Abstract
Current literature has limited reports of iliac artery interventions performed via transradial approach (TRA). We report four successive cases of bilateral common iliac ostial stenting using simultaneous hugging stent (SHS) technique through bilateral TRA. This technique allows the patient and the operator to exploit the benefits of TRA while treating this complex substrate.
Highlights
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Current literature has limited reports of iliac artery interventions performed via transradial approach (TRA).
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We report four successive cases of bilateral common iliac ostial stenoses stenting using simultaneous hugging stent (SHS) technique through bilateral TRA.
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This technique allows the patient and the operator to exploit the benefits of TRA for this complex substrate.
1
Introduction
The high-risk clinical profile of patients with peripheral vascular disease, with increased incidence of post-procedural complications, makes the use of endovascular techniques coupled with safe access-site strategies, best suited to provide an optimal risk–benefit ratio . Iliac artery stenting has become the preferred therapy for iliac artery disease with or without superficial femoral artery involvement . Standard routes for iliac artery intervention are retrograde ipsilateral femoral artery access and antegrade contralateral cross-over femoral access. Bilateral retrograde access is preferred in the cases of bilateral aorto-iliac stenosis, whereas antegrade crossing-over access is preferable in cases of contralateral iliac artery occlusions which are poorly approachable retrogradely . Transradial approach has also been used for unilateral iliac artery interventions .
We report a series of four successive cases of bilateral ostial common iliac artery stenoses managed through bilateral transradial route using simultaneous hugging stent (SHS) technique.
2
Case report
2.1
Case-1
A 74-year-old diabetic and hypertensive male was referred to us for the chief complaint of bilateral claudication with a 70 m distance threshold. The arterial Doppler study revealed critical bilateral ostial iliac lesions and moderate disease in both femoral and popliteal systems. In view of diseased femoral sites, we chose to work through the radial route. Both right and left radial artery sites were prepared and 6F introducer sheaths (Radifocus, Terumo, Japan) were inserted using the standard technique. An abdominal aortic angiogram performed using right radial route revealed significant bilateral ostial iliac stenoses ( Fig. 1 -A). Two long (125 cm) 5F multi-purpose catheters (Cordis, USA) were negotiated over 0.032″ (260 cm long) hydrophilic guide-wires (Glidewire, Terumo, Japan) through right and left radial routes. A 0.032″ Glidewire was placed across right iliac stenosis and the 5F Multipurpose catheter was negotiated over it and its tip was placed in the distal right external iliac segment. However, the Glidewire failed to cross the left iliac stenosis, hence the 5F Multipurpose catheter was removed and a 6F JR4 guide catheter (Launcher, Medtronics, USA) was placed proximal to the culprit lesion. A 300 cm long 0.014″ BMW PTCA guidewire (Abbott Vascular, USA) was used to cross the lesion and it was dilated using a 5 × 20 mm Viatrac 14 Plus (Abbott Vascular, USA) PTA catheter ( Fig. 1 -B). After dilatation, guide catheter was slided over the deflated balloon segment across the lesion. Then PTA balloon catheter & 0.014″ guidewire were removed and 0.035″ extra-stiff Amplatz guide-wire (Boston Scientific Corp. USA) was advanced through the guiding catheter into the distal iliac segment. The Glidewire from right iliac segment was also removed and replaced by 0.035″ extra-stiff Amplatz guide-wire. A road-map technique was used to check the proximal and distal end of the lesion. 8 × 39 mm, and 9 × 59 mm balloon-expandable stents (Omnilink, Abbott Vascular, USA) were navigated through the 6F introducer sheaths over-the-wire under fluoroscopic guidance and placed across the lesions in right and left common iliac arteries respectively with some protrusion into the abdominal aorta in a hugging fashion guided by the road-map ( Fig. 1 -C, D). The stents were deployed simultaneously at 10 bar pressure ( Fig. 1 -E). A second inflation was performed at a similar pressure. Balloons were removed and abdominal aortic angiogram was performed to evaluate the end result of simultaneous hugging stent (SHS) technique ( Fig. 1 -F). A 3D reconstructed image of the final result is shown in ( Fig. 1 -G). Hemostasis of both the radial arteries was obtained using TR band (Terumo, Japan) and patient was discharged on the next day. One month follow-up confirmed resolution of claudication and normal vascular Doppler study at the intervention site.
2.2
Case-2
A 68-year-old diabetic and hypertensive female with coronary artery disease (past history of multi-vessel stent implantation) was referred to us for further management. She had limiting thigh claudications bilaterally. She was recently diagnosed with bilateral ostial iliac stenoses. Her ankle–brachial index (ABI) was 0.74 on the left side and 0.64 on the right side. Repeat duplex Doppler study at our institute confirmed the diagnosis. She was 60 in. tall and weighed 210 lb. In view of femoral access related risk, we decided to perform a diagnostic angiogram using TRA. Bilateral ostial iliac stenosis was identified and ad-hoc intervention was contemplated. Both right and left radial arteries were prepared and 6F introducer sheaths (Radifocus, Terumo, Japan) were introduced using standard technique. Abdominal aortogram was performed through right TRA to define the lesions ( Fig. 2 -A). The same technical steps as mentioned in case-1 were followed and after pre-dilatation and preparation of the lesions, 8 × 59 mm & 8 × 39 mm balloon expandable stents (Omnilink, Abbott Vascular, USA) were deployed using SHS technique ( Fig. 2 -B). ( Fig. 2 -C shows the final result). Hemostasis for both the radial arteries was obtained using the standard technique and patient was discharged the next day. Six weeks follow-up confirmed asymptomatic status and normal duplex Doppler study at the intervention site.
2.3
Case-3
An 82-year-old diabetic male with coronary artery disease (history of CABG surgery 16 years ago) presented to us with severely limiting bilateral claudication. Duplex Doppler study revealed significant bilateral ostial iliac stenoses, diffuse long segment disease in both superficial femoral arteries and occluded right anterior tibial artery. Patient was considered for intervention through bilateral radial approach using SHS technique. Abdominal aortogram confirmed the diagnosis ( Fig. 3 -A). Stents were deployed with optimal end result ( Fig. 3 -B,C). Patient was discharged on the next day. Follow up at eight weeks revealed improved claudication distance and normal duplex Doppler study at intervention site.
