
“ Patent Hemostasis ”
could reduce the rate of
RA occlusion
Transradial CAS
ADVANTAGE
• Easy access in otherwise very complex aortic arcs
• Immediate patient mobilisation
• Reduced hypotensive response
• No bleeding
• Anticoagulation is not an issue
• Reduced nursing cost
• Outpatient performance in selected cases
Transradial CAS
DISADVANTAGE
• Significant learning curve for new TRA operators
• Sometimes longer procedure for “easy case”
with type I aortic arch
• Proximal PD and larger devices could not
be used freely in all cases
• Radial artery occlusion ≈ 6 %
Transradial CAS
MISTAKE
• Perform TRA only when FA is not possible !!!
Starting Transradial CAS Program
• Good reason and MOTIVATION
• Begin with diagnostic angio from RA
• One-on-one teaching by experienced radialist
• Become familiar with equipment (SIM 1-3 etc)
• Be selective initially
• Keep patience and perseverance
• Once competent :
Transradial CAS Program
Just Do It Regularly !!!
Conclusions I
• TRA & TUA CAS is feasible and safe when performed
by experienced TRA operator
• Easy access in difficult anatomies (bovine arch LCCA)
and most of the innominate artery take offs
• Severe angulations at the origin might be negotiated
safely and efficiently with DLRC as alternative of Direct
and Simple Loop cannulation for CAS
Conclusions II
• Allows early patient mobilization
• Eliminates bleeding complications
• Further studies are needed before recommending
wrist access (TRA or TUA) for CAS as primary
approach over femoral access