Transradial access for visceral endovascular interventions in morbidly obese patients: safety and feasibility

Predicting difficult transradial approach guiding into left internal carotid artery on unruptured intracranial aneurysms

BACKGROUND

The transradial approach (TRA) is less invasive than the transfemoral approach (TFA), but the higher conversion rate represents a drawback. Among target vessels, the left internal carotid artery (ICA) is particularly difficult to deliver the guiding catheter to through TRA. The purpose of this study was thus to explore anatomical and clinical features objectively predictive of the difficulty of delivering a guiding catheter into the left ICA via TRA.

METHODS

Among 78 consecutive patients who underwent coil embolization for unruptured intracranial aneurysms through TRA in a single institution between March 1, 2021, and August 31, 2022, all 29 patients (37%) who underwent delivery of the guiding catheter into the left ICA were retrospectively analyzed. Clinical and anatomical features were analyzed to assess correlations with difficulty in guiding the catheter into the left ICA.

RESULTS

Of the 29 aneurysms requiring guidance of a catheter into the left ICA, 9 aneurysms (31%) required conversion from TRA to TFA. More acute innominate-left common carotid artery (CCA) angle (P < 0.001) and older age (P = 0.015) were associated with a higher conversion rate to TFA. Receiver operating characteristic analysis revealed that optimal cutoff values for the innominate-left CCA angle and age to distinguish between nonconversion and conversion to TFA were 16° (area under the curve [AUC], 0.93; 95% confidence interval [CI], 0.83-1.00) and 74 years (AUC, 0.79; 95% CI, 0.61-0.96), respectively.

CONCLUSION

A more acute innominate-left CCA angle and older age appear associated with difficulty delivering the guiding catheter into the left ICA for neurointervention through TRA.

Retrospective Comparative Study to Assess the Safety and Efficacy of Transradial Arterial Access for Hepatic Tumor Embolizations: A Single Operator Experience

Objectives To assess the efficacy and safety of transradial arterial access (TRA) for hepatic tumor embolizations and compare the outcomes between the TRA and transfemoral arterial access (TFA)

Materials and Methods A retrospective analysis of all consecutive hepatic tumor embolization procedures done through TFA or TRA by a single operator from November 2017 to April 2019 was performed. The procedural variables, including fluoroscopy time, radiation dose (reference air kerma [RAK]), conversion and complication rates, and patient preferences were recorded. The primary endpoint was technical success, which was defined as the successful completion of the embolization procedure. Procedural variables including radiation exposure and patient preferences, and complications were analyzed as secondary endpoints.

Results Out of 102 procedures in 90 patients, 44 were performed through TFA and the rest by TRA. A technical success rate of 98.2% and a crossover rate of 1.7% were recorded for TRA. There were no major vascular complications and similar rates of minor complications (8.6% for TRA, 2.3% for TFA; P = 0.055), without any clinical sequelae. After the initial learning curve, no significant differences for other procedural variables were noted between the two access sites. Faster ambulation were achieved following TRA (P < 0.055). All 12 patients who underwent repeat TACE after initial TRA chose this again over TFA.

Conclusions TRA is safe and effective for hepatic tumor embolization. Its safety and efficacy profile is comparable to that of TFA, with added improved patient comfort and faster ambulation.

Advances in Knowledge New catheter options and modifications of the existing techniques as explained in this article proved radial arterial access as a safe and effective alternative in hepatic arterial embolization.

Non-target digital ischemia in an ulnar artery distribution following transradial access: Case report and review of best practice techniques

Transradial access is a safe approach for visceral endovascular interventions, with lower complication rates compared to transfemoral access. This report describes an unusual case of ulnar artery thrombosis following splenic artery aneurysm embolization via left transradial approach, resulting in non-target digital ischemia and eventual amputation of the ring and little finger distal phalanges. Technical considerations to reduce the incidence of access complications are also reviewed, along with practice modifications undertaken at our institution following this case to improve outcomes.

