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Table 15.1 Results from a meta-analysis of 66 observational studies
detailing outcomes for TASC C and TASC D aorto-iliac occlusive disease following endovascular treatment or open (bypass) surgery- please
note this is non-randomised data. The table summarises weighted proportion for each treatment strategy. Standard endovascular treatment
refers to kissing iliac stenting [7]
Standard
Patency (95%
condence
interval)
Patency
1year primary 90% (88–93%) 88%
1year
secondary
3years primary 78% (73–84%) 82%
3years
secondary
5years primary 71% (60–82%) N/A 88% (86–90%)
5years
secondary
endovascular
treatment
(n=3204)
96% (94–98%) 97%
93% (89–96%) 97%
89% (80–95%) N/A 95% (93–97%)
CERAB
(n=240)
(83–92%)
(94–99%)
(75–88%)
(92–99%)
Open bypass
surgery
(n=5875)
96% (95–97%)
97% (95–97%)
93% (91–94%)
97% (95–98%)
Pre-Operative Preparation
All patients should undergo a structured anaesthetic assessment, given that endovascular aorto-iliac procedures for
TASC D and D lesions can be challenging technically and
lengthy. Further, angioplasty and post-dilatation of the iliac
lesions can be painful. Depending on local expertise and the
patient’s co-morbidities, the procedures can be performed
under general or loco-regional anaesthetic. There is no highquality evidence focusing on outcomes following these endovascular procedures based on type of anaesthetic. In our
recent cohort studies in the UK and Europe, the type of anaesthetic did not impact on peri-operative outcomes or major
adverse cardiac events for patients undergoing CERAB or
kissing stenting [4, 7]. In our meta-analysis of 9319 patients
with TASC C and D aorto-iliac disease undergoing open or
endovascular reconstruction, type of anaesthetic also did not
inuence peri-operative outcomes [7]. These ndings might,
however, reect the fact that none of the available evidence in
this context is of randomised nature and selection or reporting
bias is highly prevalent in the available literature [7]. Before
proceeding with reconstruction of their aorto- iliac axis,
patients should be commenced on Clopidogrel, high-dose
statin therapy, and blood pressure medication (where necessary), based on local guidance. Best medical therapy is a
paramount constituent of treatment as antithrombotics, statin
therapy, optimum glycemic and blood pressure control have
been shown not only to improve long-term outcomes but also
reduce the chance of peri-operative events, such as acute kidney injury [18]. Cardiopulmonary exercise testing has been
shown to have an important role in planning aortic procedures; however its role in PAD remains unclear [19]. Further,
we strongly advocate the initiation of supervised exercise
therapy alongside best medical therapy for those who present
with claudication rather than CLTI, before proceeding with
any type of intervention, given that level 1A evidence strongly
suggests that exercise with best medical therapy are the most
important constituents of treatment in this instance.
Anticoagulation andAntithrombotic
Medication
There is high quality randomised evidence to support the
prescription of Clopidogrel 75 mg daily in patients with
symptomatic peripheral arterial disease, who require intervention for aorto-iliac revascularisation. More recent randomised evidence has shown benet of anticoagulation in
the form of novel oral anticoagulants in patients undergoing
intervention for PAD; however, this was not compared to
Clopidogrel. Dual antiplatelet therapy is not widely advocated. Overall, prescription of antithrombotic therapy should
be individualised based on each patient’s risk of bleeding
and benets of each treatment strategy, e.g., anticoagulation
vs. monotherapy with Clopidogrel (antiplatelet). Antiplatelet
therapy should be started upon patient presentation and continued post-operatively.
Imaging
We strongly advocate the use of computed tomographic
angiography with three-dimensional reconstruction in order
to plan any endovascular aorto-iliac procedure, especially for
patient with occlusive PAD. Duplex ultrasonography should
be used when necessary for a dynamic assess of the infrainguinal arteries, especially the below-knee run-off. Duplex
ultrasonography during the procedure should be used for
femoral or upper-limb access and to measure the diameter of
the femoral arteries in case an endovascular femoral intervention is planned. Imaging of high quality is paramount in
terms of safely and accurately planning any endovascular
procedure in this context.
