Abstract: Endovascular treatment of peripheral artery disease is challenged by limited access options when the disease involves the common femoral artery. We described a case of transradial intervention of severe common femoral artery stenosis with orbital atherectomy and discuss the technique, advantages, and limitations.
J INVASIVE CARDIOL 2013;25(11):616-619
Key words: transradial, endovascular, common femoral artery stenosis, orbital atherectom
Percutaneous endovascular treatment of peripheral artery disease (PAD) involving aorto-iliac disease and superficial femoral artery (SFA) disease is well accepted.1 Claudication or critical limb ischemia caused by common femoral artery (CFA) disease is preferably treated by surgery because of the easy accessibility and favorable long-term outcomes of endarterectomy.2 However, endovascular treatment of CFA disease with atherectomy, balloon angioplasty, and provisional stenting is also associated with a high success rate, low in-hospital complication rate, and acceptable restenosis rate at medium-term follow-up.3 Feasibility reports of transradial intervention of aorto-iliac disease are reported in the literature,4,5 but transradial treatment of PAD involving CFA or SFA is not described. We report a case of transradial CFA atherectomy and discuss the technique for transradial peripheral intervention.
A 55-year-old Caucasian man presented to our endovascular clinic for complaints of Rutherford class-III claudication involving his hips and thighs bilaterally. His past medical history included ischemic cardiomyopathy, hypertension, hyperlipidemia, and tobacco abuse. On physical exam, +1 palpable left femoral pulse, non-palpable right femoral pulse, and weak bilateral pedal pulses were noted. Ankle brachial index on the left leg was 0.67 and right leg was 0.71. A diagnostic angiogram from left radial access showed heavily calcified and occluded right common femoral artery (Figure 1A) and severe right iliac stenosis (Figure 1B). On the left, a heavily calcified, subtotally occluded common femoral artery (CFA) and a subtotally occluded proximal left superficial femoral artery (SFA) were noted (Figure 2). Mid SFA and popliteal arteries were patent, with 2-vessel runoff bilaterally. At the time of the diagnostic procedure, the right iliac artery was successfully treated with an 8.0 x 30 mm balloon-expandable cobalt stent (Medtronic Corporation) via left radial approach (Figure 3). A vascular surgery consult suggested treating the left common femoral artery and SFA percutaneously, as it was felt to be a suboptimal target for endarterectomy. The vascular surgeons suggested surgical endarterectomy for the right CFA occlusion.
A relatively high left radial access was achieved approximately 6 cm proximal to the radial head. A small amount of local anesthetic (lidocaine) was injected for cutaneous anesthesia. An Introcan Safety IV cannula (B. Braun) was advanced after flashback of blood was seen, passing the needle through the posterior wall of the radial artery. The needle was removed and the plastic cannula was pulled back very slowly parallel to the skin. A 0.021˝ wire was inserted when blood flow was seen. A short 5 Fr glide sheath (Terumo Corporation) was placed. A combination of 200 µg nitroglycerin and 2.5 mg verapamil was injected intraarterially. A 0.035˝ J-wire was advanced in the left external iliac artery while guided by a 5 Fr Multipurpose catheter. The 5 Fr sheath was exchanged for a 6 Fr 110 cm Ansel sheath (Cook Medical) over a 260 cm, 0.035˝ wire and was advanced into the left external iliac artery (EIA). A 0.018˝ Treasure wire (Asahi Corporation) and Quick-Cross catheter (Spectranetics Corporation) were used to cross the lesions. Over a 0.018˝ Quick-Cross catheter, the Treasure wire was exchanged for a 0.014˝ ViperWire (Cardiovascular System, Inc). A 2 mm CSI Diamondback classic crown was used to perform orbital atherectomy of the left CFA and left SFA (Cardiovascular System, Inc) (Figure 4A). Two passes were performed at each speed level, starting with 60,000 rpm to 120,000 rpm. Subsequently, a 6 x 100 mm Aquatrack balloon (Medtronic Corporation) was used to perform angioplasty with 4 minutes of inflation (Figure 4B). Repeat angiogram showed very good result, with 30% residual stenosis and no dissection (Figure 5). Prior to removing the sheath, an additional dose of versed and morphine was given to the patient. The sheath was removed and a TR band (Terumo Corporation) was applied to achieve hemostasis. Four hours post procedure, the patient was discharged home.
The patient was seen in the endovascular clinic 1 month after his procedure with complete resolution of symptoms in the left lower extremity — Rutherford category 0. Ankle brachial indices were 1.00 and 0.85 using the posterior tibial and dorsalis pedis arteries, respectively, on the left leg.
In patients with a high-risk cardiac history, percutaneous treatment of PAD involving CFA and SFA is preferred over higher risk femoral-popliteal bypass surgery.1 CFA intervention is challenged by limited access choices in the presence of bilateral femoral artery disease. Femoral access in the presence of PAD is associated with a higher incidence of access-related complications.6,7 Brachial artery access had the highest rate of access-related complications in comparison to radial and femoral, in a randomized control trial.8 Radial access can be a safer alternative for CFA treatment in patients with an absent femoral pulse due to severe iliac artery stenosis, or contralateral femoral occlusion.
