Published on November 10, 2014
Radial approach and carotid stenting
1. Sasko Kedev MD, PhD, FESC, FACC University Clinic of Cardiology Skopje, Macedonia [email protected] Radial Approach and Carotid Stenting
2. Ø Consulting Fees/ Honoraria Ø Boston Scientific Ø Medtronic Ø Meril Ø Terumo Ø Bayer AG Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company Disclosure Statement
3. Why Radial Access for CAS ?
4. FEMORAL APPROACH LIMITATIONS Ø Aorto-iliac disease or occlusion Ø Previous surgical bypass at this level Ø Diseased and Complex aortic arch with Ø Tortuous SAA originating from elongated, or type II, III, or bovine aortic arch
5. Aorto-iliac Disease or Occlusion
6. Tortuous SAA Originating from Elongated or Bovine Aortic Arch
7. ACCESS SITE COMPLICATIONS I The most common adverse event after CAS from the femoral approach MOST TECHNICAL FAILURES ARE RELATED TO A COMPLEX ARCH
8. Risk of catheter-related emboli in patients with atherosclerotic debris in the thoracic aorta Karalis DG et al. Am Heart J. 1996 Jun;131(6):1149-55.
9. ACCESS SITE COMPLICATIONS II Vascular access is 1st reason of bleeding complications & MACE after PCI BLEEDING INCREASES MORTALITY ! ! !
10. Alternatives to FA Ø Brachial Ø Radial / Ulnar Ø Direct puncture
11. Radial Access - Alternatives Ø Right Radial Artery is 1st choice ! Ø Right Ulnar Artery Ø Left Radial Artery Ø Left Ulnar Artery
12. Ulnar Artery Access Ø Alternative of TRA Ø Larger diameter and straighter course Ø More deeply seated Ø Near ulnar nerve
13. Ø Patient comfort and satisfaction Ø Reduced nursing cost Ø Reduced vagal reaction Ø Reduced hypotensive response Ø Reduced bleeding complications IMPORTANCE OF EARLY AMBULATION TRANSRADIAL CAS
