transradial carotid artery stenting - vascular disease management · 2019-10-18 · vascular...
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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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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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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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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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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:
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