Superficial femoral artery stenting via radial access using R2P® Misago® stents: First-in-human report of the new R2P® system

Combining transradial access and sheathless femoral access for complex iliac artery chronic total occlusions

BACKGROUND

The transradial approach (TRA) is associated with fewer serious access site-related complications compared with the transfemoral or transbrachial approach. However, TRA has associated problems in complex aortoiliac (AI) lesions, including the procedural difficulty. A bidirectional approach was used combining TRA with a sheathless technique for femoral artery (FA) puncture to treat complex AI lesions, as a minimally-invasive approach. This report describes a representative cases with AI chronic total occlusion in which the combination of TRA and a sheathless technique for FA puncture was useful for guidewire crossing.

CASE PRESENTATION

Case 1 was a 71-year-old man with intermittent claudication (IC). Control angiography showed total occlusion of the left common iliac artery (CIA) ostium to the distal external iliac artery (EIA). Guidewire externalization was achieved by combining TRA using a 6Fr guiding sheath and a sheathless technique for the left FA. Two nitinol stents were deployed in the CIA to EIA. Case 2 was a 63-year-old man with IC. Control angiography revealed total occlusion of the right CIA ostium to the common femoral artery (CFA) with severe calcification. The antegrade wire could not pass through the CTO lesion because of the calcified CFA occlusion. A 21-G metal needle was used to penetrate the CFA calcification through the distal true lumen of the CFA, and the wire was inserted into the EIA for wire externalization. Three nitinol stents were deployed in the CIA to EIA, and a drug-coated balloon was dilated in the CFA with hemostasis of the distal puncture site. In both cases, the retrograde puncture site was hemostatic during the procedure and postoperative bed rest was not required.

CONCLUSIONS

TRA combined with a sheathless technique from the FA has the potential to treat AI complex lesions in a less invasive manner.

Percutaneous debulking strategy for severe nodular calcification in common femoral artery

BACKGROUND

Despite marked progress in endovascular treatment (EVT) techniques and devices, calcified lesions remain one of the toughest obstacles to EVT success. Moreover, because the common femoral artery (CFA) is known as a "non-stenting zone," endovascular strategies for this area are controversial.

CASE PRESENTATION

Here we describe the technical tips for a novel, less invasive, and effective debulking strategy for severe nodular calcification using an endovascular maneuver. This technique was demonstrated in a 73-year-old man with severe calcified stenosis of the CFA. To complete a stent-less strategy for CFA, we conducted aggressive debulking of the nodular calcification, established a bidirectional approach from the radial artery and the superficial femoral artery (SFA), and inserted a balloon-guiding catheter in the SFA. Under distal protection provided by this catheter, we crushed the nodular calcification 43 times using myocardial biopsy forceps. After achieving a volume reduction of nodular calcification through this maneuver, we completed the procedure by inflating a 6-mm drug-coated balloon catheter. Final angiography demonstrated a reduced filling defect of the contrast medium in the CFA and favorable blood flow as far as the ankle. The puncture site on the SFA was closed with a vascular suture assisted by balloon inflation inside the vessel, which allowed the patient to be ambulatory immediately after the procedure without requiring bed rest.

CONCLUSIONS

Severely calcified lesions in the CFA are usually difficult to treat using an endovascular strategy, but our novel and less invasive method may become a promising technique for managing these lesions.

Transradial peripheral vascular intervention using Fowler’s position and Terumo R2P system for patients with heart failure: two case reports

Background

Positioning a patient on the catheterization table is important for proper cardiac or respiratory function during peripheral vascular interventions. Fowler’s position, where the patient’s head is a 45° angle, is more effective in reducing venous blood volume returning to the heart from the periphery compared with the supine position. The Terumo R2P system has been developed for transradial peripheral vascular interventions.

Case presentation

Two patients with heart failure (a 75-year-old Japanese female and a 74-year-old Japanese male) underwent lower-extremity peripheral vascular interventions in Fowler’s position to prevent worsening heart failure. Because their head position was opposite the C-arm of the X-ray machine, the left radial artery was selected as the access site. The Terumo R2P system was used for transradial peripheral vascular intervention. We successfully treated superficial artery diseases with long shaft balloons and rapid-exchange Terumo R2P Misago stents.

Conclusions

Although lower-extremity peripheral vascular intervention using Fowler’s position and the Terumo R2P system has several limitations, including device availability and technical complexity, it may be effective for particular patients who have higher risk of worsening heart failure in the supine position.

Distal radial artery approach for endovascular therapy

It has been reported that the distal transradial approach (dTRA) is safe and useful for percutaneous coronary intervention (PCI). In this study we evaluated the safety and efficacy of the dTRA for endovascular therapy (EVT). The dTRA for EVT was performed in 43 lesions from 35 patients. Approach site was determined at the discretion of the operator. Clinical data were analyzed retrospectively. Average patient age was 74.0 ± 6.5 years; 30 (86%) were male; average height was 161.1 ± 8.4 cm. Diabetes mellitus, hypertension, dyslipidemia, and smoking habit were present in 19 (54.3%), 31 (88.6%), 29 (82.9%), and 29 (82.9%) patients, respectively. Target lesions were iliac artery in 38 (88.4%) patients, superficial femoral artery in 4 (9.3%) and renal artery in the remaining patient (2.3%). Eight lesions (18.6%) were chronic total occlusions. Thirteen (30.2%), 2 (4.7%), and 28 (65.1%) lesions were treated using 4.5, 6, and 7 French long guiding systems, respectively. All lesions were successfully treated without any procedural or access site-related complications. No additional puncture sites were required. Ankle brachial index significantly improved from 0.62 ± 0.20 to 0.92 ± 0.17 (p < 0.0001) post-treatment for the lower limbs. There were no radial artery occlusions, target lesion revascularization, or complications 1 month later. Similar to PCI, the dTRA for EVT is safe and feasible without any specific complications in carefully selected patients.