14. Ø Anchoring technique Ø Telescopic approach TRANSRADIAL CAS
15. Left ACC 100% Case 1.
17. Terumo advantage wire in RECA
18. Amplatz stiff wire in RECA
19. Destination sheath 6Fr
20. Final Result
21. Before / After
22. TRANSRADIAL CAS Ø Anchoring technique Ø Telescopic approach
23. SIM COOK in to Shuttle SheathCase 2.
24. Shuttle Sheath Positioning
25. LICA 95 %
26. Final Result
27. Before / After
28. TRANSRADIAL CAS Ø Direct Cannulation Ø Simple Loop Cannulation Ø Deep Loop retrograde Cannulation
29. CAS of RICA – Direct cannulation Before / After Case 3.
30. TRANSRADIAL CAS Ø Direct Cannulation Ø Simple Loop Cannulation Ø Deep Loop retrograde Cannulation
31. Before / AfterCase 4.
32. TRANSRADIAL CAS Ø Direct Cannulation Ø Simple Loop Cannulation Ø Deep Loop retrograde Cannulation
33. TRA CAS of LICA – DLRC – Transfer Catheter Case 5.
34. TRA CAS of LICA – DLRC – Transfer Catheter
35. TRA CAS of LICA – DLRC – 5F JR GC
36. TRA CAS of LICA
37. TRA CAS of LICA – DLRC – 7F MP GC
38. TRANSRADIAL CAS Ø Right Wrist Access Ø Left Wrist Access
39. Left TRA CAS of RICA – Simple Loop Cannulation Case 6.
40. Left TRA CAS of RICA – Final result
41. Before / After
42. TRANSRADIAL CAS Ø Tortuous Internal Carotid Artery Ø String Sign Ø Contralateral Occlusion Ø Acute Carotid Syndrome
43. TUA for CAS of Tortuous LICA Male M.J 81 y.o. Case 7.
44. TUA for CAS of LICA – 6F GS
45. Tortuous LICA Subocclusion in Octogenarian
46. Stent: Precise 7.0/40mm
47. Final Result
48. Before / After
49. TUA for CAS of LICA Male M. D. 80 y.o. Case 8.
50. Ulnar Artery Access: LICA
51. Ulnar Artery Access: CAS of LICA
52. Before / After
53. TUA for CAS of LICA with contralateral occlusion Male J. A. 66 y.o. Case 9.
54. RICA 100%
55. Destination sheath 6Fr
56. Final result Final result
57. Before / After
58. Before / After
59. Male G. D. 54 y.o. TRA CAS of RICA in highly symptomatic patient CAD Asia, Sept. 2012; Pune, India Case 10.
60. RICA 99%
61. Final Result
62. Final Result
63. Before / After
64. TRA CAS of LICA in patient with acute stroke Male I. V. 62 y.o. Case 11.
65. Right TRA
66. LICA 99%+Thrombus
67. Cook 5F
68. Stent:Adapt 4/9/40mm
69. Final result
70. Final result
72. TRA CAS of LICA in highly symptomatic patient with amaurosis fugax Male D. M. 64 y.o Case 12.
73. Right TRA
74. LICA 99%+Thrombus
75. “Wireless” Telescopic Aproach
76. Shuttle Sheath 5F
77. Adapt 4/9/40mm
78. Final result
79. Final result (distal spasm)
81. 1 Month Follow up
82. TRA CAS of RICA in highly symptomatic patient Case 13. Male G.T. 64 y.o.
83. Right TRA
84. RICA 99%
85. MP 8F (RICA intermittent occlusion)
86. Xact 8/6/40mm
87. Baloon post-dilatation 5.0/20mm
88. Final result
90. Male K. A. 58 y.o. TRA CAS of LICA in patient with Acute Carotid Syndrome Case 14.
91. LICA 99%
92. Shuttle Sheath 5F
93. Adapt 4-9/40mm
94. Baloon post-dilatation 5,0/20mm
95. Final result
96. Final result
97. Before / After
98. Male D. M. 64 y.o. TRA CAS of RICA with MoMa proximal protection Case 15.
99. Right TRA
100. 8F: MoMa PPD
101. RICA 99%
102. MOMA proximal protection device
103. Final result (Adapt 4/9-32mm)
104. CAS LICA Sheathless MoMa proximal protection device Male B. C. 65 y.o. Case 16.
105. LICA 99%
106. Sheathless MoMa insertion
107. MoMa PPD
108. Stent: Wallstent 7.0/30mm
109. Final result
111. TRA for CAS of RICA and Stenting of occluded Right Subclavian Artery Male E. A. 66 y.o. Case 17.
112. Occlusion of right subclavian artery
113. Balloon pre-dilatation 4,0/12mm
115. TRA CAS of RICA
117. Stent: AVE Bridge 7.0/16mm
118. Final result
119. Before / After Subclavia RICA
120. Methods Ø 602 consecutive pts with CA stenosis >80% Ø Radial acess 475 pts (78%) Ø Ulnar acess 101 pts (17%) Ø Age 64.5 (48-81) years Ø 443 Male / 159 female
121. Complications at 30 Days Ø Death 2/602 (0.19%) Ø Major stroke 2/602 (0.19%) Ø Minor stroke 4/602 (0.58%) Ø Intraprocedural TIA 7/602 (1.37%) Ø Major vascular complications 1/602 (0 %)
123. Patent Hemostasis
124. Patent Hemostasis
125. Transradial CAS Ø Easy access in otherwise very complex aortic arcs Ø Immediate patient mobilisation Ø Reduced hypotensive response Ø No bleeding Ø Anticoagulation is not an issue Ø Reduced nursing cost Ø Outpatient performance in selected cases ADVANTAGE
126. Ø Significant learning curve for new TRA operators Ø Sometimes longer procedure for “easy case” with type I aortic arch Ø Proximal PD and larger devices could not be used freely in all cases Ø Radial artery occlusion ≈ 10 % DISADVANTAGE Transradial CAS
127. MISTAKE Ø Perform TRA only when FA is not possible !!! Transradial CAS
128. Conclusions Ø TRA for CAS is feasible and safe when performed by experienced TRA operator Ø Easy access for CAS in difficult anatomies (bovine arch LCCA)and most of the innominate artery take offs) Ø Allows early patient mobilization Ø Eliminates bleeding complications Ø Further studies are needed before recommending wrist access for endovascular procedures as primary approach over femoral access