Transradial Embolization, an Underused Type of Uterine Artery Embolization Approach: A Systematic Review

Background and Objectives: The most utilized approach for the embolization of uterine arteries is the transfemoral path. However, the transradial approach (TRA) has been gaining popularity among cardiologic interventions in the last years but only few studies have shown its applicability in uterine myoma treatment. The objective of this paper is to assess the feasibility, safety and efficacy of TRA when compared with the transbrachial, transulnar or transfemoral approach (TFA) for uterine arteries embolization (UAE). Materials and methods: A systematic review of the literature that analyzes the TRA for UAE it was carried out, in order to assess its safety and effectiveness. It was systematically searched the literature (Google Scholar, PubMed/MEDLINE, Cochrane Library and Embase) using the words ''uterine artery embolization''/''uterine embolization'' and ''transradial''/''radial''. All the relevant papers published until March 2020 were retrieved and analyzed. Results: Ten studies were considered eligible for this topic. TRA is a comparable method with TFA for uterine artery embolization. Conclusions: These studies allowed us to conclude that TRA is as safe and efficient as TFA. Its advantages include few complications, shorter hospitalization period, and rapid mobilization but a steeper learning curve has the disadvantage of a longer learning curve compared to TFA. Yet, these findings are built on few reports and more research is needed.

Transradial approach and its variations for neurointerventional procedures: Literature review

Background:

The transfemoral approach (TFA) has been the standard in neuroradiology over the years. However, the transradial approach (TRA) and its variants offer several benefits over the TFA.

Methods:

Review of the literature about TRA and its variations. We present our results for different neurointerventional procedures at our institution between January 2018 and December 2019.

Results:

We wrote an educational review describing anatomical and technical aspects, advantages, and complications of this approach. In the past year we increased the percentage of neurointerventional procedures performed through radial or ulnar arteries.

Conclusion:

There are clearly proven benefits of employing a wrist approach in patients for neurointerventional procedures and its utilization should especially be considered on a daily basis.

Safety and Feasibility of Transradial Access in Patients Presenting With Traumatic Injuries: A Single Urban Center Experience

PURPOSE

To evaluate the efficacy, safety, and feasibility of transradial approach (TRA) for endovascular management of traumatic bleeding.

MATERIALS AND METHODS

A retrospective review was performed at a single level 1 trauma institution from August 2018 to July 2019. Patients presented to the interventional radiology department who were intended to be treating using TRA for the management of trauma-induced bleeding were selected. Demographics, indication for embolization, embolization site, preprocedural labs, hemodynamic stability, technical success, and complications were recorded.

RESULTS

Transradial approach was attempted in 29 (74.4%) of the 39 patients identified by operators who prefer TRA. Four patients received treatment using TRA on 2 separate occasions, for a total of 33 procedures completed with a technical success of 97% (32/33). Transradial approach was safely completed in 9 patients (27.3%) with preprocedural hemodynamically unstable status. For the 10 patients who received treatment via a transfemoral approach (TFA), traumatic disfiguration of the left upper extremity, preexisting arterial lines placed by the trauma team, and external iliac artery injuries requiring covered stent placement were the most common indications for TFA over TRA. There were no procedural or access site-related complications.

CONCLUSION

Transradial approach for the endovascular management of bleeding in a trauma setting is safe and effective with a high technical success rate and no complications.

Anatomical and Technical Considerations for Bariatric Embolization

Obesity is a well-known major public health concern associated with significant morbidity and mortality. Bariatric arterial embolization (BAE) is a minimally invasive, image-guided therapy that targets hormones linked to obesity by defunctionalizing specific portions of the stomach with the delivery of embolics. The goal of BAE is to induce weight loss through a reduction of appetite-mediating hormones with transarterial embolization of the gastric fundus. This article will review the anatomical and technical considerations for successful BAE.

