TRANSRADIAL - NCVH Cardiovascular Conference NCVH/5-27-Wed/PDFs/0832_Cezar Staniloae.pdf ·...
Transcript of TRANSRADIAL - NCVH Cardiovascular Conference NCVH/5-27-Wed/PDFs/0832_Cezar Staniloae.pdf ·...
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TRANSRADIAL PERIPHERAL VASCULAR INTERVENTIONS
Cezar Staniloae NYU Heart and Vascular Institute
May 27, 2015
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Radial Artery is an Ideal Acess Site • Easily accessible even in subjects with severe PVD • Major advantage in terms of bleeding complications1,2 • Cannulation benefit for most arterial beds • Improved quality of life3
• Time-sparing hemostasis • Same-day discharge
1. Kiemeneij F, et al. ACCESS Trial. JACC, 1997
2. RIVAL Trial. Lancet 2011
3. Cooper CJ, et al. Am Heart J, 1999
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ACCUITY - Access
0 10 20 30 40 50 60 70 80 90
100
Radial (798) Femoral (11988)
Stone G et al. N Engl J Med 2006
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Wrist - Subclavian = 50-65cm
L Wrist - Renal A = 90cm
L Wrist - Common Iliac = 110-115cm
L Wrist - CFA = 125-135cm
R Wrist - R Carotid = 65-70 cm
R Wrist - L Carotid (bovine arch) = 65-70cm
L Wrist - Popliteal A= 160-180 cm
Anthropometric measurements
L Wrist - Foot= 200-230 cm
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Subclavian Artery Stenting Technique
1. Access: 5 Fr short sheath (occasional US guidance)
2. Diagnostic imaging: 5Fr MP
2. Exchange for 5-6 Fr 70-90 cm sheath
3. Image either retrograde or antergrade
4. Stable position of the camera – landmarks
5. PTA / Stenting
6. Final imaging: via sheath or pigtail
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Subclavian Artery Stenting Ideal guide support
▼ Useless femoral access
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Subclavian Artery Stenting Catheter in the Aorta
Useless catheter from the groin ▲
Stenting
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Subclavian Artery Stenting
Advantages of Radial Approach
1. Excellent guide support
2. Prevent excessive guide manipulation in the aortic arch
3. Limited contrast use
4. Absent access-site bleeding complications
5. Immediate ambulation
6. Early discharge
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Carotid Artery Stenting
2. LICA - when it arises from the innominate artery (bovine arch)
TRA IS the preferred access site for:
1. RICA in the presence of type III aortic arch, or severely disease arch
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Carotid Artery Stenting
RICA in presence of type III aortic arch, or severely diseased aortic arch
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LICA in Bovine Arch Technique
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Carotid Artery Stenting
TRA IS NOT the preferred access site for:
1. LICA - lack of support and potential for guide prolapse in the aortic arch
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Carotid Artery Stenting Technical considerations
• 1. Advance the 6Fr Shuttle sheath in the subclavian a.
• 2. Cannulate the R-CCA (or the L-CCA when arising from the innominate artery) using a 5Fr IM / AR-2 catheter
• 3. Wire the ECA
• 4. Telescope SS over the 5fr IM
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Carotid Artery Stenting TRA
• 2-center report: • CAS - attempted from TR in 382 patients • Procedural success: 347/382 (91%) patients
– 201/216 (93%) right CA, – 14/16 (88%) bovine left CA – 132/150 (88%) left CA.
