Ep. 627 Radial Access for Peripheral Interventions: Techniques & Considerations with Dr. Shailendra Singh

Enjoy the podcast, but one more? Download our new BackTool app. You'll get early access to episodes, case discussions, and courses all in one place. Just search BackTool in the App Store or Google Play on your phone. This week on the BackTable podcast, and I will say I try to be very quick with radial to peripheral cases, because the longer you stay in there, the risk just increases, the pain increases, the spasm increases. I don't want to sit there for four hours trying to mitigate a case from radial to peripheral. I just don't think it's a good idea from my perspective and the patient's perspective. So I will take that extra step in pre-operative planning. Like I said, sometimes more imaging or a CTA, just to understand what we're getting into. And then we will have all our tools laid out. [Music] BackTable listeners thinking radial to peripheral or R2P. Tarummo interventional systems R2P portfolio brings longer length tools designed to help you build a repeatable workflow, from access to delivery to closure. Now with R2P glide wire advantage available in.018 and.035. With working lengths up to 500 centimeters in.018 and 450 centimeters in.035, to support long shaft device delivery when clinically appropriate. To explore R2P training opportunities, talk with your Tarummo representative or visit TarummoIS.com/education. Tarummo R2P, radial ready, peripheral proven. [Music] Hello everyone. We're very excited about the episode today, radial to peripheral. We have an expert with us, Dr. Shay Singh and my partner, Dr. Sam Saifo. We're going to be discussing ins and outs and a deep dive in radial to peripheral. Dr. Shay Singh, please let us know where you went to training and where you are right now, what are you enjoying doing? Yeah, thank you so much for the kind invitation to join you today. And as Hadi said, my name is Shay Singh. I'm an interventional cardiologist in Pennsylvania at Lehigh Valley Heart and Vascular, part of Jefferson Health. There I'm the associate director of interventional cardiology. My training was in New York. I was at Northwell Health, North Shore Long Island Jewish Medical Center, part of the Zucker Medical Center. I've been doing radial to peripheral interventions for the last six to seven years. And I'm very happy and excited to have a great discussion with you guys today. Excellent. You know, we were kind of chatting offline about how you started with that. Do you mind sharing your story quickly before we dive into the technical aspects? Yeah, absolutely. I finished training in intervention and peripheral in 2018. And so that was a time where we were doing pretty much everything for a coronary through the radial. Obviously, their times were a use femoral, but we were right in that juxtaposition where most interventions coronary related were radial. So we didn't have as much experience though in my center as doing a lot of radial to peripheral. But as we were talking earlier, one of the things we did often, and I did kind of right out of fellowship, is that I would do angiograms of the bilateral run offs or angiograms through the radial artery to understand more about the pathology anatomy of patients. Who had peripheral vascular disease. But after that, I really had an interest because I realized what the benefits of radial are as we know. And I was able to actually attend a course that Dr. Seifo here was the director of. So I actually came down to the hard hospital in Plano. And I got to actually live see his work radial to peripheral along with Dr. Potluri. I believe he was doing complex coronary intervention. So it was a nice on site hands on course. And that really gave me a lot of confidence to do this on my own. So then since that point, I've been doing radial to peripheral for almost seven years now. So Shay, first of all, thank you for joining us in our course in my apology if we thought you anything wrong. You're a very skilled interventionist. I think it's the point of the course is to give basic introduction. But for the audience, sometimes, you know, especially for someone who does a lot of femoral access for peripheral intervention. But you also, as you mentioned, adopted the radial for coronary. And I think that's your daily activity. How did the experience you collected using radial to coronary help you adopting to radial to peripheral? Yeah, absolutely. I think number one, I think as a very early interventionist, do you find that once you get around the subclave interbrechial septalic, your catheter sometimes just goes in the descending. And then at that tracks and you're trying to actually come back into the ascending to get angiography. But I realized how easy it was. And with more skills and understanding catheters and wires to getting to the abdominal aorta and more distally. Also, you understand some of the benefits from the patient perspective and the safety perspective. And as tools have been more innovative, we've been able to treat disease more efficiently. And thankfully, some of the industry partners have continued to look at