Description of Technique and Short-Term Outcomes of Radial Artery Access for Vascular Disease

Objectives:

Radial artery access is widely utilized in coronary angiography with reported lower rates of vascular complications and better patient comfort. There is limited data in the literature regarding radial access in peripheral endovascular procedures. We hypothesize that radial access is safe and feasible for peripheral endovascular procedures.

Methods:

A retrospective chart review was performed for all patients who underwent angiography using radial artery access between August 2013 and December 2017. Patient demographics and perioperative data were recorded and analyzed.

Patient Selection:

The operating surgeon screened patients presenting for elective angiography for possible radial artery access. Ultrasound guidance was used in all cases. Upon cannulation, the sheath was infused with an antispasmodic cocktail, and the patients were systemically anticoagulated.

Results:

Forty-seven out of 52 patients successfully completed their procedure (90% success rate). The patients were mostly female (60%), elderly (mean age of 71 years), and had several comorbidities. Preoperative diagnoses were variable. Procedures were both diagnostic (58%) and interventional (42%) with maximum sheath size used being 7F and median fluoroscopy time of 7.5 minutes. Only 2 patients experienced perioperative complications, and both of these were minor hematomas that resolved with manual pressure.

Conclusions:

Transradial arterial access for peripheral vascular angiography and interventions is safe and feasible. With low complication rates and increased patient comfort, transradial access serves as an excellent alternative to transfemoral access for a variety of endovascular procedures.

Nonfemoral Arterial Hemostasis Following Percutaneous Intervention Using a Focused Compression Device

Purpose

Upper extremity and tibiopedal arterial access are increasingly used during endovascular therapies. Balloon compression hemostasis devices in these anatomic locations have been described, but most utilize a compression surface extending well beyond the puncture site. We report single-center experience with an arterial puncture-focused compression device following upper extremity and tibiopedal access.

Patients and Methods

A series of 249 focused compression hemostasis devices (VasoStat, Forge Medical, Bethlehem, Pennsylvania, USA) were used in 209 patients following lower extremity (n = 63) and upper extremity (n = 186; radial: 90%) arterial access procedures using 4–7 French sheaths. Demographic, operative, and follow-up data were collected. Logistic regression was used to evaluate potential association between patient/operative variables and time to hemostasis.

Results

Primary hemostasis was achieved in 97.2% (242/249) following sheath removal; in 7 cases (2.8%) puncture site oozing occurred after initial device removal and required reapplication. Secondary hemostasis was 100% (249/249). Seven complications (2.8%) were recorded: 5 minor hematomas (2%) and 2 transient access artery occlusions (0.8%). Mean time to hemostasis enabling device removal was 55 ± 28 min. Elevated body mass index (BMI) was not associated with increased time to hemostasis (p = 0.31). Accessed artery, sheath size, and heparin dose were also not associated with time to hemostasis (p = 0.64; p = 0.74; p = 0.75, respectively).

Conclusions

The focused compression hemostasis device enabled rapid hemostasis with a low complication rate. Time to hemostasis was independent of BMI, access site, sheath size, or heparin dose.

Transradial and Transfemoral Uterine Fibroid Embolization Comparative Study: Technical and Clinical Outcomes

PURPOSE

To compare clinical and technical outcomes of transradial (TRA) uterine artery embolization (UAE) with those of the transfemoral (TFA) approach.

MATERIALS AND METHODS

Consecutive patients who underwent UAE with TRA and TFA in an academic hospital between May 2014 and June 2018 were included in this study. The ability to perform the procedure as planned, complication rates, and reduction in uterine volume, fibroid enhancement, and symptomatic improvement were compared using descriptive statistics, Student t-test, and chi-square test.

