Fig. 27.1
The average distance from the left RA at wrist level (L) to the different target arteries
27.4 General Considerations
Site of access is selected depending on the target vessel. Majority of the TRPI are achieved by left radial artery. The right radial artery is used for the right upper extremity, right vertebral artery and bilateral carotid procedures. Moreover, right radial artery can also be chosen in case of poor or absent left radial pulse triggers.
Access is attained regularly, with a short introducer sheath (1 Fr), inserted into the RA at the planned working site. Diagnostic angiography is completed after infusion of local vasodilators. For selective angiography, 140–150 cm vertebral-shaped catheters are the best options. To guide the wire into the descending aorta from the subclavian artery, Internal Mammary (IM) may be used. After familiarization with the anatomy, the size, shape, and length of the sheath can be chosen. 0.035-in. wire is left in place with the help of diagnostic catheter and then the working sheath may be brought to the target site. To avoid spam complications, it is advised to use moderate-to-deep sedation.
27.5 The Transradial Approach for Percutaneous Interventions of Supra-Aortic Arteries
27.5.1 Subclavian Artery Interventions
The TRA is considered effective not only because it presents with less complications attenuating the site of access, but they also for the stability provided by the guide support’s help in the placing the sheath right next to the stenotic site (Fig. 27.2).
Fig. 27.2
Left TRA for left subclavian artery intervention. (a) Severe stenosis (arrow). (b) Stenting with optimal result
- 1.
Access the RA with a short sheath and perform angiography with a 5 Fr, 100 cm multipurpose catheter.
- 2.
After the anatomy is recognized, a 45 cm, 6 Fr or 7 Fr introducer sheath should be used for ipsilateral TRA, and brought right next to the lesion.
- 3.
Go through the lesion with a 0.035 in. angled stiff, hydrophilic guidewire.
- 4.
Pre-dilate the stenosis with an undersized balloon.
- 5.
Progress with the 5 Fr Pigtail catheter into the transverse aorta to see the aorto-subclavian junction through aortography.
- 6.
Finish the rest of the procedure traditionally by using bone markers for locating and placing the stent.
27.5.2 Carotid Artery Interventions
Carotid artery stenting is a recognized treatment method as a substitute for carotid endarterectomy in cases of revascularization of atherosclerotic internal carotid artery stenosis in those who are at high risk for surgery [4, 5].
Traditionally, the femoral approach is usually used. The TRA is challenged due to the acute angle between the common carotid artery and subclavian artery. Though, in consideration with presently accessible equipment, TRA in use of carotid stenting is suggested in the following situations.
Treating right carotid artery via stent upon extremely diseased aortic arch.
Treating left carotid artery via stent when the vessel rises from innominate artery,
- 1.
Access the right RA with a 6 Fr, 90 cm Shuttle sheath and advance to the innominate artery.
- 2.
Use of 5 Fr Simmons-1 catheters (Terumo Corporation) as the main catheter to assess the common carotid artery. For contralateral TRA, the 5 Fr Tig-1 Optitorque catheter (Terumo Corporation) is an alternative catheter.
- 3.
Advance a 0.035 ̋ Amplatz super-stiff wire into the external carotid artery or deep in the common carotid artery distant from the origin of the internal carotid artery.
- 4.
Aim at ideal co-axial placement of a 6 Fr or 7 Fr carotid sheath of your choice for common carotid artery, the following part of the practice is achieved in standard manner.
27.5.3 Vertebral Artery Interventions
Vertebral artery stenosis angioplasty and stenting is a relatively new alternative modality of management (Fig. 27.3). A current study has documented the safety and effectiveness of the TRA to this intervention [6].