how they can facilitate this. It's just kind of grown over the years to where now I'm pretty confident that when I look at a lesion and a subset and a patient with their demographics and things that I can be confident making a radial approach successful. I think it really requires some pre-procedural planning. But after doing so many interventions through the coronary, this has just made my confidence level higher to do these types of procedures. How long do I take you to feel really comfortable? I think that after you understand that one of the greatest parts is really getting the tools to do this. But once you have the sheath, I think that's kind of no pun intended. But that's the foundation and basis of operations. Once you understand that where your sheath is going to be for treating these blockages and getting it there, that really gave me the confidence to be able to fix these blockages. But I think after five to ten cases, you become really confident. You go through the algorithms, you start to see the things that can go wrong, things that can go right and really paying attention to those nuances. I think of front understanding how delicate the radial artery is, understanding good technique, ultrasound guidance, parameters and dimensions for the radial artery, size wise. And then really being generous with sedation, adequate sedation and cocktails. I'm frequently giving multiple cocktails to avoid radial artery spasm. That can be the arch nemesis of this case in the radial to peripheral world. So you mentioned something briefly that I think is extremely important because this is one of the highly debated topics among radial interventionists. You mentioned that as a radial interventions for the corner, you are commonly go to the descending order. But so I remember when I was starting learning to radial to peripheral, everybody I talked to, to tell me, oh, you just go left radial. That's kind of the history behind using the upper extremity to go to fix anything lower with the radial. Are you a right radialist, left radialist in if you are right radialist, how do you maneuver the arch to be able to get to the descending order, especially in like let's say type two or type three arch. Yeah, oh, this is great. I mean, I've gone back and forth through my experience, but I'm pretty much predominantly a right radial R2P user. That being said, and it's just the ease of what we're comfortable with. We do right real every day, many cases a day at a high volume center. My staff, my fellows, people are all experienced in that and we have the setup. But I'm very keen to look at these cases really specifically based on the patient factors like height, tortuosity, and where I'm targeting way before. So my preoperative planning for these cases, I would say is even more intense to know exactly what I'm getting into. Sometimes that just involves a duplex. Many times it involves a CTA. I'm not hesitant to do that to understand more so I can really play out how the strategy is going to be. That's helpful to the patient for less time on the table to my staff, the workflow, and knowing what type of devices I'm going to use. When I get into the right radial, one of the things I always do commonly is a user JR4. I'll use that with a normal wire will go up and then I use that and I lay it out in the LAO projection and I'm able to kind of cross over. Occasionally, I have had a lot of success with the PIGTAL catheter as well because then you can utilize that to maneuver and open it up with the wire into the descending portion. But I really have found over as I've evolved that doing things that you're comfortable with and do every day just continue to do those same steps which has been really helpful to me. The only times I will go left radial is when LENTH is extremely important to me because you do as you know about get 10 to 15 millimeters depending on the patient and the tortuosity. So if I know LENTH is going to be or there's something I really want to use that will be really close which is happening. many times, I will go left radial. I've also done it where we've turned everything around in the room and then I've done it where I do the arm over. We've been now kind of just doing pulling the left arm over using kind of a makeshift support device and that's what I do in, you know, getting Lima angiography anyway. So there you said that as well. Now for every case I do prep the femurals and for any occlusion that's more than just, you know, 10 or 15 millimeters, I'm also prepping the foot. And Dr. Singh, you mentioned ultrasound, you know, I'm, let's say, interventional cardiologist. I've been doing PCI's for a long time and I don't use ultrasound. Why is ultrasound so important for this type of work? Yeah, absolutely. I think that, you know, when you look at sheet size and the length of the sheath, it is very different than just putting in a short sheath with a guide. I think that's can't be understated. The major thing to understand about this is that once you put this long sheath in, it really does cause a lot of forces and spasm and different vasoactive problems to the vasculature. And just from that