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CAROTID ARTERY STENTING Vascular Disease Management ® March 2017 E67 Transradial Carotid Artery Stenting Peter A. Soukas, MD C arotid artery stenting (CAS) is now a well- established technique for the treatment of both symptomatic and asymptomatic cer- vical bifurcation disease. CAS procedures are typi- cally performed from a femoral access, but there are limitations to this route (Table 1). Multiple single- center studies and randomized trials have proven the safety, efficacy, and reduced vascular complication rates of transradial (TR) catheterization and percu- taneous coronary intervention (PCI). 1 These same techniques have been adapted for the performance of CAS. Transradial CAS has several potential ad- vantages compared with transfemoral (TF) access (Table 2). Limitations of TRA-CAS will also be reviewed (Table 3). Herein, we present a case report of TRA-CAS, review the data, and offer a suggested CAS access algorithm (Figure 1). CASE REPORT The patient is a morbidly obese 70-year-old male with past medical history of severe tobacco abuse with oxygen-dependent chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD) with myocardial infarction in 1997 with subsequent coronary artery bypass graft x4, prior history of alcohol abuse having quit in 1979, insulin-dependent diabetes mellitus, hypertension, hyperlipidemia, obstructive sleep apnea (OSA), and hypothyroidism with known right internal carotid artery stenosis, confirmed by recent computed tomography angiography (CTA) to now have >80% stenosis. He was felt to be high risk for carotid endarterectomy as well as for transfemoral CAS due to OSA, short thick neck, oxygen-dependent COPD, CAD, and morbid obesity. For these reasons, he was referred for transradial CAS. Table 1. Limitations to transfemoral access for CAS Tortuous or occlusive aorto-iliac disease Common femoral artery disease or prior vascular surgery “Bovine” arch/diseased aortic arch/arch anomalies/type III arch Higher risk of cerebral emboli from catheter manipulation in diseased arches Abdominal/iliac aneurysms Higher risk of local vascular complications: hematoma, arteriovenous fistula, pseudoaneurysm Prolonged best rest, patient can’t sit up after procedure Morbidly obese patient/hostile groin from scar or prior surgery Table 2. Advantages to transradial CAS Reduced emboli by avoiding diseased arches Reduced bleeding/vascular complication rates Increased patient comfort, may sit up after procedure Easy access to treat “bovine” arch/type III arches Can still utilize proximal protection in patients with ≥3 mm radial arteries Table 3. Limitations of TRA-CAS Technically challenging, requiring multiple techniques to engage the carotids; steep learning curve Limited by vessel size; often can’t use proximal embolic protection Spasm/tortuosity/kinks result in crossover to transfemoral access in up to 10% of cases; may require light sedation to prevent spasm Difficult to cannulate bovine left common carotid artery in type I arch or right common carotid artery in cases of acute angles >50°, with resultant difficult guide catheter or sheath delivery More radiation c/w transfemoral access Difficult guide catheter, sheath delivery/support, especially with more acute angles 8 Fr MoMa proximal embolic protection device may not be long enough in taller patients (>170 cm) Radial artery occlusion up to 10%; carefully consider transradial access in end-stage renal disease patients, who may require radiocephalic arteriovenous fistula for dialysis Copyright 2017 HMP Communications For Personal Use Only

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Page 1: Transradial Carotid Artery Stenting - Vascular Disease Management · 2019-10-18 · Vascular Disease Management ® March 2017 E67. Transradial Carotid Artery Stenting. Peter A. Soukas,

CAROTID ARTERY STENTING

Vascular Disease Management® March 2017 E67

Transradial Carotid Artery StentingPeter A. Soukas, MD

Carotid artery stenting (CAS) is now a well-

established technique for the treatment of

both symptomatic and asymptomatic cer-

vical bifurcation disease. CAS procedures are typi-

cally performed from a femoral access, but there are

limitations to this route (Table 1). Multiple single-

center studies and randomized trials have proven the

safety, efficacy, and reduced vascular complication

rates of transradial (TR) catheterization and percu-

taneous coronary intervention (PCI).1 These same

techniques have been adapted for the performance

of CAS. Transradial CAS has several potential ad-

vantages compared with transfemoral (TF) access

(Table 2). Limitations of TRA-CAS will also be

reviewed (Table 3). Herein, we present a case report

of TRA-CAS, review the data, and offer a suggested

CAS access algorithm (Figure 1).

