Use of radial access for carotid interventions with protection device, P Montorsi

1. Use of radial access for carotid interventions
with protection device
Piero Montorsi, MD
Associate Professor of Cardiovascular Diseases
Department of Clinical Sciences and Community Health, University of Milan
Director, 2nd dep’t Invasive Cardiology
Centro Cardiologico Monzino, IRCCS, Milan, Italy

2. Speaker name: Piero Montorsi, MD
Consultant for Boston Scientific, Medtronic

3. CAS through radial/brachial approaches
Is it a safe & effective technique?
N=382
2012
N=260
2014
We…
can…
do it !!

4. RSA-RCCA (TRA)
IA-LCCA (TRA)
Sharp angle +
lack of anatomic support +
CAS through the transradial approach
Why a difficult technique?
device stiffness
=
high rate of failure

5. Transradial/brachial CAS
The Monzino’s experience
0
15
30
45
60
75
90
105
120
’00
02
‘03 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 ‘10 ‘11 ‘12 ‘13 ‘14
TR/TBA/TU
267/926 (29%)
CASprocedures/year(n)
N=1197
‘15
TR/TB/TU w Filter
(n=191, 84% radial)
TR/TB w Mo.Ma
(n=76, 55% radial)
6/’16
66% (34/51 pts)
73%

6. Transradial/brachial CAS with proximal protection
Patient population ‘close-up’
 Number of pts: 76/267 (28.4%)
 Indications:
- Symptomatic pts
- Asymptomatic pts with high risk clinical and or
anatomic characteristics
 Vascular access:
- Radial/brachial approach (according to clinical
assessment and/or Doppler US)
 Type of PP: 8F Mo.Ma (Medtronic)
 Type of stent: 5F-compatible stents
 Anticoagulantion: Heparin (TR), Bivalirudin (TB)
 Closure: TR-band+’patent’ hemostasis (TR) and manual
compression (TB)

7. 6F Sheath
(Avanti, Cordis)
11 cm
OD: 2.67mm
‘6F in 5’
(GSS, Terumo)
10 cm
OD: 2.46mm
+
GC 6F
+
CW7/Precise 8
Roadsaver
(any size)
8F Sheath
Avanti (Cordis)
OD: 3.3 mm
11 cm5.5 cm
CAS with Mo.Ma (8F)CAS with filter
Radial artery cannulation

8. RSA-RCCA
Bifurcation
(+ RICA stenosis)
LCCA take off from the
aortic arch
(+ LICA stenosis)
TR/TB CAS with proximal protection
Technical success/failure rate
LCCA take off from the
IA: BAAC
(+LICA stenosis)
First attempt failure rate
26/75 (34.6%)
0% 40% 80%Technical success 75/76 (98.6%)
Crossover rate: 1.3%

9. TR/TB CAS with proximal protection
LICA lesion in BAAC
Type 2 bovine aortic arch
+ LICA stenosis.
CT-angio (LAO 45° view)
5F diag RJ in
LCCA through
right brachial
artery
8F MO.MA system
ECA+CCA balloons occlusion
(arrows)
Final result
CW (7x30), post-
dilated with a
5.5x20mm

10. TR CAS technical failure
Sharp angle between RSA-RCCA bifurcation
RICA stenosis
Right radial
approach
Attempt to position the Mo.Ma system over a .035’’
stiff wire (Supracore)  prolapse into the IA

11. Transradial CAS with proximal protection
The No.MA2 technique
26/75 (34.6%)
‘first attempt’ failure

Reduce the device stiffness

1. Mandrel removal
(5-10cm)
and try again

12. Transradial CAS with proximal protection
The No.MA2 technique
TS: 1/26 (3.8%)

13. Transradial CAS with proximal protection
The No.MA2 technique
0.035” Emerald wire
loaded into the working
channel (mandrel
withdrawn)
0.035” stiff wire
loaded into the
distal port
No.Mandrel 2 wires technique
(No.MA2 technique)
26/75 (34.6%)
first attempt technical failure

1. Mandrel removal (5-10cm)
and try againif fails

Improve wire support


14. TR CAS technical failure
Sharp angle between RSA-RCCA bifurcation
RICA stenosis
Right radial
approach
Attempt to position the Mo.Ma system over a .035’’
stiff wire (Supracore)  prolapse into the IA

15. Sharp angle between RSA-RCCA bifurcation
Mo.Ma placement with the No.Ma2 technique-1
6FRJ guide into ECA A second stiff wire was
positioned deep into ECA.
6FRJ guide removed
The 2 stiff wires loaded into the ECA channel and the
working channel, respectively and Mo.Ma system
positioned in RCCA
Stiff Angled
Glide Wire
4MP, 125 cm
6 Guiding cath.

16. Sharp angle between RSA-RCCA bifurcation
Mo.Ma placement with the No.Ma2 technique-2
Cristallo Ideale
7-10x40mm
Postdil 5.5x20
Occlusion test8F Mo.Ma in place
ECA balloon inflation
and test for ECA
exclusion
Final result

17. Sharp angle of RSA-RCCA bifurcation
Mo.Ma placement with modified technique
78yom. Right hemisphere
minor stroke.
Right ICA ‘near-occlusion’
Right radial approach
5FRJ cath in RCCA
over .035’’ Terumo
wire
Terumo wire echanged
for a .035’’ stiff wire.
5FRJ removed.
Failure to advance the
8F Mo.ma device
Additional wire in ECA
through a coxial system
(4FMP125 + 6FRJ
guide)