data, we know that any artery less than two millimeters is at risk for number one, having those issues. But two, you do see a lot, probably a higher rate of radial artery occlusion after I mean, we are a center that does is very keen on patent hemostasis after with TR bands and things like that. And something from my patients, I'm always very interested in their post radial anatomy, radial artery occlusion symptoms. So we monitor those closely. But I think really looking at ultrasound, I do 100% ultrasound in every case and I'm really looking for the size. And then just the variance that we see, you know, we see some of these accessory radials or really the branching and things like that. I'm very keen if there's anything out of the ordinary doing a small angiogram and looking at the where the radial arteries going, the bifurcation into the break, you'll all those things. It's a really nice way to also understand the ulnar. And so I'll look at the ulnar, look at where it's at and I'll kind of know I've done that and I've positioned myself to go to the ulnar in case that the radial was small but open. The only thing to watch out for is that making sure you get hemostasis at the end because as you know, there's really no bone there like the siloid for the radial. See if you'd be very careful. Yeah, I think I think what you mentioned here is important. The size, I think for the radial to coronary, we don't even look at it. We put a sheet in every size because we're now putting a long sheet. You just from a personal experience, we've done 400 radial to peripheral and we had two complications in one of them recently and that's when you forget the basics of what you just mentioned. Resistance, you stop, you take a picture. We didn't. And I think you learned from your mistake. You mentioned also the ulnar and I think this is something where the name may be confusing when people say radial to peripheral thinking that well, I'm not supposed to use ulnar. Someone would have called it ulnar to peripheral. Yeah, that's right. You mentioned also the pital prop. I go called the rolling isendrom. The last thing I want to do is see my, my self rolling their eye when I ask you for pital access. Let's talk about that for one second. I think extremely, extremely important. Pital access, what's your threshold of saying, hey, I want the pital access. Is that for you to put a sheet in or just for access for wiring and snaring and what's your protocol? Every case, CT only, what kind of CTOs? Yeah, yeah. So, and this is something, again, full disclosure that I've evolved to. It's not what I used to do, but now what I've come to the agreement of is I really enjoy using the pital in selective cases that we know are going to be long CTOs and you may be depending on the kind of anatomy and how the cap is, you just find that you have, you're more successful retrograde. And I find that it's become very algorithmic for me and in wire escalation with catheters. And so any CTO like that's longer than 30 millimeters, I have the foot prepped. But I do now have a timeline for kind of wire escalation and a grade, whether I'm up and over or even radial. And then when that timer goes off, I get pital access. I get pital access with a small needle. I'll put like a V18 before where I need to be and then I'll take a micro catheter my wire of choice. I don't put in a sheath unless I know I'm going to have to use this as a basis of operations. Sometimes I'll just put the micro puncture short inner dilator in momentarily to get kind of some firmness depending on how the foot is and where in the foot I am or PTAT versus on top of the foot or the DP. But I think the other thing to realize is that I've been really successful from wiring from below, connecting and then treating from above. And then I pretty much remove my gear from from the small artery in the tibial or the DP. Honestly also from a practical experience, you know, the right SFA occlusions, you know, in terms of laterality, the right SFA for us standing on the right is a little bit more painful than working and on a left SFA iPhone in practical experience that sometimes go in radial and pital taking pictures from above in hostile groin, morbid obesity, back issues for kind of recovery. It's very convenient, especially in a CLTI case where you can permit yourself to access pital and work from below. It is so convenient and so radiation friendly, don't you think? Absolutely. Yeah, I think that's another great point. How do you say that when you're doing some of these complex below the knee cases, I've kind of utilized, I'm utilizing the tibial and pitals much more. And although really trying to maintain good, safe habits, it's really nice to have that imaging and just to understand what's happening as you're going. If you do these primary peatles, you kind of start working and you're really not sure what's going on. While the steps are kind of going, you're doing your steps, but you're like, I wish I just had maybe a little spur of contrast at one second, you know. And so it really is nice for that. And we use that commonly, even for, I'll just kind of switch gears