RESULTS

There were 91 patients in the TFA group and 91 patients in the TRA group, with 1 crossover to TFA due to vasospasm (1 of 91; 1%). The tallest patient in the TRA UAE group was 178 cm and 4 patients taller than 178 cm in the TFA UAE group. Larger particles (900-1,200 μm) were more often used in the TFA group than in the TRA group (P < .001). There were similar low rates of minor access site complications. In the TFA group (6 of 91, 7%), 5 patients had groin hematomas, and 2 patients had groin pain compared to the TRA group (5 of 91, 5%): in which 4 patients had transient focal occlusion of the radial artery and 1 patient had focal pain, all of which resolved with conservative management. There were similar rates of uterine volume reduction in 40% ± 17% in the TFA versus 36% ± 16% in the TRA group (P = .22) and no residual enhancement in 49 of 58 [84%] in the TFA group versus 66 of 77 [86%] in the TRA group (P = .84). There were similar reductions in modifying symptoms (60 of 64 [94%] in the TRA group; and 37 of 40 [93%] in the TFA group; P = NS) was noted at follow-up.

CONCLUSIONS

Transradial UAE in women up to 178 cm tall and transfemoral UAE have similar technical and clinical outcomes, with low rates of access site complications.

Bariatric Embolization of Arteries for the Treatment of Obesity (BEAT Obesity) Trial: Results at 1 Year

Background Bariatric embolization is a new endovascular procedure to treat patients with obesity. However, the safety and efficacy of bariatric embolization are unknown. Purpose To evaluate the safety and efficacy of bariatric embolization in severely obese adults at up to 12 months after the procedure. Materials and Methods For this prospective study (NCT0216512 on ClinicalTrials.gov ), 20 participants (16 women) aged 27-68 years (mean ± standard deviation, 44 years ± 11) with mean body mass index of 45 ± 4.1 were enrolled at two institutions from June 2014 to February 2018. Transarterial embolization of the gastric fundus was performed using 300- to 500-µm embolic microspheres. Primary end points were 30-day adverse events and weight loss at up to 12 months. Secondary end points at up to 12 months included technical feasibility, health-related quality of life (Short Form-36 Health Survey ([SF-36]), impact of weight on quality of life (IWQOL-Lite), and hunger or appetite using a visual assessment scale. Analysis of outcomes was performed by using one-sample t tests and other exploratory statistics. Results Bariatric embolization was performed successfully for all participants with no major adverse events. Eight participants had a total of 11 minor adverse events. Mean excess weight loss was 8.2% (95% confidence interval [CI]: 6.3%, 10%; P < .001) at 1 month, 11.5% (95% CI: 8.7%, 14%; P < .001) at 3 months, 12.8% (95% CI: 8.3%, 17%; P < .001) at 6 months, and 11.5% (95% CI: 6.8%, 16%; P < .001) at 12 months. From baseline to 12 months, mean SF-36 scores increased (mental component summary, from 46 ± 11 to 50 ± 10, P = .44; physical component summary, from 46 ± 8.0 to 50 ± 9.3, P = .15) and mean IWQOL-Lite scores increased from 57 ± 18 to 77 ± 18 (P < .001). Hunger or appetite decreased for 4 weeks after embolization and increased thereafter, without reaching pre-embolization levels. Conclusion Bariatric embolization is well tolerated in severely obese adults, inducing appetite suppression and weight loss for up to 12 months. Published under a CC BY-NC-ND 4.0 license. Online supplemental material is available for this article.

Prone transradial catheterization for combined single-session endovascular and percutaneous interventions: approach, technical success, safety, and outcomes in 15 patients

PURPOSE

We aimed to report approach, safety, technical success, and clinical outcomes of prone trans- radial access (PTRA) and demonstrate feasibility for procedures requiring simultaneous arterial intervention and prone percutaneous access.

METHODS

Fifteen patients underwent PTRA, seven females (47%) and eight males (53%), mean age of 55 years (range, 19-78 years). All patients underwent PTRA for combined transarterial and posterior-approach percutaneous interventions. Variables included sheath size (French, F), type of anesthesia, arterial intervention technical success, posterior-approach percutaneous intervention technical success, estimated blood loss (mL), fluoroscopy and procedure time, complications, and follow-up.