Advantages of radial access. The presence of severe tortuosity and heavy calcification of the iliac arteries hinders the usual crossover technique in many patients. Although the long distance from the radial artery to the CFA makes radial access for CFA disease seem counterintuitive, the subsequent geometry yields a straight line from a sheath parked in the aorta (or ostial iliac artery) to the disease in the iliac or femoral artery. This allows easy delivery of balloons, stents, or other devices.9 Radial access also eliminates the need of mechanical compression of the femoral artery in patients with PAD. In patients who have experienced both radial and femoral access, there is a strong preference for the radial approach due to increased functioning and less discomfort.10 Early ambulation and same-day discharge can be achieved almost immediately after removing the hemostatic band from the wrist, which makes it a truly outpatient procedure and further reduces morbidity as well as the cost of the procedure.
Limitations of radial access. The limitation of radial access is mainly related to the diameter of the artery and the distance from the target vessel. The diameter of the radial artery varies from 2.0 mm to 3.0 mm, with a mean diameter of 2.6 mm.11 Only sheaths ≤6 Fr can be used in most patients, which limits the choices and sizes of devices that can be used for intervention. Furthermore, long (≥65 cm) 6 Fr sheaths have a larger outer diameter than a short 6 Fr sheath, which increases the risk of radial artery spasm (Table 1). Also, the left radial approach has to be used, since it saves 10-15 cm of distance at the aortic arch. At least a 90-cm long sheath and 135 cm working shaft length of the treatment device is required (balloons, stents, atherectomy devices, etc). The last limitation is the lack of literature supporting transradial peripheral interventions except in anecdotal case reports or single-center registries.4,5
Technique and troubleshooting. It is mandatory that the radial operator be well versed with radial anatomy and its anatomical variants. Left radial access is generally preferred for the distance (as noted above), but also has the advantage of not crossing the aortic arch and cerebral vessels. For diagnostic angiograms, a 5 Fr short radial sheath is used for access. Entering the descending aorta from the left radial can be challenged by severe tortuosity of the subclavian or by remodeling of the aortic arch. A left anterior oblique view, and an angled glide wire along with a JR 4 catheter can be used to enter the descending thoracic aorta. A Pigtail catheter or JL 4.0 catheter12 can also be used to enter the descending aorta. A 5 Fr 125-cm long pigtail catheter is used to perform an abdominal aortogram. Subsequently, it is advanced to the distal abdominal aorta and bilateral lower extremity run-off can be performed. A 125 cm 5 Fr Multipurpose catheter or 150 cm 0.035˝ support catheter (eg, Quick Cross [Spectranetics Corporation] or NaviCross [Terumo Corporation]) can be used to perform selective angiogram by advancing the catheter down to the popliteal artery. We routinely calculate the catheter length required to reach the ostial iliac artery, which guides us in determining the feasibility of a radial approach for intervention. Finally, a vasodilator cocktail and anticoagulation use along with a patent hemostasis technique should be used for all radial access cases.10
Currently, we have equipment length only supporting intervention up to the superficial femoral artery in most patients (most products have at most a 135 cm-long shaft). The radial artery can be accessed 2 to 3 inches more proximal to the usual access site, which may make the difference in terms of reaching a target. At this level, the radial artery is deeper but still separated from major nerves in the forearm. Compressibility of the puncture site against the bone should be confirmed, and extra attention to hemostasis is required. A short 6 Fr sheath is used for access and subsequently exchanged for a long sheath over 0.035˝ wire parked in the distal abdominal aorta. A sheath length of 110 cm is required to reach the ostial iliac artery, which will allow angiographic guidance through the sheath to deploy devices. In our experience, if the patient is taller than 5´10˝ or has severe tortuosity of the subclavian artery, the 110 cm sheath only reaches the distal abdominal aorta. In such cases, a 125 cm multipurpose catheter can be used to do selective angiogram guided by image overlay, radiopaque ruler (Vascu Tape; LeMaitre Vascular), or bony landmarks, and a balloon or stent can be deployed at the disease target. A working shaft length of 120-135 cm will be required for a device to reach the CFA depending on the patient’s height and vessel tortuosity. A 0.014˝-0.035˝ 300 cm wire can be used to cross the lesion per operator’s discretion. We have listed devices available for transradial peripheral intervention in our lab that have adequate shaft length and compatibility with a 6 Fr sheath (Table 2).
Prior to sheath removal, additional conscious sedation or pain medication should be given. This is because spasm is very common with long bulky sheaths. The sheath is removed with continuous, gentle pullback. An additional dose of sublingual nitroglycerin may help if spasm occurs. As the sheath is pulled back into the radial artery, about 15 cc of blood should be aspirated and the sheath should be flushed with heparinized saline. An additional dose of exit vasodilator cocktail (nitroglycerin 200 µg and verapamil 2.5 mg) is recommended. A hemostatic band is applied and the rest of the sheath can be removed.
Conclusion. Transradial atherectomy of CFA stenosis is feasible and radial access can be a safer alternative for endovascular peripheral intervention in many situations with the proper understanding of the equipment and limitations.
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From the Deborah Heart & Lung Institute, Browns Mills, New Jersey.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure
of Potential Conflicts of Interest. Dr Sanghvi is a consultant for Cordis Corporation
and on the speaker’s bureau for Boston Scientific; reports honoraria for Medtronic and
provisional patents (Radial peripheral guide sheath and EASY radial sheathless access).
Manuscript submitted May 16, 2013 and accepted July 9, 2013.
Address for correspondence: Kintur Sanghvi, MD, Director of Transradial Program,
Deborah Heart & Lung Institute, Browns Mills NJ 08015. Email: firstname.lastname@example.org