here, but like an Iliac CTO, I mean, having that base of operations from the radial coming in a grade for me is much better than coming up and over, especially in the common, because you have that base of operations, you can rescue the other side. You have many different opportunities that you really don't have when you come up and over, it's a lateral, when you go up into that segment, a lot of times you go sub-intimal. And I found that very youthful coming from the radial approach into the Iliac. I had a new also, this is kind of common, I love to hear you're in front of it. For someone who does a lot of CLTI, we access anywhere, we access legs, thigh, popliteal, direct access to FAA, old stand, but there are still people who resistant to a radial approach. And that's based on possible fears. I'm not sure if those fears are, are free that's really have been proven by any data, but also just because they have not done radial. I'm not talking about cardiologists work very comfortable doing radial, but other subspecialty also treat vascular. For both of you and now, here, shape hers and how do you, I would love to hear you put as well on in this one. What are the, if someone had adopt radial for peripheral? What are the cases that would you say, I recommend, those type of cases to start with the first 25 cases and you 100% confident that they become radial to prefer believers. What are the type of cases that someone should start with? Yeah, great question. Him. Well, so I like you guys are, we are a fellowship site. So we have an interventional fellowship and I'm faculty there. So, and we have a general fellowship. So one of the things, which I did and I think this is helpful is first just starting with doing really simply angiography from the radial approach to peripheral distal peripheral lesions. Even so we had a patient just the other week where we wanted to understand more about the tibial after the tp trunk kind of understanding that in the setting of a wound. So what we did was we took a catheter all the way down from the radial and we were able to understand it better. We decided to treat it, but I think one of the things that is really helpful is understanding that you can do angiography, understanding getting the catheters down into the distal aorta and then taking selective angiography on both limbs. Then I think you should start by understanding what is required to get the sheets that you need. As you know, the sheets for if we're talking about trumo sheets are two p which are excellent slender sheets. They come from 75 all the way to 149. And so understanding that you're going to now look at lesions that are approachable, that you have enough length, the tools that you need to take. But I personally starting out getting back to your question, Sam is I avoided CTOs that I knew were heavily calcified and long. Those are tough and a grade, I would say SFA. you know, that I would avoid those first, but anything that's moderate to severe but has a channel, I think now with the tools that we have, the length of wires, we have, at the rectumy devices, IVL that can sometimes get there depending on where you're talking about, and DCB and angioplasty options. This is a huge opportunity to treat more significant disease. I would say, the only other caveat which comes into play is the seismetrics, right? So if you're looking at a six-french radial sheath, you have to look at what options you have for stenting. What's really nice is that you now have stents like the VBX. If you're going to be able to put a covered stent, they can really be expanded larger, but I had a case where I didn't have the VBX in the Iliac, and it was like a 10 to 11 millimeter vessel that you still have a problem if you don't have the seismetrics. So that made me go Ipsilateral and place the stent from the Ipsilateral femoral with a larger sheath, a French, but I think those things being said, I would start with simple, simpler cases that don't require too much in terms of crossing and then kind of work your way up. A hundred percent agree, those are super helpful tips and one of the things that I look at also, one of the few times when I'm meeting a patient and I really look at their height in terms of, you know, someone taller than six feet, you can get a diagnostic no question, 150, you can get it on any of you everybody, but in terms of primary sheath, you don't want to have too tall of a patient, sometimes the arnspan is really really so I kind of take a look, I have a measuring tape in my lab code, sometimes if patients are borderline, and number two, what I started doing probably 20 cases into it, especially when I struggled in type three arches like Sam was talking, I literally opened up the imaging like 20 years ago in the system, tried to find a CT scan of the chest without contrast, even that helps you, if you see that terrible type three arch, obviously that makes you go left radio versus non-radial at all, you don't want to spend more than two minutes in the arch trying to get down, if you spend more time, obviously this is the time when things can go bad and an octogenarian with tons of calcium and