Transseptal Approach toAortography and Carotid ArteryStenting in Pulseless Disease

George Joseph, 1* MD, DM, S. Krishnaswami, 1 MD, DM,Dibya K. Baruah, 1 MD, DM, Sajy V. Kuruttukulam, 1

MD, DM, and O.C. Abraham, 2 MD

We report on a patient with pulseless disease (Takayasu’sarteritis) in whom access to the central circulation by extremityarterial cannulation was not possible due to absent pulses in allfour limbs. The transseptal approach was used for aortography,bilateral selective carotid angiography, and successful electivestent deployment in the right common carotid artery. Cathet.Cardiovasc. Diagn. 40:416–420, 1997. r 1997 Wiley-Liss, Inc.

Key words: angiography; carotid stenosis; angioplasty

INTRODUCTION

Vascular access via the femoral or brachial arteries isoften difficult to obtain in patients with pulseless disease(Takayasu’s arteritis). This is especially so in type IIIpulseless disease, where both the aortic arch and/or itsbranches and the abdominal aorta and/or its branches areinvolved [1]. This is not an infrequent occurrence, giventhat type III pulseless disease is the most common type inJapanese (65%), Mexican (65%), and Indian (53%)patients [1–3]. Pulseless disease afflicts approximately 1in 1,000 persons in the United States and 6 in 1,000worldwide [4]. Vascular access is essential for aortogra-phy and percutaneous interventional procedures, both ofwhich are important components in the management ofpulseless disease [5,6]. We describe in this report the useof transseptal catheterization for aortography and carotidartery stenting in a patient with type III pulseless diseaseand absent arterial pulses in all four extremities.

CASE REPORT

A 40-year-old Asian male presented with a 3-yearhistory of bilateral lower extremity claudication involv-ing the gluteal, thigh, and calf muscles, and a claudication

distance of 25 ft on level ground. He also complained ofeasy fatigability of shoulder and arm muscles bilaterally.Physical examination revealed absent pulses in all fourextremities, loud right carotid bruit with diminishedpulse, and normal left carotid pulse. Using a noninvasiveDoppler probe, systolic pressures of 86 and 64 mm Hgwere obtained in the right and left brachial arteries,respectively, and 18 and 20 mm Hg in the right and leftposterior tibial arteries, respectively. Color Doppler inter-rogation of the right common carotid artery revealed 80%focal stenosis and turbulent flow with peak velocity.4m/sec. Magnetic resonance angiography revealed normalthoracic aorta and narrowing of the left subclavian arterynear its origin. The abdominal aorta was normal aboveand narrowed below the level of the renal arteries withabsent flow signals 5 cm beyond the origin of the leftrenal artery. The distal abdominal aorta and bifurcationwere not seen. Though the diagnosis of pulseless diseasewas clear (5 of 6 American College of Rheumatology1990 criteria [7] having been met), it was felt that moredetailed information was necessary to formulate manage-ment strategy. Having used transseptal catheterization inthe past for both diagnostic and therapeutic left heartprocedures, we decided to utilize this approach foraortography as well.

Angiography

After informed consent and under mild sedation, theright femoral vein was cannulated percutaneously andtransseptal puncture performed by standard technique [8]using a Brockenbroughy transseptal needle and 8 FrenchMullinsy transseptal sheath and dilator (both from USCIDivision, C.R. Bard, Tewksbury, MA). Echocardio-graphic guidance was not utilized. Five thousand units ofheparin was administered.A7 French Swan-Ganz balloon-tipped catheter (Arrow, Reading, PA) was advancedthrough the mitral valve, looped around at the leftventricular apex, and passed out the aortic valve succes-sively into the ascending, arch, and descending aorta (Fig.1). The transseptal sheath was advanced into the leftventricle to help preserve the loop formed at the apex.The Swan-Ganz catheter was removed and replaced witha 125-cm-long 5 French multipurpose catheter (Medi-corp, Villers-Les-Nancy, France) over a 0.035-in. ex-change wire. Abdominal aortography was performedfollowed by arch aortography. Using the same 5 Frenchmultipurpose catheter and with the help of a 0.018-in.Flexyywire (Schneider, Minneapolis, MN), the right andleft common carotid arteries were selectively entered andangiography was performed.

