1. 经桡肾动脉支架术 Transradial Approach in Renal Stenting Jianfang Luo 罗建方 Guangdong General Hospital

2. Renovascular Disease Sites and Characteristics Atherosclerotic Atherosclerotic Ostial in nature Ostial in nature Usually extends into the aorta Usually extends into the aorta >90% of renal stenoses >90% of renal stenoses Often Bilateral in patients >50 years Often Bilateral in patients >50 years Fibromusclar dysplasia (FMD) Fibromusclar dysplasia (FMD) Series of arterial webs Series of arterial webs More common in females More common in females Atherosclerotic Fibromusclar dysplasia

3. Prevalence Prog Cardiovasc Dis 2009;52:184-195

4. Clinical presentation Hypertension Renal dysfunction Cardiac disorder syndromes

5. Traditional intervention of renal artery stenosis Transfemoral intervention (TFI) Guiding catheter: 6/7/8F (RDC, JR) Guiding wire: 0.014 /0.018” Stent: 5,6,7/15-24mm

6. Limitations of TFI

8. Transradial intervention (TRI) may be an alternative approach

9. Why TRI - renal artery stenting ? Anatomy Anatomy Avoid difficulties of TFI Avoid difficulties of TFI Most common course of renal artery points downward Most common course of renal artery points downward Renal artery diameter : 4~7 mm allows for low profile devices Renal artery diameter : 4~7 mm allows for low profile devices A= 75°B= 85° Device 6F long guiding catheter / wire / balloon 6F GD compatible stent systems

10. A long Guiding Catheter

11. 6F 125cm guiding catheter compatible stent systems Stent Shaft (L) GW 6F Guiding Stent (L) (cm) (inch) (mm) (mm) Palmaze Blue 142 0.014 5,6 12,15,18,24 Hippocampus 145 0.014 4~7 10,15,20,24 Express SD 150 0.018 4~6 15,18

12. TRI via right radial artery TRI via left radial artery

13. Indications Steeply down-going renal arteries Steeply down-going renal arteries Avoid manipulation within an infra-renal AAA Avoid manipulation within an infra-renal AAA Patients without femoral access Patients without femoral access Aortic or iliac occlusion Aortic or iliac occlusion By the way on TRI-PCI By the way on TRI-PCI

14. Limitations Distance: Radial to renal artery Distance: Radial to renal artery May be prohibitive in tall patients （ >175cm) May be prohibitive in tall patients （ >175cm) Subclavian tortuosity / Type Ⅲ aortic arch Subclavian tortuosity / Type Ⅲ aortic arch Not prohibitive in most, but can make guiding manipulation challenging Not prohibitive in most, but can make guiding manipulation challenging Access issues Access issues Failure to gain access higher with radial artery Failure to gain access higher with radial artery

15. Type of aortic arch ⅡⅠⅢ

16. Stiffness of stent catheter shaft HippocampusExpress SDPalmaze Blue ˃ ˃

17. Case 1 M, 64Y, Complaints " Shortness of breath after repeated activity for 3 yrs " M, 64Y, Complaints " Shortness of breath after repeated activity for 3 yrs " Hypertension, DM Hypertension, DM CREA of admission : 130 umol/l CREA of admission : 130 umol/l

18. 6F JR4.06F JR4 Pre-dilatation stent not cross lesion! TFI - renal stenting

19. Stenting TRI - 6F 125cm MPA1 TRI - renal stenting

20. Final result TRI - renal stenting

21. Case 2 M, 67Y, Complaints " Lower extremity pain after activity for 7 yrs " M, 67Y, Complaints " Lower extremity pain after activity for 7 yrs " Hypertension, DM Hypertension, DM CREA in admission : 254 umol/l CREA in admission : 254 umol/l

22. TRI - 5F MPATRI - 6F 125cm MPA1 TRI - renal stenting

23. Final result TRI - renal stenting

24. Conclusion TRI has obvious advantages in patients with difficult TFI and caudally angulated renal arteries TRI has obvious advantages in patients with difficult TFI and caudally angulated renal arteries TRI for renal stenting might represent a valuable approach to reduce complications and improve patient’s comfort comparing with TFI TRI for renal stenting might represent a valuable approach to reduce complications and improve patient’s comfort comparing with TFI Appropriate patients’ and compatible devices’ selection are needed when consider to apply TRI for renal stenting Appropriate patients’ and compatible devices’ selection are needed when consider to apply TRI for renal stenting

25. Thank you !