Transradial Endovascular Treatment of Femoral Artery Stenosis
Transradial Endovascular Treatment of Femoral Artery Stenosis
A 55-year-old Caucasian man presented to our endovascular clinic for complaints of Rutherford class-III claudication involving his hips and thighs bilaterally. His past medical history included ischemic cardiomyopathy, hypertension, hyperlipidemia, and tobacco abuse. On physical exam, +1 palpable left femoral pulse, non-palpable right femoral pulse, and weak bilateral pedal pulses were noted. Ankle brachial index on the left leg was 0.67 and right leg was 0.71. A diagnostic angiogram from left radial access showed heavily calcified and occluded right common femoral artery (Figure 1A) and severe right iliac stenosis (Figure 1B). On the left, a heavily calcified, subtotally occluded common femoral artery (CFA) and a subtotally occluded proximal left superficial femoral artery (SFA) were noted (Figure 2). Mid SFA and popliteal arteries were patent, with 2-vessel runoff bilaterally. At the time of the diagnostic procedure, the right iliac artery was successfully treated with an 8.0 x 30 mm balloon-expandable cobalt stent (Medtronic Corporation) via left radial approach (Figure 3). A vascular surgery consult suggested treating the left common femoral artery and SFA percutaneously, as it was felt to be a suboptimal target for endarterectomy. The vascular surgeons suggested surgical endarterectomy for the right CFA occlusion.
(Enlarge Image)
Figure 1.
(A) Right common femoral artery occlusion. (B) Heavily calcified subtotal occlusion of right Iliac artery, using MP catheter from left radial.
(Enlarge Image)
Figure 2.
Heavily calcified subtotal occlusion of the left common femoral artery and proximal left superficial femoral artery.
(Enlarge Image)
Figure 3.
Successful treatment of the right Iliac stenosis using an 8.0 x 30 mm Cobalt stent.
A relatively high left radial access was achieved approximately 6 cm proximal to the radial head. A small amount of local anesthetic (lidocaine) was injected for cutaneous anesthesia. An Introcan Safety IV cannula (B. Braun) was advanced after flashback of blood was seen, passing the needle through the posterior wall of the radial artery. The needle was removed and the plastic cannula was pulled back very slowly parallel to the skin. A 0.021" wire was inserted when blood flow was seen. A short 5 Fr glide sheath (Terumo Corporation) was placed. A combination of 200 μg nitroglycerin and 2.5 mg verapamil was injected intraarterially. A 0.035" J-wire was advanced in the left external iliac artery while guided by a 5 Fr Multipurpose catheter. The 5 Fr sheath was exchanged for a 6 Fr 110 cm Ansel sheath (Cook Medical) over a 260 cm, 0.035" wire and was advanced into the left external iliac artery (EIA). A 0.018" Treasure wire (Asahi Corporation) and Quick-Cross catheter (Spectranetics Corporation) were used to cross the lesions. Over a 0.018" Quick-Cross catheter, the Treasure wire was exchanged for a 0.014" ViperWire (Cardiovascular System, Inc). A 2 mm CSI Diamondback classic crown was used to perform orbital atherectomy of the left CFA and left SFA (Cardiovascular System, Inc) (Figure 4A). Two passes were performed at each speed level, starting with 60,000 rpm to 120,000 rpm. Subsequently, a 6 x 100 mm Aquatrack balloon (Medtronic Corporation) was used to perform angioplasty with 4 minutes of inflation (Figure 4B). Repeat angiogram showed very good result, with 30% residual stenosis and no dissection (Figure 5). Prior to removing the sheath, an additional dose of versed and morphine was given to the patient. The sheath was removed and a TR band (Terumo Corporation) was applied to achieve hemostasis. Four hours post procedure, the patient was discharged home.
(Enlarge Image)
Figure 4.
Orbital atherectomy and balloon angioplasty of left common femoral artery/superficial femoral artery from left radial approach.
(Enlarge Image)
Figure 5.
Final result of left common/superficial femoral artery intervention.
The patient was seen in the endovascular clinic 1 month after his procedure with complete resolution of symptoms in the left lower extremity — Rutherford category 0. Ankle brachial indices were 1.00 and 0.85 using the posterior tibial and dorsalis pedis arteries, respectively, on the left leg.