plaque and now you have a stroke while you're intervening on a CLT, I thank goodness we haven't seen it in practice, but we take our precautions, but it is possible, those catheters can be aggressive, and Dr. Seifo wanted to ask you in your course when people ask you about some French compatible devices and the fact that six French is the ceiling, how do you educate them about backup plans, especially in the ILEA territory? Yeah, to build on what you mentioned, I usually recommend simple cases like what Shaeha mentioned, but also I think the cases that made me believe our patient with Evar, patient with Kissing Stent, where I really, especially if BMI is like 30, 35, 40, the last thing I want to do is touching their groin and those patients have usually in a multi-level disease, so their pitils are not great and honestly go ready, we can do everything. So seven French compatible, the nice thing about them, they're three companies who make cradle to peripheral sheet, they all have six French, the Troomus six French is actually 6.2 in reality, and I've actually was able to deliver seven French compatible devices through them without issue, like IBL, I've delivered L6, I've delivered M5 plus 8 millimeter VBX, I was able to deliver the 8 millimeter VBX with difficulties, but still I think when you get to a point what Shaeha has mentioned, if I have an 11 millimeter ILEA, I think that's just not the right thing to do to deliver much smaller stand and try to post that with 11 millimeter. The good thing is we just published an abstract actually and hopefully the people will come out from the room all about their Massago stand with published on TCT and it's looking at the larger size Massago, so we'll talk about up to 12 millimeter, remember those self-expanding stands, so they're good for this so commonly an external ILEA, but of course still also is a problem. If you definitely need seven French and I really, I still wonder what seven French I need at this point, but if you still need seven French you definitely didn't have to go groin. You mentioned something about what about, you know if something bad happened and I love that question, I really this my favorite question to be asked because I believe that going radial and having a complication of the ILEA from the radial is the safest thing to happen because what's it going to do? Enflate the balloon from the radial, give a nice tampon adding, have all the time in the world to stick groin seven French eight French, put Moire through, put a cover stand, deflate the balloon, deploy the stand. Let's say you're epsilon lateral and you have a perforation from the groin, it is extremely difficult to do the same thing. You're going to have to inflate the balloon, try to go up and over, you don't have a room to put you wire and you know the ILEA rupture in my opinion is the most stressful intervention, the complication you can have. People worry about corny perforation, I don't think they've seen an ILEA perforation. That's my approach, but I think there is, there is a debate there, you know the, the way I look at radial interventionists in three categories. One is the radius, 200%, I think that's me, but I don't expect people to do so. I think she's the same thing, you're the same thing, if in cases that's not CLTI. Two is people who do it in most of the cases, but selectively they say this is, I don't have the equipment. And third, I think elective or selective radialists, and I think those are the ones that's very helpful. I stopped doing occluded common iliac via groin long time ago, it's just much easier from the radial. Where were you guys? What was your first ever radial case that you looked at and you're like, man, I wish I learned this before. Yeah, so for me actually saying this is really good, and you know, just understanding, I got the question for my fellows as well as, you know, what was the genesis for going radial? It seems like a lot, you know, you're over here and then you're fixing something down here, laying, especially coronary fellows. And for me, actually my first case, which I'll never forget, was a case that actually was the only way to, I thought that I could actually help this patient. She had eight procedures, multiple coronary interventions through the groin, morbid obesity, and anagrate attempt prior with a severe hemorrhage. So mentally she was scarred from that experience, and she was really didn't want her femurals to be touched if possible. She came in with breast pain. It was a distal SFA P1 segment occlusion. I was one vessel runoff. So I typically in those cases, I reserve actually getting into that space only if I have to. And so with bilateral Iliac kissing stance done about eight years ago. So it was up and over was not going to be desired. And really to be a pito, we talk about the other alternative access sites, which I'm sure both of you do quite well. I don't have that down in terms of like just sticking the popliteal and being really confident that we're going to get great hemostasis. And so at that time I was definitely not doing those kind of cases. So I decided on the table, we're going radial. And we