CASE REPORTThe patient is a morbidly obese 70-year-old male

with past medical history of severe tobacco abuse with

oxygen-dependent chronic obstructive pulmonary

disease (COPD), coronary artery disease (CAD)

with myocardial infarction in 1997 with subsequent

coronary artery bypass graft x4, prior history of alcohol

abuse having quit in 1979, insulin-dependent diabetes

mellitus, hypertension, hyperlipidemia, obstructive

sleep apnea (OSA), and hypothyroidism with known

right internal carotid artery stenosis, confirmed by

recent computed tomography angiography (CTA) to

now have >80% stenosis. He was felt to be high risk for

carotid endarterectomy as well as for transfemoral CAS

due to OSA, short thick neck, oxygen-dependent

COPD, CAD, and morbid obesity. For these reasons,

he was referred for transradial CAS.

Table 1. Limitations to transfemoral access for CAS

Tortuous or occlusive aorto-iliac disease

Common femoral artery disease or prior vascular surgery

“Bovine” arch/diseased aortic arch/arch anomalies/type III arch

Higher risk of cerebral emboli from catheter manipulation in diseased arches

Abdominal/iliac aneurysms

Higher risk of local vascular complications: hematoma, arteriovenous fistula, pseudoaneurysm

Prolonged best rest, patient can’t sit up after procedure

Morbidly obese patient/hostile groin from scar or prior surgery

Table 2. Advantages to transradial CAS

Reduced emboli by avoiding diseased arches

Reduced bleeding/vascular complication rates

Increased patient comfort, may sit up after procedure

Easy access to treat “bovine” arch/type III arches

Can still utilize proximal protection in patients with ≥3 mm radial arteries

Table 3. Limitations of TRA-CAS

Technically challenging, requiring multiple techniques to engage the carotids; steep learning curve

Limited by vessel size; often can’t use proximal embolic protection

Spasm/tortuosity/kinks result in crossover to transfemoral access in up to 10% of cases; may require light sedation to prevent spasm

Difficult to cannulate bovine left common carotid artery in type I arch or right common carotid artery in cases of acute angles >50°, with resultant difficult guide catheter or sheath delivery

More radiation c/w transfemoral access

Difficult guide catheter, sheath delivery/support, especially with more acute angles

8 Fr MoMa proximal embolic protection device may not be long enough in taller patients (>170 cm)

Radial artery occlusion up to 10%; carefully consider transradial access in end-stage renal disease patients, who may require radiocephalic arteriovenous fistula for dialysis

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CAROTID ARTERY STENTING

Vascular Disease Management® March 2017 E68

TECHNIQUEPretreatment with dual-antiplatelet therapy (DAPT)