RESULTS

Mean sheath size was 4 F (range, 4-6 F; SD = 0.5). Arterial interventions included transarterial embolization of renal (n=6), hepatic (n=2), and pelvic vessels (n=2), diagnostic arteriography (n=4), and embolization of an arteriovenous malformation (n=1). Posterior-approach intervention technical success was 100% (15/15). PTRA technical success was 100% (15/15). Posterior-approach percutaneous interventions included retroperitoneal (n=5) and pelvic (n=1) mass biopsies, nephrostomy tube placement (n=2), cryoablation of pelvic (n=2) and renal (n=1) masses, sclerotherapy of arteriovenous malformations (n=2), foreign body removal from the renal collecting system (n=2), ablation of a renal tumor (n=1), intracavitary injection of pulmonary mycetoma (n=1), and ablation and cementoplasty of a vertebral body tumor (n=1). The biopsies were diagnostic (6/6). There were no minor or major access-site complications.

CONCLUSION

PTRA is a safe and feasible method for performing combined arterial and posterior approach percutaneous interventions without the need for repositioning.

Prevalence of chronic kidney disease among patients undergoing transradial percutaneous coronary interventions

BACKGROUND

While transradial approach to conduct percutaneous coronary interventions offers multiple advantages, the procedure can cause radial artery damage and occlusion. Because radial artery is the preferred site for the creation of an arteriovenous fistula to provide dialysis, patients with chronic kidney disease are particularly dependent on radial artery for their long-term survival.

METHODS

In this retrospective study, we investigated the prevalence of chronic kidney disease in patients undergoing coronary interventions via radial artery. Stage of chronic kidney disease was based on estimated glomerular filtration rate and National Kidney Foundation - Kidney Disease Outcomes Quality Initiative guidelines.

RESULTS

A total of 497 patients undergoing transradial percutaneous coronary interventions were included. Over 70.4% (350/497) of the patients had chronic kidney disease. Stage II chronic kidney disease was observed in 243 (69%) patients (estimated glomerular filtration rate = 76.0 ± 8.4 mL/min). Stage III was observed in 93 (27%) patients (estimated glomerular filtration rate = 49 ± 7.5 mL/min). Stage IV chronic kidney disease was observed in 5 (1%) patients (estimated glomerular filtration rate = 25.6 ± 4.3 mL/min) and Stage V chronic kidney disease was observed in 9 (3%) patients (estimated glomerular filtration rate = 9.3 ± 3.5 mL/min). Overall, 107 of 350 patients (30%) had advanced chronic kidney disease, that is, stage III-V chronic kidney disease. Importantly, 14 of the 107 (13%) patients had either stage IV or V chronic kidney disease.

CONCLUSION

This study finds that nearly one-third of the patients undergoing transradial percutaneous coronary interventions have advanced chronic kidney disease. Because many of these patients may require dialysis, the use of radial artery to conduct percutaneous coronary interventions must be carefully considered in chronic kidney disease population.

Prone Transradial Catheterization for Combined Single-Session Transarterial Embolization and Percutaneous Posterior Approach Cryoablation of Solid Neoplasms

Transradial access (TRA) has been associated with improved post-procedure hemostasis and patient satisfaction, and decreased hemorrhagic complications, sedation requirements, recovery times, and procedure-related costs when compared with traditional transfemoral catheterization. Supine TRA has been described for the treatment of myocardial infarctions, aortoiliac and femoropopliteal stenoses, and a variety of neoplasms. This original research describes prone transradial catheterization to facilitate combined single-session transarterial embolization and percutaneous cryoablation of solid neoplasms from a posterior approach without repositioning. Prone TRA access, transarterial embolization, and percutaneous cryoablation were successful in all cases described. Mean procedure time was 210 min (range: 140-250 min). One minor complication, transient bacteremia which responded to antibiotics, was reported. No major complications occurred.