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

Abstract Background: The transradial approach (TRA) is a less invasive treatment approach for aortoiliac (AI) lesions than the transfemoral or transbrachial approach. However, this approach has some problems for complex lesions, including the procedural difficulty. We used a bidirectional approach combining the TRA with a sheathless technique for femoral artery (FA) puncture to treat complex AI lesions, as a minimally-invasive approach that is almost equivalent to a single-puncture method. Here, we describe representative cases with AI chronic total occlusion in which the combination of TRA and sheathless technique for FA puncture was extremely useful. 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 distal external iliac artery (EIA). We used an antegrade TRA, and advanced a guidewire into the subintimal space under intravascular ultrasound (IVUS) guidance. With the retrograde wire passing through a micro-puncture and IVUS-guided parallel wiring, we achieved wire externalization. We successfully deployed two nitinol stents to the entire lesion. Case 2 was a 63-year-old man with IC. Control angiography revealed total occlusion of the right CIA ostium to common femoral artery (CFA) with severe calcification. The antegrade wire reached the distal EIA using the TRA, but was prevented from progressing by the calcified CFA occlusion. A 21-G metal needle was used to penetrate the CFA calcification through the distal true lumen and the wire was inserted into the EIA for wire externalization. We successfully deployed three nitinol stents in the CIA to EIA, and dilated a drug-coated balloon 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.