Endovascular Strategy andTechnique
Basic Endovascular Toolkit forTASC C andD
Lesion AIOD Endovascular Revascularisation
• Vascular ultrasound for access in the common femoral
arteries and also brachial or axillary arteries when necessary (e.g. severe occlusive disease in the aorta and common iliac arteries, not allowing adequate angiography
from the common femoral access).
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A. Saratzis
• Standard-access wires and sheaths, including a short 5 or
6 Fr sheath.
• Longer-access sheaths for patients requiring upper-limb
access, at least 90cm in length– longer 110cm sheaths
might be necessary (depending on length of iliac
occlusions.
• Micropuncture catheter kits for upper-limb percutaneous
access if deemed necessary (e.g. aortic occlusion).
• Selective catheters (e.g. Glidecath).
• Floppy and stiff or semi-stiff hydrophilic
glidewire.035′‘.
• Variety of.018″ hydrophilic wires (to remain intraluminal
if necessary), including chronic total occlusion purposebuilt wires where necessary.
• Pigtail angiographic catheter for initial diagnostic angiogram, either from femoral access (iliac arteries) and/or
from proximal upper-limb access when necessary.
• Support catheters for recanalisation of occlusions or
severe stenosis (guiding catheters)– ideally in a variety of
different congurations; Bernstein and C2 preferred
options.
• Use of 4 Fr or small support catheters is highly advocated
in case of chronic total occlusions, together with guiding
catheters of larger diameter for “telescoping” in order to
achieve better support (e.g. use of a CXI catheter alongside a GlideCath).
• Angled catheters in case of subintimal recanalisation
strategy (e.g. Bernstein or other similar catheter).
• Variety of angioplasty balloons for pre- and post- dilatation (following stenting).
• 5–16mm covered and uncovered balloon mounted stents
+/− self expanding stents for the external iliac arteries
(various lengths, depending on pre-operative crosssectional imaging, preferably in the form of computed
tomographic angiography).
A list of basic suggested material is summarised in
Table15.2.
For patients with severely calcied disease of the iliac
arteries, common femoral arteries, and/or distal aorta, intravascular lithotripsy or atherectomy (femoral) might be considered, based on local expertise and technology
availability.
Decision Making onTechnique Selection
Detailed pre-operative imaging is crucial in terms of deciding the recanalisation and treatment technique. Covered
stents in the common iliac arteries are supported by the
COBEST trial, especially in those with occluded iliacs. The
choice of a CERAB approach, i.e., use of a covered aortic
stent with covered iliac kissing stents deployed inside the
Table 15.2 Suggested endovascular toolkit for the endovascular treatment of steno-occlusive aorto-iliac disease
Manufacturer
Wires
Any standard- access
wire
Glidewire oppy Terumo Radifocus
Glidewire stiff Terumo Radifocus 0.035”
STARTER Rosen Boston scientic
V-18 control
guidewire
Chronic total
occlusion (CTO)
wires
Sheaths
Any standard- access
sheath (femoral)
Access sheaths from
upper limbs or
axillary artery
Catheters
Angled Terumo Radifocus
Quick cross support
(low-prole)
CXI support Cook medical
Balloons
Any standard
angioplasty balloon
Stents
BeGraft peripheral BeGraft Size & length depending
BeGraft aortic
V12 Advanta Getinge Size & length depending
Zilver Cook medical Size & length depending
IVUS catheter
(intravascular
ultrasound)
a
Manufacturers and stent types might differ per region, institutions or
country. Covered and uncovered iliac or aortic stents should be available prior to commencing any type of endovascular aorto-iliac endovascular treatment, based on pre-operative imaging
b
The BeGraft aortic stent can be post-dilated to diameters which can
accommodate for an aortic size up to 16mm; other manufacturers also
produce covered stents which can be post-dilated to a diameter that can
match that of the infra-renal aorta. Choice depends on local availability
and pre-operative imaging. We advocate the use of covered aortic and
common iliac stents; however, this is not based on randomised evidence
assessing clinical and cost-effectiveness
Any 0.035”
corporation
Boston scientic
corporation
Various
manufacturers
Choice depends on
local availability
Any 5–10 Fr/11cm
Any 5–10 Fr/55–110cm
Spectranetics/
Phillips
Various
manufacturers
b
BeGraft Size & length depending
Where necessary Assess intra- or
a
Size/length
0.035″
0.035”
0.018”
0.018–0.035”
(depending on anatomy
and site of occlusion in
iliac arteries)
0.035″/5 Fr/65–90cm
0.018–0.035″/4
Fr/65–90cm
0.018–0.035″/4 Fr/
various lengths
4–16mm
on CT measurements
+/− IVUS
on CT measurements
+/− IVUS
on CT measurements
+/− IVUS
on CT measurements
+/− IVUS
extra- luminal
positioning +/−
diameter of said vessel
prior to stent
deployment
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aortic stents (which is deployed rst) depends on the conguration of the disease in the distal aorta and bifurcation.