18. Additional 0.035” Emerald wire below
bifurcation through 6FRJ guide
ECA
Both MO.MA
balloon inflated
Final result after
Cristallo stent 7-
10x40mm
Sharp angle of RSA-RCCA bifurcation
Mo.Ma placement with modified technique

19. LCCA
LSA
IA
HU: 34
Left ICA PSV: >4m/s
Sharp angle of IA-LCCA bifurcation
Mo.Ma placement with the No.Ma 2 technique

20. Sharp angle of IA-LCCA bifurcation
Mo.Ma placement with the No.Ma 2 technique
8F MO.MA
in place
Coaxial system: 6FRJ
guide+4FMP 125,
loaded on Terumo wire
from R brachial
approach
6FRJ
4FMP
125
6FRJ guide
in ECA. 4FMP
removed
Terumo wire
exchanged for .035”
standard wire +
.035”stiff wire
(Magic Torque, BSI).
6FRJ guide removed.
8F MO.MA loaded
on the 2 wires
(No.Ma technique)
Final
result

21. Sharp angle between RSA-RCCA bifurcation
Mo.Ma placement with the No.Ma2 technique-1
74yom. Recent right hemisphere minor stroke. Type III aortic arch. Failure
of CAS by femoral artery. Rescheduled from the right RA approach
Early arterial frame Late arterial frame

22. Sharp angle between RSA-RCCA bifurcation
Mo.Ma placement with the No.Ma2 technique-3
.035’’
Emerald
.035’’
Magic
Torque
5FIM
.035’’
Terumo
6FRJ

23. Sharp angle between RSA-RCCA bifurcation
Mo.Ma placement with the No.Ma2 technique-2
OA
STA

24. The No.Ma2 technique
Which type for the additional wire?
14 pts: 1 stiff + 1 Emerald wire
7 pts: 2 Emerald wire
2 pts: 2 Stiff wire
1 pt : 1 stiff wire + 1 Terumo wire
1 pt: 1 Emerald wire + 1 V18 wire
At least 1 stiff wire in 15/26: 61.5%

25. Transradial CAS with proximal protection
Bifurcation disease: potential issues
The ECA occlusion/stenosis:
 does not allow positioning of a stiff wire deep into this vessel to support any
device advancement (i.e. GC, sheath)
 does not allow the use of the standard proximal protection (Mo.MA 8F Ultra)

26. Up to
205
mm
15
mm
85 mm
Standard System set up
Y-connector+MO.MA w
mandrel
System set up variant #1
No Y-connector
System set up variant #2
Mandrel exchanged for
a 4F 125cm MP
Transradial CAS with proximal protection
Mo.Ma Ultra mono balloon: Instructions for use-1

27. Transradial CAS with proximal protection
Mo.Ma Ultra mono balloon: Instructions for use-1
The No Mandrel 2 wire technique (The ‘No.Ma2’ technique)
Stiff wire
0.035’’
Emerald wire
0.035’’

28. Type I aortic arch
LCCA from the aorta
LICA stenosis
1. Right fetal PCA
2. No left PCoA
3. Patent ACoA
ICA
ECA
ICA
CCA
CCA
ECA
1
2
3
Willis circulation
Transradial CAS with proximal protection
in bifurcation disease

29. Transradial CAS with proximal protection
in bifurcation disease
R radial access.
5F Tiger into LCCA
 .035” standard
wire tip shaping
8F MO.MA mono
loaded on the 2
standard wires
(No.Ma technique)
Additional .035”
standard wire
through 6FRJ guide
5F Tiger exchanged
for coaxial system
(6FRJ+4FMP, 125 cm)
6FGC
4FMP
CTA (VR)
45°RAO view

30. Transradial CAS with proximal protection
in bifurcation disease
CM injection (early to late frame) Spider Rx
filter,6 mm
CW 7x30
post-dil
5.5x20
Final result74mmHg

31. TR/TB CAS
Radiation exposure
TR/B CAS w
Mo.Ma (n=61)
TR/B CAS w
Filter (n=153)
P value
Fluoroscopy time (sec) 780±361 957±511 0.018
DAP (Gym2) 6884±2964 7252±6052 0.66
Contrast medium (ml) 109±38 135±47 0.0003

32. Tranradial approach for CAS
Role of the learning curve on radiation exposure
Source DF Type III SS Mean
Square
F Value Pr > F
Year 1 5,3E+08 5,3E+08 20,19 <.0001
Group 1 4525130 4525130 0,17 0,6793
Source DF Type III
SS
Mean
Square
F Value Pr > F
Year 1 3,6E+07 3,6E+07 4,35 0,0418
Carotid side 1 3287317 3287317 0,4 0,5297
N=214 N=61Left
Right
Filter
Mo.Ma
Filter vs. Mo.Ma/year Right vs. left carotid w Mo.Ma/year

33. Right TR CAS with Mo.MA for LICA stenosis and BAAC
Unusual technical failure: Mind the patient height!
ECA
CCA
balloon
5 cm to
bifurcation
Mo.MA system length: 95 cm
Patient’s height: 181 cm
If >170 cm
Brachial approach
or
high radial artery puncture

34.  Patients: 76/267 (28.4%, 42 RA, 34 BA)
 Crossover to FA: 1.3% (1/76)
 Crossover to filter: 6.5% (5/76)
- intolerance to occlusion: 4 pts
- Mo.Ma too short: 1 pts
 MACCE (PPA): 0% (0/71)
 Major vascular complications: 1.3% (1/76)
- brachial artery pseudoaneurysm
 Chronic artery occlusion (31d-F/u): 7.1%
- radial artery: 3/42
- brachial artery: 0/34
Transradial CAS with proximal protection
Personal Experience
September
23
2016
by Doppler US