Abstract
We present a case of a patient with total chronic occlusion of the right common iliac artery that underwent percutaneous stenting with combined transpedal and transradial approaches. With this novel strategy, femoral access can be avoided.
Highlights
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Chronic total occlusion of iliac artery are usually treated using percutaneous femoral access
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Femoral access exposes patient to higher risks of vascular bleeding and complications
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Combined transpedal and transradial access allows endovascular treatment of CTO of iliac artery while avoiding femoral access
1
Introduction
Historically, surgical bypass strategies have been employed for mainstay management of aortoiliac occlusive disease, however, bypass rates have been steadily declining. Medicare claims data from 1996 to 2011 revealed a 165% increase in the rate of diagnostic lower extremity angiograms, as well as, greater than 3 fold increase in therapeutic percutaneous endovascular procedures . The advancement in percutaneous management of aorto-iliac disease with angioplasty and stenting is driven by improvements in catheters, balloons, stents, closure devices, and increased operator experience. This has directly translated to comparable success rates with vessel patency and limb salvage when compared to surgical repair . The aforementioned observation is further evidenced by Medicare claims data report of a 48% reduction in above-the-knee amputations, despite a significant reduction in surgical revascularization rates .
The most recent guidelines as prescribed by the Trans-Atlantic Inter-Society Consensus (TASC) II (Inter-Society Consensus for the Management of Peripheral Arterial Disease), published in 2007, recommend surgical intervention for aortoiliac lesions characterized as TASC II type D, and percutaneous endovascular intervention for TASC II type A and B. Surgery is the preferred approach for low-risk patients with TASC II type C lesions, however, percutaneous intervention may be the optimal therapy when operator’s experience, patient’s preference, and co-morbidities are taken into consideration .
Typically, percutaneous intervention of the iliac artery is performed in a retrograde fashion via the femoral artery . However, alternative access sites including radial artery and transpedal access are becoming increasingly utilized particularly as an adjunct or as a bail-out strategy after failed antegrade approach in patients presenting with critical limb ischemia . Femoral artery access is associated with increased rates of vascular complications including hematoma and pseudoaneusrym as compared to radial artery approach. The RIVAL study reported hazard ratios of 0.4 for large hematoma and 0.3 for pseudoaneurysm, when comparing radial access to transfemoral access in patients with acute coronary syndromes undergoing percutaneous coronary intervention . Radial access, in addition to mitigating the vascular complications related to angioplasty, is associated with lower morbidity, substantial peri-procedural bleeding reduction and facilitates early mobilization and discharge .
However, transradial approach alone may not be successful in certain subsets of patient with complex iliac disease. Spasm of the radial artery, tortuosity of the subclavian artery, and inadequate support of sheath/catheter can limit the success . Indeed, there may be sub-optimal imaging quality associated with lower profile catheters as well as technical limitations for stent delivery.
We present a case of a patient with total chronic occlusion of the right common iliac artery that underwent percutaneous endovascular intervention with combined transpedal and transradial approaches. The iliac artery occlusion was successfully stented via the distal anterior tibial artery with complete avoidance of femoral access.
2
Case report
A 58-year-old man who was a former smoker, and with history of hyperlipidemia and coronary artery disease presented with Rutherford class 3 claudication. A diagnostic peripheral angiogram was notable for complete total occlusion (CTO) of the right common iliac artery ( Fig. 1 A ) with mild diffuse atherosclerotic disease in the superficial femoral artery and infra-popliteal vessels. Percutaneous endovascular intervention was decided, and the right distal anterior tibial artery was cannulated using an echogenic needle and a 4Fr Precision Glidesheath (Terumo Co., Tokyo, Japan) under ultrasound guidance. The 4Fr sheath was introduced to a maximum of 2–3 cm into the tibial artery, and adequate positioning of the sheath was verified by gentle manual contrast injection while maintaining the wire in place. After that, the 4Fr sheath was upsized to a 6Fr Slender Glidesheath (Terumo Co., Toyko, Japan). This Slender glidesheath has an outside diameter equivalent to a 5Fr sheath but can accommodate 6Fr equipment. Nitroglycerin 200 μg, Verapamil 1 mg, and heparin 5000 IU were given intra-arterially. Target ACT > 250 s was achieved. A 4Fr Tempo Aqua Vertebral 125 cm Catheter (Cordis Corp., NJ, USA) was advanced up to the right common iliac artery. A 4Fr Front Runner XP catheter (Cordis Corp., NJ, USA) loaded inside the Tempo Aqua catheter and 0.018’ V-18 ControlWire 300 cm (Boston Scientific, Mass, USA) were attempted to puncture the distal cap of the occlusion. However, it was extensively calcified, and retrograde recanalization was unsuccessful. Subsequently, the left radial artery was cannulated with a 6 F 110 cm Flexor Shuttle Sheath (Cook Corp., MN, USA) and positioned in the proximal right common iliac artery. A 0.018” Astato 30 (Asahi, Japan) guidewire penetrated the proximal cap and ended in the subintimal space. Then, a 0.035” Aquatrack 260 cm Stiff Shaft Straight (Cordis Corp, NJ, USA) was used to recanalize the obstruction retrogradely with the Asato 30 guidewire serving as landmark ( Fig. 1 B). After successfully recanalization, a 5.0 × 40 mm Power Flex Pro Balloon (Cordis Corp., NJ, USA) was inflated at the lesion ( Fig. 1 C) followed by the deployment of a Smart Stent 8.0 × 80 mm (Cordis Corp., NJ, USA). The lesion was then post-dilated with a 7.0 × 60 mm Power Flex Pro Balloon (Cordis Corp., NJ, USA), and excellent re-establishment of normal flow to the infrainguinal vessels via the common iliac artery was obtained ( Fig. 1 D).
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