There is no randomised evidence showing superiority of the
CERAB technique over kissing stenting; however, the advocates of CERAB base their choice on the minimal guttering
effect when using a CERAB conguration and a more anatomical reconstruction. Further, the use of covered stents in
the aorta and common iliac arteries might be safe in case of
long occlusions, at least in theory, where vessel rupture
might be more likely when attempting to cross the lesion. In
our international cohort study, we found that the combination of covered aortic and iliac stents in the iliacs and aorta
confers a benet in terms of patency when treating patients
with TASC C and D disease.
A common area where patients might require reintervention is the external iliac artery. We advocate treatment of stenosis of the external iliac artery with liberal
stenting (using self-expanding stents) and also liberal treatment of common femoral artery disease, to allow adequate
outow. The external iliac arteries and common femoral
arteries are the most common sites of disease recurrence in
these patients in our cohort studies and meta-analysis.
Fig. 15.2 Planning map for
patients with TASC C and D
aorto-iliac disease based on
pre-operative imaging
Overall, careful pre-operative planning is paramount. One
should be aware of the exact site and length of occlusions in
the aorto-iliac axis, assess patency of the aortic visceral
branches, patency of the internal iliacs and state of run-off. In
our practice, we use the below schematic (Fig.15.7) in order
to plan any endovascular aorto-iliac procedure, based on preoperative computed tomographic angiography (which is superior in assessing calcied plaques). In terms of deciding when
to chimney the inferior mesenteric artery or renal arteries, we
advocate the use of chimneys in arteries of more than 4mm in
diameter. This decision is complex and should be based on
each patient’s risk prole and individual imaging characteristics. We avoid using chimney stents for the renal arteries and
would prefer open surgical reconstruction in case of aortic
occlusive disease very proximal to the renal arteries, are future
re-intervention (surgical) in patients with renal chimneys can
be very challenging. The lengths of the occlusions and lengths
of stents (together with diameters) should be calculated preoperatively with centre-line three- dimensional reconstruction.
Intra-operative angiograms can be deceiving. Intravascular
ultrasound, where and when available, can also help with sizing iliac stents appropriately (Fig.15.2).
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Access andCrossing theLesion
The initial angiogram is crucial in terms of crossing the
lesions. As a result, we have a low threshold for accessing the
aorta from above in patients with occlusive aortic disease i.e.
inserting an aortic sheath and angiographic catheter from the
arm(s) (typically left upper limb to minimise the risk of
stroke). Femoral access with or without endarterectomy (in
case of severe femoral disease) is of course mandatory.
Ultrasound guided percutaneous access minimises complications and should be used.
Anticipated Complications
The most common complications relate to access, especially
in the groin. We strongly advocate common femoral endarterectomy in patients with severely calcied femoral arteries
and stenosis exceeding 50%. This optimises outow and
offers superior control.