were successful. We went left radial. We were able to fix the blockage. This was a time where we didn't have DCBs. So we did angioplasty. We did plaque modification. We got a nice result. She left the same day. But what I didn't realize was how amazing she felt with the experience. She said, you know, I've had over eight procedures. This was something that I could leave in two to three hours. And she never stopped complimenting us on that. And then I finally triggered a whole other thing is understanding that the faster ambulation, potentially obviously safer from a bleeding perspective, three patients satisfaction and turnaround time played a huge role. While that was a huge undertaking for our lab to understand, okay, now we're going to take something from the left radial all the way down to the right SFA. I'm going to be successful in crossing the CTO and then fixing this. That was a whole other thing. But I think, you know, when reflecting on the first cases, you realize that this is feasible. It's something that really is beneficial. And the staff plays a huge role in understanding that now patients can really benefit from something much safer. So I think as you were saying, it's something that kind of happened fortuitously, but has really improved kind of our workflow and treatment algorithm for some of these patients. And she, like you said, this is a huge benefit from a workflow. Spent one of this kind of stands out now that ASEs and OBLs are sizeable portion of where these procedures are done. So that's a massive plus from that standpoint. Now I wanted to ask you about like the difficulties that you had from access all the way down. If we can walk through that, the first one is obviously spasm. So you're advancing the sheath, you have spasm, what do you do? Yeah, so great question. In terms of spasm, the key is upfront, I believe, really good sedation. So as soon as I walk in the room, we get a blood pressure, the patients prepped or getting prepped, I already, if they're able, I give them generous sedation. And then I have the artery. I actually give much more local anesthetic than I would in the in the coronary cases. I give more generous, even a little bit more proximal in the arm. I find, and I don't know if that's more just for my sake, but I try to numb up that whole area. I'm really advancing the first short sheath and getting a feel for getting into the space, into the descending, to see how this patient's can act. If I already have some spasm or I'm a little concerned, I then pretty much stop. I give more sedation and then I reintroduce cocktails. Yeah, so I'm usually giving cartine in our lab, two to four hundred milligrams. I give nitroglycerin, two to four hundred, as well as heparin. Sometimes we also will have verapimil. So depending on kind of the hemodynamics, what's going on, I'm very generous with giving repeat doses of that within the radial artery. And every time there's an exchange or there's a time, I'm always flushing the sheath so that there's no, I don't think any thrombus or anything else developing within that. I do hydrate these patients so they're getting fluids as well throughout this. But I'm always assessing comfortability because once I know they're waking up and they're starting to feel things more, that's again where things can go sour. So I'm really having my nursing and my staff just understanding that. And if there is like, oh, you know, the patient's really getting a little awake and feeling things, I give another round of sedation. So I think those are all really key because the major thing from my perspective is once I get and I target a zone where my sheath is going to be for the intervention, I want to lock it into place as the base of operations and I don't move it. I don't advance it. I don't pull it back. That's where it's going to be and I pretty much lock it into place. So tell us about your experience, especially also the catheters that you use going down the descending and type two arches. Yeah, I think she mentioned that I'm a big fan of GR4, 5 french 125, dexerity. It has a nice curve to it. Many, many of the operators that I also use and I am multi, multi hole I am 5 french 125. Some like vert. I'm not a big fan of the vert. Just hard to get up and over. All those kind of type two type three, but it's nice for taking picture because when you get to the iliac, it's not against the wall. But I think the secret sauce is what shea mentioned before it's the pigtail. I mean, 5 french pigtail does magic and because of what you flip it and you can use a, you know, I don't use the glide wire and like as my first wire, I just use a J wire and it works commonly more than 85% of the time. For those really complex cases, glide, soft glide works really nicely. The radial, like an edit technology, you should not do your first case as the most complicated case. Then you're not going to be a believer. You know, you can't do your first limb flow in a case that patient had, I don't know, multiple intervention and things like that. You can't do your first detour. And someone had a multiple bypasses. You can't do your first biobstual scaffold and