Division of Endovascular Interventions Mount Sinai Hospital July 22 2020 Patient History 70yoM with a PMHx of HTN HLD asthma NIDDM CKD III HFpEF LVEF 55 MGUS CAD sp CABG and PAD sp femfem bypass who presents with lifestyle limiting claudication that has progressed to pain at r ID: 914789
Download Presentation The PPT/PDF document "Transradial Approach for Common Femoral..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Transradial Approach for Common Femoral Artery Intervention Involving Fem-Fem Bypass
Division of Endovascular Interventions
Mount Sinai Hospital
July 22, 2020
Slide2Patient History
70yoM with a PMHx of HTN, HLD, asthma, NIDDM, CKD III,
HFpEF
(LVEF 55%), MGUS, CAD s/p CABG and PAD s/p fem-fem bypass who presents with lifestyle limiting claudication that has progressed to pain at rest (Rutherford 4)
PMHx: as above
PSHx
: 2vCABG 2007 (patent LIMA-LAD, occluded SVG-RPDA), PAD s/p bilateral iliac stenting c/b L common iliac occlusion s/p R
L fem-fem bypass 2007 and repeat R common iliac stent PTA in 2015
Meds: Aspirin, Atorvastatin, Furosemide, Ipratropium-Albuterol, Isosorbide-Mononitrate, Lisinopril, Metformin, Metoprolol Succinate, Rivaroxaban (2.5mg BID)
Slide3Patient History
Lower Extremity Arterial Duplex:
50-99% stenosis of distal R common femoral artery (PSV 398 cm/s) immediately proximal to the bypass graft
L common iliac artery stent occluded with retrograde flow within the L external iliac artery and antegrade flow resuming distal to the anastomosis of bypass graft.
ABI
Bilateral ABI 0.98 without exercise performed.
Slide4Patient History
Slide5Patient History
Slide6Patient History
Slide7Approaches for Access
Direct Superficial Femoral Artery Access
Transpedal
Access
Transradial
Access
Pros
Full spectrum of readily available sheaths, catheters, balloons and devices
Convenience
Decreased vascular and bleeding complications
Decreased vascular and bleeding complications
Early ambulation and patient comfort
Reasonable selection for single access above knee intervention
Cons
Post procedure management of access site
Closure devices not available in US, besides
Vascade
Increased risk of
vascular complications
Risk of injury to pedal vasculature
Only minority of peripheral labs are capable and equipped to perform pedal access
Pedal access is generally a secondary access to facilitate lesion crossing
No bailout options requiring covered stents for aortoiliac intervention
Increased radiation
Not many devices available for below knee intervention
DCB not currently available greater than 135cm SL
Technical challenges
Slide8Radial Access Challenges
Radial artery spasm
Brachial artery spasm
Subclavian tortuosity
Radial artery occlusion
Slide9Truesdell et al.
Interv
.
Cardiol
(2015) 7(1), 55-76
Slide10Radial Sheaths
Slide11Radial PTA Balloons
Truesdell et al.
Interv
.
Cardiol
(2015) 7(1), 55-76
Slide12Radial PTA Balloons
Slide13Radial Balloon Expandable Stents
Truesdell et al.
Interv
.
Cardiol
(2015) 7(1), 55-76
Slide14Radial Self Expanding Stents
Truesdell et al.
Interv
.
Cardiol
(2015) 7(1), 55-76
Slide15Radial Drug Coated Balloon
Limited use for
infrainguinal
intervention based on available shaft lengths
Lutonix
: 130cm
In.Pact
Admiral: 130cm
Stellarex
: 135cm
Slide16Radial Atherectomy Devices
Limited use for
infrainguinal
intervention based on available shaft lengths with exception of Diamondback 360 and
HawkOne
Diamondback 360 Orbital Atherectomy 1.25mm/1.5mm Solid Crown: 200cm (5F sheath capability)
HawkOne
S Directional Atherectomy: 151cm
Jetstream: 145cm
RotaLink
Plus: 135cm
Slide17Radial Filters
Truesdell et al.
Interv
.
Cardiol
(2015) 7(1), 55-76