A. Saratzis
Peri-Operative Care andSurveillance
There is no randomised evidence regarding surveillance
post-operatively in the case of TASC C and D aorto-iliac
lesions. The cost-effectiveness of surveillance also remains
debatable. Newer procedures and congurations, e.g.,
CERAB have also not been assessed in randomised studies
in terms of post-operative surveillance. Duplex ultrasonography in patients with long occlusion or where newer techniques have been used (CERAB) might be of benet;
however timing and strategies to address stenoses remain
unclear. We personally advocate a Duplex ultrasound with a
non-contrast computed tomographic scan (to assess stent
deployment) 30days after CERAB procedures followed by
3-monthly duplex and clinical assessment.
Case Presentation
Based on the CTA, the aorto-iliac occlusion qualied for a
TASC D lesion (Fig. 15.3). Following a multidisciplinary
team meeting discussion, we decided to proceed with an
endovascular recanalisation and stenting, using covered balloon expandable stents in the form of a covered endovascular
reconstruction of aortic bifurcation (CERAB) procedure,
under local anaesthetic. The procedure took place in a hybrid
operating theatre, led by a consultant vascular surgeon, via
percutaneous bilateral femoral artery access and left sided
brachial artery puncture. The patient was consented for standard risks and benets for this procedure and agreed to pro-
Fig. 15.3 Baseline computed tomographic (CT) angiogram disclosing
bilateral calcied iliac occlusions with a distal aortic occlusion
ceed. The common femoral arteries and left brachial artery
were punctured using 5 Fr micropuncture catheter kits (Merit
Medical, Utah, USA), which is our standard practice for calcied arteries. Two 5 Fr access sheaths were introduced in
the common femoral arteries and a 90cm 7 Fr sheath was
advanced via the left brachial artery to the level of the suprarenal aorta, to obtain proximal angiograms; this is our standard practice for long bilateral iliac and aortic occlusions in
order to obtain a target in terms of recanalisation from distal
(femoral) to proximal (aorta) (Fig.15.4).
Following the initial angiogram, a combination of stiff,
half stiff, and oppy 0.35″ hydrophilic wires (Terumo
Corporation, Japan) were used to cross the iliac lesions with
support catheters (CXI 90cm and 110cm support catheters,
Cook Medical, Arizona, USA) both from above and below
(aortic sheath and femoral access) the aortic and iliac occlusions. The occlusions were crossed bilaterally in a subintimal plane, given the degree of calcication as well as length
of the disease. Through and through wires were then snared
using a 6 Fr goose snare via the right femoral artery. The
right axis was crossed rst (Figs.15.5 and 15.6).
Once both iliac axes and the infra-renal aorta had been
recanalised (subintimal plane), two stiff wires of 300cm in
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Fig. 15.5 Crossing of the right aorto-iliac axis using a combination of
stiff 0.035″ hydrophilic wires (Terumo Corporation, Japan) with telescopic support via an 0.035” CXI catheter (Cook Medical, Arizona,
USA) in a C2 5 Fr guiding catheter (subintimal plane). The hydrophilic
wire from the proximal access (upper limb) was snared via the right
groin access sheath
Fig. 15.4 rst intra-operative angiogram, disclosing an aortic occlusion below the renal arteries and long bilateral calcied iliac occlusions.
Contrast injected from the 7 Fr proximal sheath via an angiographic
pigtail catheter using a pump (automated) injector
length were inserted and the aortic stent (14 mm wide
BeGraft aortic stent, Bentley, Germany) was deployed rst
under uoroscopic control, ush to the aortic bifurcation;
positioning was conrmed using multiplane uoroscopy.
The aortic stent was 39mm in length. Following that, three
common iliac balloon expandable stents (9mm in diameter
each) were deployed to the level of the iliac bifurcation,
with post-dilatation to 9mm using plain angioplasty balloons in a kissing stent conguration. The iliac stents were
extended up to the level of the distal external iliac arteries
sequentially; covered self-expanding stents of 8 mm in
diameter were used on each side (Viabahn stents, Gore
Medical, Arizona, USA). It is now our standard practice to
use covered self-expanding stents in long external iliac
occlusions (Fig.15.7).
Post-operatively the patient was discharged after 2days.
