Transradial No-Touch Technique for Renal Artery Stenosis

Disclosure: Disclosure: Orlando Marrero reports he is a clinical consultant for interventional cardiology for Boston Scientific. Dr. Zaheed Tai reports the following: Terumo (proctor for transradial course), Spectranetics (proctor for laser course, speaker, advisory board), Medicines Company (speakers bureau).

Orlando Marrero can be contacted at orlm8597@yahoo.com. Dr. Zaheed Tai can be contacted at zaheedtai@gmail.com.

Question: Do you do renal angioplasty from the left or right radial artery?

Peripheral procedures are feasible from the radial approach, although current equipment (based on recommended sheath size and catheter or device length) may limit the vascular bed that can be treated. The left radial will allow for more distal access. Following is a case where a “guide extension” was required for the procedure despite left radial access.

Case report

This is a 72-year-old gentleman with a history of left renal artery stenosis diagnosed by magnetic resonance angiography (MRA) after work up of hypertension by his primary physician. He had difficult-to-control blood pressure and was previously on 3 medications (angiotensin receptor blocker [ARB], calcium channel blocker and beta blocker). He had been taken off an angiotensin-converting enzyme (ACE) inhibitor because of worsening renal insufficiency on ACE inhibitor therapy. A diuretic was added, and after poorly controlled blood pressure monitoring and worsening renal function, he was referred for renal angioplasty to allow for better management of his hypertension.

The left radial artery was prepped and draped in a sterile fashion, and accessed with a 6 French GlideSheath (Terumo). We attempted to advance a Judkins right (JR)4 diagnostic catheter into the left renal artery in order to exchange by the no-touch technique for a guide. However, because of tortuosity in the arch, the 100 cm catheter did not reach the origin of the renal ostium; it was slightly short. We exchanged to a 6 French 90 cm guide, hoping to overcome the tortuosity and allow catheter engagement; however, the catheter was still short of the ostium. We did not have longer guides or catheters available (Medtronic does make a 110 cm guide); therefore, we made a makeshift long guide (Figure 1). We took a 7 French JR4 guide and cut the proximal portion. This was followed by cutting a 6 French sheath (with the ends flared by a 7 French dilator) and using this piece to connect the two pieces of the 7 French guide, thereby extending the guide by about 10 cm. Following placement of a 7 French 90 cm Destination sheath (Terumo), a JR4 catheter was advanced short of the ostium and a Balanced Middle Weight (BMW) wire (Abbott Vascular) was advanced into the artery. Utilizing the no-touch technique, the extended guide was advanced over a 0.035-inch wire and the 0.014-inch wire to the ostium (Figure 2). The 0.035-inch wire was removed and the guide engaged the left renal artery. We then placed a second wire, a Runthrough wire (Terumo), deeper into the renal artery as a buddy wire, and advanced a 5.0 x 20 mm AngioSculpt balloon (AngioScore Inc) (Figure 3). We predilated the proximal portion of the vessel at 8 atmospheres and then advanced a 6.0 x 14 mm stent to cover the lesion. The buddy wire was removed and the stent was deployed at 8 atmospheres. We then postdilated with a 6.0 mm balloon at nominal. There was ostial fibrocalcific disease that was post dilated with the 6.0 mm balloon (Figure 4). Upon completion, there was good stent apposition and improved blood flow in the renal artery without any evidence of wire perforation or embolization (Figure 5). The wire was removed and repeat angiography was performed.

The patient tolerated the procedure well and was discharged the same day. He has done well at follow-up, although still requiring multiple medications, and his systolic blood pressures have consistently been in the 130s.

Discussion

Renal artery revascularization has been the topic of much debate and is beyond the scope of this article, but has been beneficial in certain cohorts. Renal artery revascularization has demonstrated benefit in subsets of patients with heart failure, recurrent pulmonary edema and hypertension.^1-3

Transradial renal artery stenting is safe and feasible.⁴ The small caliber and tortuous nature of the radial artery may prove challenging. The use of the larger catheters may result in more spasm. Balloon-assisted tracking of the guide may be a useful technique under these circumstances.⁵  

In general, the angle of the renal artery off the aorta favors a radial approach, which is more attractive than a retrograde femoral access. The left radial artery is preferred over the right. This will save approximately 10 cm of distance, as one does not have to traverse the aortic arch. Knowledge of anthropometric measurements is important for achieving success.⁶ In a person that is 5 feet, 6 inches, the 100 cm guide should have reached; however, the tortuosity in the arch and subclavian contributed to initial failure. Longer guides are available and should be considered or as in this case, a longer guide can be made. There are case reports of guide shortening⁷, but none were found describing lengthening. The remaining equipment (balloon, scoring balloon, stents, etc.) is 6 French compatible and long shaft balloons are available, although for a renal artery intervention, standard lengths should be adequate. 

References

1. Kane G, Xu N, Roubicek T, et al. Renal artery revascularization improves heart failure control in patients with atherosclerotic renal artery stenosis. Nephrol Dial Transplant. 2010; 25: 813-819.
2. Bloch MJ, Trost DW, et al. Prevention of recurrent pulmonary edema in patients with bilateral renovascular disease through renalartery stent placement. Am J Hypertens. 199: 12: 1-7.
3. Leertouwer TC, Gussenhoven EJ, Bosch JL, van Jaarsveld BC, van Dijk LC, Deinum J, Man In ’t Veld AJ. Stent placement for renal arterial stenosis: where do we stand? A meta-analysis. Radiology. 2000; 216: 78-85.
4. Scheinert D, Ludwig J, at el. Transradial approach for renal artery stenting. Catheter Cardiovasc Interv. 2001 Dec; 54(4): 442-448. 
5. Patel T, Shah S, Pancholy S. Balloon-assisted tracking of a guide catheter through difficult radial anatomy: A technical report. Catheter Cardiovasc Interv. 2012 May 28. doi: 10.1002/ccd.24504. (Published online Nov 14, 2012.)  
6. Staniloae CS, Korabathina R, Coppola JT. Transradial access for peripheral vascular interventions. Cathet Cardiovasc Intervent. 2013; 81: 1194-1203.
7. Stratienko AA, Ginsberg R, Schatz RA, Teirstein PS. Technique for shortening angioplasty guide catheter length when therapeutic catheter fails to reach target stenosis. Cathet Cardiovasc Diagn. 1993; 30: 331-333.