Treating High-Risk, Complex, and Severe Lower-Extremity PAD-CLI via Brachial Access

Introduction: As peripheral arterial disease (PAD) and critical limb ischemia (CLI) continue to rise in prevalence and complexity, early treatment of PAD-CLI is encouraged to mitigate the occurrence of limb amputation, and further, patient mortality. Patients with PAD-CLI most commonly develop the condition due to atherosclerosis of the lower limb arteries, often requiring resolution via endovascular intervention if PAD-CLI symptoms interfere with daily living. The arteries most affected by PAD-CLI are the superficial femoral and popliteal arteries, and thus, chronic insufficiency to the lower limbs may lead to muscular necrosis, causing great discomfort to PAD-CLI patients. These patients may require bilateral lower-limb angioplasty and stent placement, for which brachial access can be utilized if radial artery access is unsuccessful. The transradial approach (TRA) for femoral and popliteal interventions has been proven to be equally safe and effective when compared with the transfemoral approach (TFA). Here, we present a case in which a patient with bilateral lower-extremity PAD-CLI was treated in 1 procedure using brachial access to undergo 2 percutaneous treatments.      

Case Presentation: A 61-year-old woman with an extensive medical history of PAD, paroxysmal atrial fibrillation, multivessel coronary artery disease, moderate-severe mitral stenosis, hypertension, recent pulmonary embolism, hyperlipidemia, hemorrhagic stroke, Chiari malformation, and type II diabetes presented with right lower extremity (RLE) swelling and numbness. Computed tomography imaging conducted prior to emergency department admission revealed both common femoral and mid-superficial femoral artery occlusion in the RLE. Arterial duplex was performed and displayed moderate stenosis in the right mid-superficial femoral and popliteal arteries, left common femoral, proximal, and mid-superficial femoral arteries. Tibial arteries showed decreased velocities in the arterial duplex and no flow was detected in the right peroneal artery. Selective limb angiography was conducted on both lower extremities with repositioning of the catheter more easily achieved due to the brachial approach. Percutaneous transluminal angioplasty was conducted in the right external iliac, common femoral, and superficial femoral arteries, followed by stent placement of the right external iliac and common femoral artery with excellent results. Significant improvements were noted in the lesion at the end of the procedure via angiography. Following the procedure, the patient was discharged on the next day to follow-up care.

Conclusion: High risk lower extremity PAD-CLI treatment may utilize brachial access when radial or femoral access cannot be successfully established. Catheterization from upper-extremity access sites has been noted to cause significantly fewer incidents of site-related bleeds when compared with transfemoral catheterization. Transradial access has additionally become more favorable for PAD interventions with the introduction of tools of greater length (~200 cm) and documentation of patient preference. Reductions in site-related complications and overall length of hospital stay in patients undergoing PAD-CLI interventions through TRA when compared with TFA highlight the safety and cost-efficiency of alternative approaches to TFA. This case demonstrates that brachial artery access is another access tool that interventionalists can use to treat patients with severe, complex lower-extremity PAD-CLI. Brachial access was favored initially in the past but with the advent of radial access or ultrasound-guided femoral access, brachial access lost its ground. However, with the extreme of disease in the ever-growing population with calcified radial and femoral arteries, brachial artery access for iliac approach appears a favorable comeback.