She remains on Clopidogrel 75 mg daily and lifelong surveillance with 3-monthly ultrasound (duplex). The rest pain
disappeared and the patient remains ulcer/pain free after
14months.
Fig. 15.6 Crossing of the left aorto-iliac axis with support from above
and below (aortic and femoral sheaths). Using an identical wire and
support catheter conguration to the right side, the left axis was crossed
subintimally
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Fig. 15.7 Post dilatation of the kissing iliac stents and completion
angiogram
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Interventions forFemoropopliteal
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RaphaëlCoscas
16
Case Presentation
A 63-year-old patient presented with bilateral disabling
lower limb claudication (<100 meters). His main risk factor
was tobacco use, which he recently quit. Medical therapy
and supervised rehabilitation program were started 6months
ago, but symptoms worsened on the right side with the
appearance of intermittent rest pain. Duplex ultrasound and
computed tomography angiography showed bilateral long
occlusions of the supercial femoral arteries, extended to the
P1 and P2 segments of the popliteal artery on the right side
(Fig.16.1). The right distal runoff was also impaired with a
single anterior tibial artery. The patient was scheduled for a
c
Fig. 16.1 Computed tomography angiography showed bilateral long
occlusions of the supercial femoral arteries (a), extended to the P1 and
P2 segments of the popliteal artery (b) on the right side. The plain arrow
R. Coscas (*)
Department of Vascular Surgery, Ambroise Paré University
Hospital, Versailles Saint-Quentin and Paris-Saclay Universities,
Boulogne-Billancourt, France
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
G. Geroulakos et al. (eds.), Mastering Endovascular Techniques, https://doi.org/10.1007/978-3-031-42735-0_16
shows the beginning of the occlusion and the dotted arrows point to the
re-entry. Distally, the only patent vessel is the anterior tibial artery (c)
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R. Coscas
saphenous bypass, but a severe coronary artery disease was
diagnosed during preoperative assessment, and he underwent the implantation of several coronary stents with an indication for prolonged dual antiplatelet therapy. A complex
endovascular therapy was then considered.
Introduction
Interventions for femoropopliteal (FP) disease are indicated
in the case of persistent disabling claudication after a rehabilitation program or in the setting of critical limb- threatening
ischemia (CLTI). Besides revascularization, cardiovascular
risk factors control, coronary arteries assessment and best
medical treatment (antiplatelet therapy and high-dose statins)
are always indicated [1]. Long and complex femoropopliteal
lesions remain good indications for open surgery if a single
segment saphenous vein is available in good surgical-risk
patients [1, 2]. These situations and discussions fall outside
the scope of this chapter. We here describe the strategy and
technical aspects of endovascular interventions for FP
disease.
Global Technical Strategy
The global technical strategy is based on the preoperative
duplex ultrasound assessment, now most of the times combined with a computed tomography (CT)-scan angiography.
We start by dening “plan A”: which ideal repair do I wish to
perform for this specic lesion? But also plan B and plan C
in the case of unplanned intraoperative issues (what are the
bail-out strategies at each step of the procedure?). Once the
plans are dened, the sizing of the vessels will help preparing the devices needed (vessel preparation tools, lengths and
diameters of balloons and stents) to determine the sheath size
used for the procedure. Main endovascular tools needed for
FP interventions are presented in Table16.1. Then, our technical strategy always follows six steps, which must be perfectly planned before starting the procedure (Fig.16.2) and
constitute the paragraphs of this chapter: (1) the arterial
access, (2) the navigation down to the target lesion and the
stabilization of the arterial access, (3) the lesion crossing
strategy, (4) the vessel preparation, (5) the anti-restenotic
therapy and (6) the arterial closure. All along the procedure,
intraoperative imaging will help the operator. This will also
be mentioned in a specic paragraph.
