Transradial Carotid Artery Stenting

Examining the Alternatives When Femoral Access Is Unavailable

Sasko Kedev

Disclosures

Interv Cardiol. 2014;6(5):463-475. 

In This Article

Abstract and Introduction

Abstract

Carotid artery stenting with embolic protection has been shown to be a proven alternative to carotid endarterectomy in patients with significant carotid disease. The transfemoral approach is the conventional access site for carotid stenting. Access site complications are the most common adverse event after carotid stenting from the femoral access and most technical failures are related to a complex aortic arch. As demonstrated in multiple studies, transradial approach reduces access site bleeding and vascular complications in coronary interventional procedures. It may offer a more direct and safer approach in cases involving a complex arch. Previous feasibility studies and case reports have demonstrated that transradial access may be a viable alternative strategy in these patients.

Introduction

Carotid artery stenting (CAS) when performed by experienced operators using embolic protection, has emerged as an alternative to carotid endarterectomy in patients with significant carotid disease.[1–5] Transfemoral approach (TFA) is the conventional access site for carotid stenting. However, this approach may be problematic due to peripheral vascular disease and numerous anatomical variations of the aortic arch and cervical arteries. Thus, transradial access (TRA) has been evaluated as an alternative strategy for CAS.

The most common adverse event after CAS from TFA are access site bleeding and vascular complications. In the CREST trial, the need for transfusion was significantly associated with a stroke.[6] Elimination of these access site bleeding complications with TRA is well documented in patients undergoing coronary interventions.

Most technical failures of CAS from the TFA are related to a complex aortic arch. The highest risk features for CAS complications are friable aortic arch atheromas in patients with type III aortic arch.[7] The symptomatic strokes (14%) contralateral to the vascular territory of the treated carotid stenosis is strongly indicative that catheter manipulations in aortic arch is a cause of atheroembolic brain lesions.[6,8] The highest prevalence of atherosclerosis distribution is in the descending aorta (38.2%), followed by arch (27.6%) distal to the innominate artery, especially with increasing age.[9]

The use of TRA may minimize catheter contact with the arch and thereby reduce stroke risk, particularly in cases of CAS involving the right internal carotid artery (ICA) or bovine left ICA.

Previous case reports and feasibility studies have demonstrated that with careful technique, TRA CAS can be successfully performed by experienced operators with a low complication rate in a high percentage of patients (Table 1 & Table 2).[10] In addition, TRA for CAS may be useful in patients with severe peripheral vascular disease, high risk for bleeding and vascular complications (female, obese, elderly) and those with a contraindication for prolonged postprocedure bed rest.[10–26] Early patient mobilization is an important benefit of this approach.

The transradial technique for carotid stenting involves several different methods for the basic anatomical types of carotid disease: right ICA, bovine left ICA and nonbovine left ICA. The purpose of this review is to describe the preferred technical transradial strategy for CAS in various types of aortic arch and carotid anatomy.

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