1Department of Cardiology, Christian Medical College Hospital,Vellore, India2Department of General Medicine, Christian Medical CollegeHospital, Vellore, India

*Correspondence to: Dr. George Joseph, Department of Cardiology,Christian Medical College Hospital, Vellore, India.

Received 9August 1996; Revision accepted 18 November 1996

Catheterization and Cardiovascular Diagnosis 40:416–420 (1997)

r 1997 Wiley-Liss, Inc.

Angiography revealed occlusion of the abdominalaorta at the level of the inferior mesenteric artery (Fig. 2)and delayed faint opacification of the aortic bifurcationand iliac arteries via collateral flow. The left and rightsubclavian arteries were occluded at their origins andwere seen to opacify from retrograde vertebral artery flowdistally (see Fig. 6). The right common carotid artery hada focal high grade stenosis (Fig. 3). The left carotidsystem was normal.On the basis of the angiographic findings, it appeared

that the right common carotid artery stenosis needed to betreated before the other lesions. Occlusion here wouldhave catastrophic consequences as neither vertebral ar-tery contributed to cerebral perfusion, and actually flowedretrograde with possible steal effect. Rectifying theabdominal aortic occlusion would require major surgerywhich would be unsafe in this situation. As entry into theright common carotid artery by transseptal approach hadbeen obtained without difficulty, we decided to offer thepatient primary stent implantation by the same approach.

Carotid Artery Stenting

Five days later, using the identical technique, afteradministering 10,000 units of heparin, selective entry into

the right common carotid artery was obtained using thesame combination of a 125-cm-long 5 French multipur-pose catheter and 0.018-in. wire. The wire was thenadvanced through the lesion into a distal branch of theright external carotid artery. Next, the catheter wasadvanced across the lesion and a second such wire placedin a distal branch of the external carotid artery. Thecatheter was then withdrawn to the proximal commoncarotid artery where a third 0.018-in. wire was intro-duced. The three wires were left in place and themultipurpose catheter and transseptal sheath were re-moved. The transseptal sheath was reintroduced to theleft ventricle over the two wires which crossed the carotidlesion. The 5 French multipurpose catheter was reintro-duced over the third wire and positioned just below thecarotid lesion, with the wire left within the catheter forstability, and a Tuohy-Borst adapter was used to obtainhemostasis. This catheter was used for angiography of thelesion during the rest of the procedure. A 5 FrenchUltrathiny 5-mm-diameter balloon (Meditech, Water-town, MA) was introduced over the two wires thatcrossed the lesion and used to partially dilate the lesion at8 atm pressure, to allow subsequent unhindered passage

Fig. 1. Swan-Ganz catheter and 0.035-in. guide wire loopedaround at the left ventricular apex and passed out the aorticvalve into the descending aorta.

Fig. 2. Abdominal aortogram showing occlusion at the level ofthe inferior mesenteric artery and multiple collateral vessels.The same angiographic catheter passes alongside in the inferiorvena cava.

Transseptal Aortography and Carotid Stenting 417

of a stent. A 7 French rolling membrane Wallstenty

(unconstrained diameter 8 mm, length 3 cm; Schneider)was similarly introduced (Fig. 4) and deployed across thecarotid lesion. Finally a Blue Maxy 7-mm-diameterballoon (Meditech) was used to dilate the stent at 10 atmpressure (Fig. 5). Postprocedure angiogram revealedgood flow, smooth luminal outline, and minimal residualstenosis (Fig. 6).The patient remained asymptomatic throughout and no

neurological symptoms or deficits were noted postproce-dure. Central aortic pressure was found to be elevated andnifedipine was administered during and after the proce-dure. Two days later, the patient developed abdominalpain, ileus, and other features suggestive of ischemicbowel. This was probably related to nifedipine-inducedhypotension in the presence of abdominal aortic occlu-sion. The symptoms subsided completely over the nextfew days with conservative management and cessation ofnifedipine. Lower extremity revascularization is plannedas the next step of treatment.