was started 4 days prior to the procedure with aspirin

and clopidogrel, with 600 mg loading dose of clopi-

dogrel and 80 mg dose of atorvastatin the morning

of the procedure. The right radial artery was accessed

with a 6 Fr Terumo radial sheath, but intraarterial ni-

troglycerin was not administered due to a prior history

of profound hypotension with sublingual nitroglyc-

erin. Verapamil was withheld due to a systolic blood

pressure of 130 mm Hg. Both right and left anterior

oblique arch aortograms with a 5 Fr straight pigtail

catheter demonstrated patency of the proximal great

vessels, a type I aortic arch, and a calcified proximal

right internal carotid artery (ICA) high-grade stenosis

with patent right external carotid artery (ECA). The

right common carotid artery (CCA) was selected with

5 Fr internal mammary (IM) diagnostic catheter that

confirmed an 85% proximal right ICA stenosis. A soft-

angled .035˝ Glidewire (Terumo) was advanced into

the right ECA, exchanged out for an Amplatz .035˝

super-stiff wire (Boston Scientific), followed by re-

moval of the diagnostic catheter, and radial sheath. A

6 Fr Shuttle sheath (Cook Medical) was delivered into

the distal right CCA. After intracranial angiography, a

NAV-6 Emboshield (Abbott Vascular) was deployed

in the distal extracranial ICA, followed by predila-

tion with a 4 x 30 mm Trek (Abbott Vascular), and

deployment of a 7 x 30 mm Precise self-expanding

stent (Cordis). Postdilation was performed with a 5 x

20 mm Maverick NC balloon (Boston Scientific), and

then with a 6 x 20 mm Aviator balloon (Cordis) in

order to then deliver the retrieval catheter. After repeat

angiography confirmed an excellent result, the Shuttle

was removed, and hemostasis achieved with TR band

(Terumo) (Figures 2A-2R).

PREPROCEDURE PLANNING FOR TRANSRADIAL CASAll patients should have CTA or magnetic resonance

angiography (MRA) imaging to plan CAS access (Figure

1). Several authors have noted a lower procedural

success rate in cannulation of the left CCA in patients

with type I aortic arches from the right radial artery.3-7

Folmar et al noted successful CAS outcomes in 97% of

right CAs, 80% of bovine CAs, and only 54% of left

CAs.3 Preprocedure imaging identifies atherosclerotic

and calcific disease, arch anomalies, and unfavorable

anatomy (acute angles of <50°) that predict technical

difficulties, thus allowing for reduced stroke risk and

need for crossover access. Typically, DAPT is started at

Figure 1. Algorithm for TRA-CAS access. Adapted from Pinter L, Cagiannos C, Ruzsa Z, Bakoyiannis C, Kolvenbach R. Report on initial experience with transradial access for carotid artery stenting. J Vasc Surg. 2007;45:1136-1141. Cop

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CAROTID ARTERY STENTING

Vascular Disease Management® March 2017 E69

least 4 days before the procedure with a loading dose

of clopidogrel or ticagrelor prior to the procedure.

RADIAL ACCESS TECHNIQUEIdeally, the radial artery should be imaged with

duplex ultrasound to determine the size of the vessel,

particularly if an 8 Fr sheath for proximal protection is

planned. A negative Allen’s test is performed, the wrist

hyperextended, local anesthesia is administered, and

the artery punctured with a micropuncture needle.

A 5 Fr or 6 Fr radial sheath is inserted, followed by a

spasmolytic cocktail, eg, 200 µg nitroglycerin and 2.5

mg of verapamil, and systemic anticoagulation with

heparin, or preferably, bivalirudin, is given aiming

for a target activated clotting time of >250 seconds.

Figure 2A. Selective right commonary carotid artery angiogram over 5 Fr internal mammary diagnostic catheter.

Figure 2B. Delivery of internal mammary catheter into right external carotid artery over soft-angled .035˝ Glidewire.

Figure 2C. The .035˝ Amplatz guidewire is shown in the right external carotid artery.

Figure 2D. The diagnostic catheter was exchanged out over the Amplatz guidewire.

Figure 2E. Sheath delivery.

Figure 2F. Pre-carotid artery stenting.

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Most reported series have used the right radial artery

due to ease of cannulation of the right CCA and

bovine left CCA, avoidance of catheter manipulation

in the arch, and for the familiarity and ease of use for

most interventionists. Patel et al performed CAS from

the contralateral RA in 20 patients after preoperative

Doppler confirmed adequate radial size, absence of

tortuosity, or atherosclerosis.4 They noted 4 of 8 left

CAS procedures failed due to technical reasons, but

were able to be successfully performed via femoral

approach. Nevertheless, they advocate for left RA

access for right ICA-CAS if there is a severe angle

between the right subclavian artery and right CCA.