Case Report
A 55-year-old Caucasian man presented to our endovascular clinic for complaints of Rutherford class-III claudication involving his hips and thighs bilaterally. His past medical history included ischemic cardiomyopathy, hypertension, hyperlipidemia, and tobacco abuse. On physical exam, +1 palpable left femoral pulse, non-palpable right femoral pulse, and weak bilateral pedal pulses were noted. Ankle brachial index on the left leg was 0.67 and right leg was 0.71. A diagnostic angiogram from left radial access showed heavily calcified and occluded right common femoral artery (Figure 1A) and severe right iliac stenosis (Figure 1B). On the left, a heavily calcified, subtotally occluded common femoral artery (CFA) and a subtotally occluded proximal left superficial femoral artery (SFA) were noted (Figure 2). Mid SFA and popliteal arteries were patent, with 2-vessel runoff bilaterally. At the time of the diagnostic procedure, the right iliac artery was successfully treated with an 8.0 x 30 mm balloon-expandable cobalt stent (Medtronic Corporation) via left radial approach (Figure 3). A vascular surgery consult suggested treating the left common femoral artery and SFA percutaneously, as it was felt to be a suboptimal target for endarterectomy. The vascular surgeons suggested surgical endarterectomy for the right CFA occlusion.
(Enlarge Image)
Figure 1.
(A) Right common femoral artery occlusion. (B) Heavily calcified subtotal occlusion of right Iliac artery, using MP catheter from left radial.
(Enlarge Image)
Figure 2.
Heavily calcified subtotal occlusion of the left common femoral artery and proximal left superficial femoral artery.
(Enlarge Image)
Figure 3.
Successful treatment of the right Iliac stenosis using an 8.0 x 30 mm Cobalt stent.
A relatively high left radial access was achieved approximately 6 cm proximal to the radial head. A small amount of local anesthetic (lidocaine) was injected for cutaneous anesthesia. An Introcan Safety IV cannula (B. Braun) was advanced after flashback of blood was seen, passing the needle through the posterior wall of the radial artery. The needle was removed and the plastic cannula was pulled back very slowly parallel to the skin. A 0.021" wire was inserted when blood flow was seen. A short 5 Fr glide sheath (Terumo Corporation) was placed. A combination of 200 μg nitroglycerin and 2.5 mg verapamil was injected intraarterially. A 0.035" J-wire was advanced in the left external iliac artery while guided by a 5 Fr Multipurpose catheter. The 5 Fr sheath was exchanged for a 6 Fr 110 cm Ansel sheath (Cook Medical) over a 260 cm, 0.035" wire and was advanced into the left external iliac artery (EIA). A 0.018" Treasure wire (Asahi Corporation) and Quick-Cross catheter (Spectranetics Corporation) were used to cross the lesions. Over a 0.018" Quick-Cross catheter, the Treasure wire was exchanged for a 0.014" ViperWire (Cardiovascular System, Inc). A 2 mm CSI Diamondback classic crown was used to perform orbital atherectomy of the left CFA and left SFA (Cardiovascular System, Inc) (Figure 4A). Two passes were performed at each speed level, starting with 60,000 rpm to 120,000 rpm. Subsequently, a 6 x 100 mm Aquatrack balloon (Medtronic Corporation) was used to perform angioplasty with 4 minutes of inflation (Figure 4B). Repeat angiogram showed very good result, with 30% residual stenosis and no dissection (Figure 5). Prior to removing the sheath, an additional dose of versed and morphine was given to the patient. The sheath was removed and a TR band (Terumo Corporation) was applied to achieve hemostasis. Four hours post procedure, the patient was discharged home.
(Enlarge Image)
Figure 4.
Orbital atherectomy and balloon angioplasty of left common femoral artery/superficial femoral artery from left radial approach.
(Enlarge Image)
Figure 5.
Final result of left common/superficial femoral artery intervention.
The patient was seen in the endovascular clinic 1 month after his procedure with complete resolution of symptoms in the left lower extremity — Rutherford category 0. Ankle brachial indices were 1.00 and 0.85 using the posterior tibial and dorsalis pedis arteries, respectively, on the left leg.