Etxegoien et al. Cath Cardiovasc Interv 2012
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Carotid Artery Stenting TRA
• Adverse events at 30 days: • 2 major strokes (0.6%) / 1 Death • 3 minor strokes (1%) • No myocardial infarction • No bleeding
Etxegoien et al. Cath Cardiovasc Interv 2012
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Abdominal vessels
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Renal Artery Stenting
• Anatomically, the renal arteries take off in a downward fashion - therefore, cannulation is easier from above
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Renal Artery Stenting Technique: L Radial Access
Either 5 Fr / 90 cm Ansel 1 sheath, or 6 fr guiding catheter MP / AR2 / HS
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Renal Artery Stenting
• TRA approach - better than femoral: – In general – Special circumstances:
• AAA • Severe PVD • Steeply angulated renal arteries
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Iliac Artery Stenting
• L radial is preferred (gain aprox 5-10 cm)
• IM catheter to direct a 260cm 0.035” wire in the descending aorta
• 5 Fr / 110 cm introducer sheaths
• 5Fr compatible self-expandable stents (Zilver 518 -Cook Medical), or balloon expandable stents
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Iliac Artery Stenting 5 Fr 110cm sheath
Post Stenting
330 cm 0.014” Viper wire
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Transradial Iliac Stenting • 80 iliac lesions treated via TRA (28%CTO) or TFA (9% CTO)
Conclusions: 1. Similar contrast use (238 vs 213 ml) 2. Similar fluoroscopy time (30 vs 27 min) 3. Shorter time to discharge (14.4 vs 20.9 hrs) 4. Lower access-site complications (0 vs 7.2%)
Staniloae et al. Cath Cardiovasc interv 2009
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CFA Interventions
• No stent zone • Frequently - atherectomy + PTA • Most atherectomy devices require 7 Fr
introducer sheaths • DB360 - CSI - the only atherectomy
device 5-6 Fr compatible
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Left radial access
Left CFA occlusion Right CFA occlusion
CFA Interventions
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CFA Interventions
CROSSER 14S
Calcified CFA, SFA, PFA
Shuttle sheath, 6Fr/ 110cm/ 0.087” via left radial access
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CFA Interventions DB 360 - 2.0 SC 30
PTA 6.0 mm balloon
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CFA Interventions
Residual calcified plaque at the bifurcation
Post PTA 6.0 at 4 atm
Residual Calcified Eccentric Stenosis
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CFA Interventions
Wire in PFA DB 360 SC Final result ▼
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New Frontiers SFA / Popliteal
• Currently - severe limitations do to lack of adequate equipment
• Atherectomy with DB 360 - shaft length
145 cm + 15cm
• PTA of the SFA with 170/180mm shaft balloons
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TRA is the approach of choice for stenting of the:
• 1. Subclavian artery
• 2. Right Carotid Artery – type 3 / diseased arch
• 3. Left Carotid Artery arising from the innominate a
• 4. Renal and mesenteric arteries
• 5. Iliac Arteries
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Limitations of TRA for Peripheral Interventions
• Lack of adequate transradial training • Limited equipment
• Paucity of clinical studies
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Equipment Shortage There is an immediate need for: 1. Larger variety of introducer sheaths (90 / 110 / 125 cm) 2. Longer Guidewires (360-400cm) 3. Stents with shaft length up to 170-180cm 4. CTO / Reentry devices with longer shaft and lower profile
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TRANSRADIAL
for Vascular Interventions BASIC EQUIPMENT
Introducer Sheaths: 5 and 6 Fr 90 cm (Terumo); (4-6Fr) 110 cm (Cook)
Wires: 0.014 / 330 Viper (CSI); 0.035 / 300 Supracor (Abbott); 0.035 hydrophilic coating (Terumo; Cordis)
Balloons:
-longest shaft 170/180mm (Cook, Medtronic)
Scoring Balloons: Angiosculpt - 5 Fr - up to 6.0 - 137-139cm shaft Cutting Ballons - 6 Fr - 137 cm Chocolate Balloons: 6 Fr – 140 cm lenght
Stents: the only 5 Fr platform - Zilver stent (Cook) -125cm 6 Fr platform - longest shaft 135 (Abbott)
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TRANSRADIAL for Vascular Interventions
ADVANCED EQUIPMENT
• CTO Devices: – CROSSER (Bard) - 146 cm shaft - 6Fr (14S) – Wildcat (Avinger) 6Fr - 110 cm; 5Fr - 140 cm – Frontrunner (Cordis) - 140 cm – TruePath (Boston Sci) – 140cm
• Reentry Devices: – Outback (Cordis) - 6 Fr - 120 cm – Pioneer (Volcano) - 6 Fr - 120cm – Enteer (EV3) – 5Fr 135-150cm – OffRoad (Boston Sci) 5-6 Fr – 100cm
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TRANSRADIAL for Vascular Interventions
ADVANCED EQUIPMENT • Atherectomy:
– DB 360 – 160cm reach (145 cm shaft + 15cm though) - all crowns fit in 5 Fr (except 2.0 mm)
– TurboHawk, JetStream, Laser – large profile
• IVUS: – Volcano - 150 cm – Atlantis (Boston Scientific) - 135 cm