In cases of radial access failure, the ulnar may be used.

The ulnar artery is straighter, larger, and less prone

to spasm, but is deeper and next to the ulnar nerve.

Figure 2G. Baseline lateral cerebral angiogram. Figure 2H. Baseline anteroposterior Townes cerebral angiogram.

Figure 2I. Embolic protection deployed.

Figure 2J. Predilation.

Figure 2K. Postdilation.

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Retrograde ulnar and radial artery angiography is

recommended to aid in optimal procedure planning

and to avoid unfavorable anatomy.8-10

TRANSBRACHIAL CASThe transbrachial (TB) approach is not routinely rec-

ommended due to the greater difficulty with vessel

access (particularly without ultrasound guidance) and

the greater frequency and severity of complications.

These may include hand ischemia, distal embolization,

brachial sheath hematoma, median nerve injury, and

compartment syndrome.11 The multicenter, random-

ized Access study, which compared TR, TB, and TF

complications, found TB access to have the highest rate

of major complications (2.3% TB vs 2.0% TF vs 0%

TR).12 Nevertheless, the TB approach is often chosen

if the radial pulse is weak, if the patient had prior radial

artery catheterization, if proximal embolic protection

is planned, and in women with small radial arteries.

Several investigators have reported the feasibility

of TB-CAS.13-16 Fang et al first reported on

the CLARET (catheter looping and retrograde

engagement technique) for CAS using TR access for

patients <175 cm and TB access for those >175 cm

in 61 patients (Figure 3).17 Two patients developed

pseudoaneurysm with arteriovenous fistula requiring

surgical repair. Montorsi et al performed TR-CAS/

TB-CAS for bovine left ICA disease in 32 and 28

patients, respectively. Two of the 28 TB patients

(3.3%) developed complications – 1 thrombosis and

Figure 2L. Post angio.

Figure 2M. 6 mm PTA.

Figure 2N.Post PTA.

Figure 2O. Embolic protection device retrieved.

Figure 2P. Post PTA.

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1 pseudoaneurysm, both treated surgically.6 Their

larger follow-up series included 154 TR and 60 TB

patients. Three TB patients (1.96%) developed vascular

complications – 1 brachial artery pseudoaneurysm and

2 brachial artery thromboses, all treated surgically.19

CAROTID ANGIOGRAPHY & INTERVENTIONVarious 5 Fr diagnostic catheters may be used for

performing selective carotid angiography, including

Simmons 1 and 2, IM, Berenstein, JR 4, and JB1 shapes.

The AR 2 may also be used for selecting a bovine left

CCA. The group from Taiwan utilizes a 6 Fr Kimny

guiding catheter (GC) for diagnostic angiography,

and the 7 Fr Kimny GC for the intervention, utilizing

the CLARET technique, where the catheters are

advanced against the right aortic cusp for support.

Figure 2Q. Final lateral cerebral angiogram. Figure 2R. Final anteroposterior Townes cerebral angiogram.

Figure 3. The CLARET technique is performed by advancing the guide catheter over a Teflon guidewire to the ascending aorta and using the right coronary cusp as a backboard to provide support to then advance the guiding catheter into the distal common carotid artery.

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CAROTID ARTERY STENTING

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Following angiography, an exchange-length extra-

support wire (Supracore, Amplatz super-stiff, TAD II

or stiff Glidewire) is advanced into the ECA, followed

by removal of the diagnostic catheter and radial sheath.