Table 16.1 Main endovascular devices needed for femoropopliteal
interventions (toolbox). The list in the example column is not
exhaustive
Procedural
step
Access Needles 18G (metallic or plastic); 21 or
Navigation
and
stabilization
Crossing CTO wires Halberd (Asahi), Astato (Asahi),
Vessel
preparation
Anti-restenotic
therapy
Closure Vascular
Intravascular
imaging
Types of
devices Examples
22G micropuncture (retrograde
access) (cook)
Sheaths 4 to 7 Fr 11cm (Terumo), slender
(Terumo), halo one (BD)
Navigation
wires
Basic
angiography
catheters
Support wires Stiff (Terumo), advantage
Long sheaths 4 to 7 Fr of 45, 55 or 70cm exor
Wires for
subintimal
crossing
Support
catheters
Re-entry
catheters
Standard
semi-compliant
balloons
Specic
balloons
Atherectomy
devices
Intravascular
lithotripsy
Bare-metal
stents
Drug-eluting
stents
Covered stents Viabahn (Gore)
Drug-coated
balloons
closure devices
IVUS IVUS (Philips)
Radifocus straight and angled
(Terumo), advantage (Terumo)
Vertebral (merit), Bernstein
(Cordis) KMP (cook) for standard
navigation and UF (Cordis), RIM
(cook) for crossover
(Terumo), Rosen (cook), Amplatz
(Boston)
(cook), depending on the material
and the distance between the
target lesion and the puncture
point
Winn (Abbott), command
(Abbott), victory (Boston)
Half-stiff J (Terumo), command
(Abbott), gladius (Asahi)
CXI (cook), Rubicon (Boston),
trailblazer (Medtronic)
Outback (Cordis), Pioneer IVUS
guided (Philips), BeBack
(Bentley)
Armada (Abbott), mustang
(Boston), saber (Cordis), Sterling
(Boston)
Conquest (BD), Angiosculpt
(Philips), Ultrascore (BD), cutting
(Boston), chocolate (Medtronic)
Rotational: Jetstream (Boston),
orbital: Diamondback (CSI,
Abbott), directional: HawkOne
(Medtronic), hybrid: Phoenix
(Philips), laser: Excimer (Philips)
M5+ (shockwave)
Absolute pro (Abbott), Everex
(Medtronic), Lifestent (BD),
Supera interwoven (Abbott)
Eluvia (Boston), Zilver-PTX
(cook)
In.Pact (Medtronic), Lutonix
(BD), Stellarex (Philips), ranger
(Boston), Luminor (iVascular)
Femoseal (Terumo), Angioseal
(Terumo), Prostyle (Abbott),
exoseal (Cordis), Mynxgrip
(Cordis)
16 Interventions forFemoropopliteal Disease
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Fig. 16.2 Current technical
algorithm for planication of
femoropopliteal interventions
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Arterial Access
Access Materials
Needles and short sheaths are necessary at this step. Needles
can be metallic or with a plastic cannula. The metallic needle
will avoid the manipulation of the needle once in the artery
but carries the risk to damage the wire inserted inside when
it will be taken out from the artery. The needles with plastic
cannulas necessitate more manipulations but are more secure
for the wire. Needles used for femoral approach are generally short (7cm). Long needles (10–15cm) are necessary in
some obese patients, especially when performing an anterograde access. Needle diameter is expressed in Gauge (G)
with the highest G being the smallest diameters. An 18G
needle is the standard when puncturing a femoral artery. A
21 or 22 G is used in alternative tiny accesses (tibial or
radial). A short, stiff wire is inserted in the needle or the cannula, which is then exchanged for a short sheath. Sheath
diameters are expressed in French (Fr) and generally correspond to the internal diameter of the sheath (what can be
inserted in the sheath). The standard sheath used for FP interventions is 6 French. Some companies have developed specic low-prole sheaths with a decreased external diameter
(Halo One, Becton, Dickinson and Company and Slender,
Terumo). Another interesting way of development has been
the advent of dedicated devices to perform the procedure
with 5 Fr or 4 Fr sheaths to minimize access bleeding issues.
Larger sheaths are sometimes necessary (7 Fr) when debulking or intravascular lithotripsy (IVL) devices are necessary.
Sheath diameter must be chosen before the procedure and
taken into account for all anticipated material diameters.
