Managing Limb Ischemia with Occlusive Large Bore Sheaths
Utilizing an External Radial to Femoral Bypass Strategy
Hady Lichaa, MD, discusses an external radial to femoral bypass strategy described in his recently published case report titled “The ‘lend a hand’ external bypass technique: External radial to femoral bypass for antegrade perfusion of an ischemic limb with occlusive large bore sheath – A novel and favorable approach.” Dr. Lichaa is an interventional cardiologist with Ascension Saint Thomas Heart, in Murfreesboro and Nashville, Tennessee.
Dr. Lichaa discusses his interest in critical limb ischemia (CLI) and the potentially poor prognosis associated with amputation, especially in patients with cardiogenic shock, explaining, “It’s important to be proactive about the topic of CLI rather than reactive.”
Dr. Lichaa reviews schematics of approaches such as ipsilateral external femoral bypass, contralateral internal femoral bypass, and contralateral external femoral bypass. While each works well and has its pros and cons, he notes that “the radial to femoral bypass stands out from multiple standpoints.”
Dr. Lichaa emphasizes the mortality benefits of radial access in acute coronary syndrome (ACS) and describes patients with cardiogenic shock and ACS as “the sickest of the sick.” He then asks, “Why can’t we access those patients radially and give them that mortality benefit?” He explains the thought process behind his algorithm, concluding, “basically, necessity was the motivation for that thought process.”
Dr. Lichaa explains that the external radial to femoral bypass strategy is easy, fast, and simple in the majority of cases; however, there are situations in which he would not use this approach, ranging from patients with very small radial arteries to patients with cardiogenic shock who have secondary seizures from hypoperfusion in whom the integrity of the circuit may be in question even after securing the patient’s arm.
He describes practical strategies for maintaining the patency of the radial artery and conduit such as the use of topical nitroglycerin paste to avoid radial artery spasms and the importance of anticoagulation (PTT close to 80 and ACT close to 300 seconds), getting the tubing short, but not too short, and downsizing the antegrade sheath for better flow between the donor sheath and the receiver sheath.
Dr. Lichaa concludes that this technique would allow operators to be faster and more efficient and that he hopes that case series and randomized trials will demonstrate decreased morbidity and mortality “by adding all the advantages of radial access versus contralateral femoral access.” In closing, he states his belief that this technique is a “win-win” for operators and their teams as well as for patients.
- Alternative Access Sites for Large Bore Procedures with Dr. Raj Tayal
- Balancing Radial and Femoral Large Bore Access Cases: Advice for Fellows from Dr. Zaher Hakim
- SCAI Vascular Access and Closure Best Practices
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