A 6 Fr sheath is then advanced into the distal CCA for

distal embolic protection cases, or an 8 Fr sheath for

MoMa proximal embolic protection (Medtronic). If

a 7 Fr GC (eg, Kimny or XF 40 [Boston Scientific])

was chosen (compatible with 5 Fr stents and distal

filters), it is then similarly advanced into the distal

CCA. This is the anchoring technique, which is used

for straightforward anatomy. Stenting of the carotid

artery is then performed in the usual fashion, followed

by hemostasis of the access site with a TR band.

Due to the acute angles between the subclavian artery

and right CCA and the innominate and left CCA, it

may be difficult to advance the GC or sheath into

the distal CCA, chiefly due to insufficient support.

Various techniques may be used to overcome these

obstacles. The first is the telescopic technique, in which

the GC or sheath is delivered over a 125 cm braided

5 Fr diagnostic catheter (Simmons 1 or 2), similar to

TF-CAS. The diagnostic catheter is delivered into

the distal CCA, followed by advancement of the GC

or sheath.

The CLARET (catheter looping and retrograde en-

gagement technique) may also be used, and is per-

formed by advancing the GC over a Teflon guidewire

to the ascending aorta and using the right coronary

cusp as a backboard to provide support to then ad-

vance the GC into the distal CCA.

Proximal embolic protection CAS is increasingly

popular as more studies report reduction in peripro-

cedural stroke rates.19-32 Trani et al33 first reported 3

Table 4. Case series of transradial carotid artery stenting.

Author Year Pts. Mean Age

(years)

Male/Female Surgery High Risk

for CEA TR TB Crossover Rate

ProceduralFailure MACCE Vascular

Complications

Folmar 2007 42 71 ± 1 26/16 21.4% 100% 42 0 0% 17% 1 minor stroke 0%

Pinter 2007 20 72 14/6 35% 100% 20 0 0% 10% 0% 1 RAO (5%)

Patel 2010 20 65 ± 5 17/3 50% 100% 20 0 20% 20% 0% 0%

Fang 2010 161 71 ± 8.9 137/12 56.5% 100% 101 60 0% 0.6% 2 major strokes 6 minor strokes 1 BPSA, 1 AVF

Mendiz 2011 88 69.5 ± 10.3 63/15 52.3% NR 79 9 0% 1.1% 2.2% strokes 0%

Etxegoien 2012 382 68 279 49% 79% 347 0 9.1% 9.1%0.6% major strokes1% minor strokes

0.3% death7% RAO

Montorsi 2014 60 73 ± 9 44/16 12.3% 75% 32 28 0% 1.7% 1 minor stroke, 1 retinal embolism 3.3%

Ruzsa 2014 260 66.8 ± 8.9 164/96 N/R 100% 130 130 0% 10% 0.9% TR, 0.8% TB 6.8% RAO

Kedev 2015 10 66 8/2 70% 70% 10 0 0% 10% 0% 0%

Lee 2016 38 69 ± 10 28/10 100% 50% 38 0 0% 0% 1 TIA 9% RAO

Montorsi 2016 214 72 ± 8 154/60 5% 63% 154 60 0% 1.6% 0% MoMa2.8% DEP 6.6% RAO

Mendiz 2016 77571 ± 10.6 TR; 69.7

± 9.4558/217 28.7% 100% 101 674

TF 0% 4.9%3% major strokes1.6% minor strokes

2.5% TIA

0.9% TF, 1 forearm hematoma

Year = publication year; RAO = radial artery occlusion; TIA = transient ischemic attack; TR = transradial; TF = transfemoral; TB = transbrachial; NR = not reported; AVF = arteriovenous fistula; DEP = distal embolic protection; surgery = prior endarterectomy surgery; BPSA = brachial artery pseudoaneursym; MoMa = Medtronic proximal embolic protection device.