Access Sites
All access sites must be discussed and considered. The main
one is of course the femoral access, but many situations are
in fact more adequate for an alternative access, either as a
single primary access or as a secondary access (bail-out).
The Femoral Access
The arterial system is generally accessed through an ultrasound (US)-guided percutaneous puncture. The most usual
access is the common femoral artery (CFA). We use an
18-Gauge needle, either metallic or with plastic cannula,
inserted with a 30–45° angle with the arterial axis. The CFA
can be accessed antegradely when the proximal SFA is free
of disease. This approach allows working with shorter materials and gives more pushability when a challenging lesion
crossing is anticipated. The proximal SFA can also be antegradely punctured in cases of calcied CFA or obesity [3].
The use of smaller (4Fr) sheaths is then recommended to
avoid issues with arterial closure [4]. Access through the
contralateral CFA with crossover is our standard of practice
when technically feasible. It mandates longer materials but
the installation, the puncture and the closure are easier. It
allows better-quality contrast injections in the profunda femoral artery (PFA) to see the re-entry in the case of chronic
total occlusion (CTO).
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R. Coscas
Another issue with femoral access is the need for patients
to stay supine several hours after the procedure [5, 6]. But
early ambulation (2–4h after the procedure) after femoral
artery puncture is feasible [6–10], especially when using
vascular closure devices (VCDs).
Upper-Limb Accesses
In some situations, the CFA can be deemed inappropriate or
unavailable for puncture, such as in the absence of palpable
femoral pulses, the presence of CFA calcications, obesity, a
history of femoral surgery (particularly with prosthetic materials) or the need for a contralateral femoral approach in the
setting of previous kissing iliac stents or bifurcated aortic
graft (Fig.16.3). Access through the upper limb, especially
from the brachial artery, has been well described as an additional [11, 12] or main [11, 13–15] access in these situations.
In contrast, upper-limb access should be used with caution in
tall patients, patients with a diseased aortic arch or patients
that will need arteriovenous access for dialysis. The arterial
system can be accessed through the brachial, radial or axillary arteries. The brachial access has the advantage to allow
using all sheath diameters for peripheral interventions. It can
be generally punctured percutaneously, but we recommend
open exposure when sheaths >6 Fr are used because manual
compression (MC) is at high risk for failure [16]. Brachial
access is however fraught with risks of local complications
(pseudoaneurysm, brachial artery thrombosis, median nerve
injury) in up to 11% cases [11, 13–15]. In one of the largest
series reporting on the use of the brachial access for aortic
and peripheral procedure [11], the Cleveland Clinic team
reported a 6.5% rate of access site-related complications
(pseudoaneurysm, brachial artery thrombosis, hematoma),
including a 4.0% rate of surgical correction. Of note, conversion to open surgical closure was needed in 2.3% cases when
the artery was initially punctured percutaneously in this
series.
The radial approach is now the rst-line approach for
coronary PTA [17, 18]. It is associated with less vascular
complications compared to femoral access [17–22]. A metaanalysis [19] of randomized controlled trials comparing
radial versus femoral access for primary percutaneous coronary interventions revealed that the radial approach was signicantly associated with a decreased risk of major bleeding
(1.4% vs. 2.9%) and access site bleeding (2.1% vs. 5.6%).
Dedicated devices for FP interventions through radial access
are now available. There are however several points to keep
in mind when planning peripheral procedures through radial
access. Absolute and relative contraindications for radial
access are summarized in Table16.2. Usually, the left radial
artery is used to avoid arch navigation in front of the carotid
ostia. It also had the advantages of gaining 5–10 cm of length
compared to a right-side puncture and crossing the innominate artery, which is sometimes tortuous. The artery is punctured at the wrist (Fig.16.4) or even in the snuffbox [23]. A
minimum diameter of 2.0–2.5 mm is required. The local
anesthesia avoids adrenaline (vasoconstriction) but include
Fig. 16.3 Example of a clinical situation where femoral accesses are
challenging. The patient combines the problem of bilateral common
femoral artery stents complicating the puncture (a) and a kissing stent
conguration in the common iliac arteries (b) precluding a crossover
approach with standard devices
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