DISCUSSION

Pulseless disease, formerly called Takayasu’s arteritis,can pose a challenge to the vascular interventionist. Thecase reported here, with no palpable extremity pulses, is

not uncommon in some parts of the world. Despite theadvent of magnetic resonance angiography, aortographyremains essential in assessment of the extent of diseaseand formulating management strategy. With increasingability to treat stenotic and occlusive lesions with angio-plasty and stenting, the importance of obtaining vascularaccess has increased.At our center, transseptal catheteriza-tion is frequently performed because of the large numberof mitral valvuloplasty procedures (.250) done everyyear. There has been minimal morbidity and no mortalityassociated with transseptal catheterization. Similarly,looping the Swan-Ganz catheter at the left ventricularapex and advancing it out the aortic valve into the aortahas been safely performed several times in the past, whenguide wires used in mitral valvuloplasty procedures wereroutinely positioned in the descending aorta.The translumbar approach [9,10] was an alternative

considered in this patient. However, experience at ourcenter with this approach is very limited. Besides, therewas concern that the part of the abdominal aorta enteredby the needle might be diseased and that retroperitonealbleeding might occur after removal of a 9 French sheath,required for carotid stenting, from the abdominal aorta.In this patient, transseptal approach to aortography,

selective carotid angiography, and carotid stent deploy-

Fig. 3. Right carotid angiogram (right anterior oblique projec-tion) showing high grade common carotid artery stenosis.

Fig. 4. Wallstent y instrument (with two distal tip markers)negotiating the loop at the left ventricular apex. A multipurposecatheter (with 0.018-in. wire within it) runs alongside.

418 Joseph et al.

ment were smooth and free of complications. It must beemphasized that, at all times, care was taken to maintain aloop of catheter or wire at the left ventricular apex.Shortening of this loop to the straight path between themitral and aortic valves could result in trauma to theanterior mitral leaflet [11].Balloon angioplasty of nonaortic lesions in pulseless

disease has been associated with a relatively low (56–85%) initial success rate and 33–75% long-term vesselpatency [12–15]. Stents have been utilized to improveresults of angioplasty in pulseless disease [16,17]. Avoid-ance of suboptimal results and complications are espe-cially important in the delicate cerebrovascular system[18] and was the rationale for elective carotid arterystenting in our case. This is increasingly the reasoning inpercutaneous interventions for atherosclerotic carotidartery disease as well [19]. Though elective carotid arterystenting is clearly the treatment of choice in situationssuch as postendarterectomy stenosis, high internal carotidartery lesions, and stenosis following cervical radiation orradical neck dissection [20], a consensus has not beenreached regarding its role in atherosclerotic carotidbifurcation disease and pulseless disease. Carotid stenting

in our patient, though not done on a protocol basis, mustbe considered investigational, and further validation ofthis technique is required before it can be routinelyoffered to patients.A limitation of the transseptal approach to carotid stent

deployment is the inability to place a large guidingcatheter in the proximal common carotid artery. Thisnecessitated the use of two 0.018-in. wires to provide asufficiently stable rail over which the balloons and stentcould track, and the side-by-side placement of a 5 Frenchmultipurpose catheter for angiography during the stentingprocedure. This limitation may be overcome in the future

Fig. 5. Balloon dilatation post-Wallstent y deployment in rightcommon carotid artery. A multipurpose catheter (with 0.018-in.wire within it) is positioned just below for angiography of thelesion.

Fig. 6. Postprocedure angiogram showing good flow, smoothluminal outline, and minimal residual stenosis. Rapid opacifica-tion of the subclavian arteries is seen bilaterally via retrogradevertebral artery flow. Both subclavian arteries are occluded attheir origins.

Transseptal Aortography and Carotid Stenting 419

by the development of a very flexible, long, 7.5 Frenchsheath and dilator which can track over the loop at the leftventricular apex and reach the proximal common carotidartery.With percutaneous carotid and cerebral interventions

being increasingly performed, this technique of transsep-tal approach to the carotids may find wider application.Besides situations of lack of access due to peripheralvascular disease, this technique could be useful in pa-tients with sharply angled innominate/left common ca-rotid artery take-off from the aorta, which makes selectivecannulation by the retrograde aortic approach difficult.The transseptal approach offers an antegrade aorticapproach with easier angles to negotiate.Complete familiarity with transseptal catheterization is

a prerequisite for this technique. Even in experiencedhands, morbidity cannot be entirely eliminated, whichwill limit use of this approach to specific situations suchas lack of vascular access. Even so, further developmentof this technique could result in it finding a niche in theinterventionist’s access armamentarium.

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