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cases of TR-CAS using the 8 Fr MoMa device and

Montorsi et al18 performed 61 cases using the MoMa

device from either a TR30 or TB31 access. The TB

access was preferred for CCA diameters >8 mm to

allow for delivery of up to a 10 mm Cristallo stent

(Medtronic) or if the radial pulse was weak or had

prior radial artery catheterization. Most of these pa-

tients (52%) had bovine configuration. Only 1 patient

(1.6%) could not have the MoMa device positioned

and was crossed over to TF approach, and another

was transitioned to a distal embolic protection (DEP)

device because the MoMa device was too short to

engage the ECA from a radial access. In 16 cases, the

first attempt to deliver the MoMa was unsuccessful

using standard techniques, but was able to be delivered

by removing the mandrel wire and adding a second

wire in the main channel (the “NoMa2” technique).

Only 1 major vascular complication occurred (bra-

chial artery pseudoaneurysm) and was successfully

repaired surgically. At an average follow-up of 8.1 ±

7.5 months, radial artery occlusion (RAO) occurred

in 2 of 30 patients (6.6%).

DISCUSSIONSeveral case reports have confirmed the utility of radial

access for CAS.13,34-41 The larger series are summarized

in Table 4. Folmar confirmed the feasibility of TR-

CAS in 42 high surgical risk patients, of whom 9 were

symptomatic. Bivalirudin was used as the anticoagulant,

74% of cases were done with a 6 Fr Shuttle, the remain-

der with a 5 Fr sheath. Overall success was achieved in

35/42 patients (83%) including 28/29 (97%) right, 4/5

(80%) bovine, but only 7/13 (54%) left carotid steno-

ses.3 Failures were due to inadequate support to deliver

the sheath to the left CCA. Only 1 patient sustained

a stroke, and there were no vascular complications. A

follow-up two-center retrospective study of 383 pa-

tients documented overall success in 347/383 (91%),

with 93% right, 88% bovine, and 88% left CA. All TR

failures due to inadequate support were successfully

performed from the TF approach. There were 2 ma-

jor strokes (0.6%), 3 minor strokes (1%), 10 transient

ischemic attacks (3%), no myocardial infarctions, and

6% of patients had asymptomatic RA occlusion.5

Fang et al reported on their experience using CLAR-

ET to perform TR-CAS and TB-CAS on 161 pa-

tients. TB access was used for patients taller than 175

cm. CAS was performed using a 7 Fr Kimny GC with

only 1 failure, which was due to ECA occlusion.17

Two patients experienced major stroke, 6 had minor

stroke, and two TB patients developed pseudoaneu-

rysm requiring surgical repair. They then compared

sheathless TRA-CAS with the previously published

TB-CAS using 7 Fr Kimny GC in 38 patients, with

a 100% success rate. One patient experienced a tran-

sient ischemic attack and 3 patients (9%) developed

RAO at 1 year.16

Pinter performed TR-CAS on 20 consecutive pa-

tients (7 symptomatic) with no deaths, strokes, or

myocardial infarctions.2 Two patients could not be

completed via RA access due to intense spasm in 1

case, and inability to cannulate the left CCA in the

other. Both were done from the TF approach. Patel

demonstrated the feasibility of contralateral TRA for

CAS in 20 patients (40% symptomatic) who all had

preoperative Doppler evaluation of RA size to rule

out loops, kinks, tortuosity, or atherosclerosis. Only

4 out of 8 patients with left CCA were able to be

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cannulated via TR access, but the rest were able to be

completed via TF access. One patient had a transient

ischemic attack, with no vascular complications or

bleeding.4

Mendiz et al initially reported on 88 patients (46

symptomatic) with 98.8% TR access and 96.6% pro-

cedural success.42 Two patients had procedural stroke

(one ischemic, the other hemorrhagic), with no myo-

cardial infarctions or deaths, and no vascular complica-

tions. Their 16-year experience was recently reported

on 775 consecutive high surgical risk patients treated

with TR-CAS (n = 101) and TF-CAS (n = 674).43

Procedural success was 100%, with a 4.9% TR cross-

over rate, and 2% stroke rate in TR patients and 2.7%

in TF patients. All crossovers were due to difficult

carotid cannulation or insufficient support in type

III arches. One TR patient had a forearm hematoma

treated medically, with a 0.9% TF vascular complica-

tion rate.

Montorsi et al demonstrated the utility of TR (n

= 32) and TB (n = 28) treatment of 60 consecutive

patients with left ICA stenosis and bovine arch. Proxi-

mal protection was used in 15 cases.6 Incidence of

in-hospital major adverse cardiovascular and cerebral

event (MACCE) was 2% in the TR group and 3.6%

in the TF group. Two patients with TB access had

vascular complications treated surgically. Montorsi et

al subsequently reported on 31 TB patients and 30 TR

patients treated with proximal embolic protection,

and 153 with DEP.18 Fifty-two percent of the MoMa-

treated patients had bovine left ICA, with only 1 case

where the MoMa device could not be delivered. In 16

cases, the MoMa device was not able to be delivered

on first attempt, but was able to be delivered using a

no-mandrel 2-wire technique (the “NoMa-2” tech-

nique). There was a 7.1% crossover rate in the DEP

group due to technical difficulty engaging the target

vessel. MACCE rate was 0% in the MoMa group and

2.8% in the DEP group (P=.18). One MoMa-treated

patient developed a brachial pseudoaneurysm treated

with surgery, and two DEP patients required bra-

chial surgical repair. At 8.1-month follow-up, 6.6%

of MoMa radial and 3.2% of DEP radial arteries were

occluded. Fluoroscopy times (15.8 min vs 12.75 min)

and contrast amounts (135 mL vs 107 mL) were higher

with DEP, but overall radiation exposure was similar.

The RADCAR study was a randomized comparison

of TR and TF approach for CAS in 260 patients.7 Type

III arches were more common in the TR group. Cross-

over rate was 10% in the TR group and 1.5% in the TF

group. All cannulation failures due to severe angulation

of the CCA origins were successfully treated from the

crossover access. Procedure and fluoroscopy times were

not significantly different, but the radiation dose was

higher in the TR group. There were no differences in

MACCE rates. Major and minor vascular complications

were 2.3% major/4.6% minor in the TF group vs 1.5%

major/7.8% minor in the TR group. Asymptomatic

RAO occurred in 6.8% of the TR group. New, lower-

profile 5 Fr stents and micromesh stents will likely expand

the number of patients eligible for TR-CAS.10,44,45

CONCLUSIONTRA-CAS is safe and efficacious, with high success rates

and very low vascular complication rates. Experienced

TR operators are able to achieve low MACCE rates

that are comparable with TF access. Consider TRA-

CAS for patients with peripheral arterial disease, morbid

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CAROTID ARTERY STENTING

Vascular Disease Management® March 2017 E76

obesity, and complex aortic arch anatomy. Although

proximal embolic protection is possible with TR access,

it is limited by vessel size, and for these patients, and

those with left CA lesions with type I arch, TF access

is still preferred. n

Peter A. Soukas, MD, FACC, FSVM, FSCAI, FACP

is the Director of Vascular Medicine & Interventional PV Lab,

Director of the Brown Vascular & Endovascular Medicine

Fellowship, The Miriam & Rhode Island Hospitals, and an

Assistant Professor of Medicine, The Warren Alpert School

of Medicine of Brown University, Cardiovascular Institute,

208 Collyer St. Suite 100, Providence, RI 02906. Email:

[email protected]

REFERENCES1. Ferrante G, Rao SV, Juni O, et al. Radial versus femoral access for coronary in-

terventions across the entire spectrum of patients with coronary artery disease: a meta-analysis of randomized trials. JACC Cardiovasc Interv. 2016;9:14-19.

2. Pinter L, Cagiannos C, Ruzsa Z, Bakoyiannis C, Kolvenbach R. Report on initial experience with transradial access for carotid artery stenting. J Vasc Surg. 2007;45:1136-1141.

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