someone who had multiple intervention. Just have to select your patients. The first few cases, just going to get the sense of it. The other thing that I think important, I think shea mentioned really briefly, but I want to ask both of you of the importance of teaching and training staff and ending new technology on Ask Shea from specific about Rado to Perfor and how do you or you've been pioneering so many things that's new. How do you get your staff to have a buy-in and believing in it? So start with Shea and then know maybe bounce do how do you have to work? Yeah, great question, Sam. For us, what was really important is educating the staff and having that very open dialogue. We do have education every Tuesday morning with the staff. So they had various topics. And so what we did for one of those discussion points is what is the interest in doing Rado to Perfor and why we do this. Talking about the same things we're talking about today. So from a patient perspective, from a workflow, from safety, all of those things, but also understanding that it's something that we do every day in the coronary space. And as interventional cardiologists, we're very experienced at that. So it's an extension of that. But we want to utilize some of those benefits to fix and help patients in the periphery. We went over different the ergonomics of the room and how we're going to set them up. We realized that, you know, just like anything else, what you're used to, you're best at. And so that's probably why I do a lot more right-radial if possible, because it's just in our workflow. We have tried doing left-radial and really flipping the room. It is feasible. It does change how kind of you're standing and the wire manipulation. I wish I could say I'm as good in that way, but it's going to take some more work to really do that in the reverse order. What we do do in a lot of cases that we do left-radial anyway is we're able to pull the arm over and we do left-radial access. Well, the staff, I think, has really grown to appreciate that what the benefits are and that I think the other thing, Sam, like I mentioned before, is I'm really up front about getting, for knowing what we're getting into before the case starts. So I have a game plan and I before the case we go over everything. I say, you know, what we've known is that this is an SFA blockage. We're looking to do such and such modification and this is kind of the plan in the stepwise approach. Obviously, that's not always 100% what's going to happen, but I really have an algorithm before I step foot in these cases because I find that workflows incredibly important. And I will say I try to be very quick with radial to peripheral cases because the longer you stay in there, the risk just increases, the pain increases, the spasm increases. So I do will take that extra step in pre-operative planning. Like I said, sometimes more imaging or a CTA just to understand what we're getting into. And then we will have all our tools laid out earlier in my experience. I did have a few cases where we weren't able to treat the way I wanted to treat either due to length, lack of tools. You know, it just wasn't the reach wasn't there. I didn't have the support. I never want to be in that situation again because then you really have to pivot, start all over and that's a real tough mindset to be in in the middle of a tough case. So I take that time up front and I think the staff really appreciates knowing the workflow being involved and engaged and I think that's helped our lab a lot. Shay, it's scary how similar our practices are. It's just exactly the same. You know, what you said, I mean, that doesn't take that long. It's not a 15 minute meeting. This is a two minute huddle right before the case and the empowerment asking the staff, Sam, you were asking me how we get them involved. Just ask them their opinion. You know, what do you think? Is that going to be easier? Is this going to be faster? More efficient. Of course, sometimes faster is not the answer, especially if we have problems with groins and patients who want to sit up quickly. So we take that into account. What do you think about this patient who's going to complain about back pain and be a very difficult, etc. So empowerment of the staff and the huddle before the case and asking for other ideas sometimes. I honestly was impressed that my staff had other suggestions like, you know what? That's even a better approach. Let's do that. And I take it and run with it. It's very, very helpful. That is definitely somewhere. And the other thing is obviously having them be part of the decision making, especially in conferences and all that like you mentioned. Yeah, that was kind of my experience. And if things don't work, you can always adjust. Correct. Yeah, we have a personal approach. You'll be surprising how, especially I think for physicians who newly graduate, we mean one thing that we do not would we have plenty of is egos. You know, I think when you come out with the way in five, six hundred PCI, I got to know so many peripheral structural you are at the top of the world, but you have a tech or a nurse who's been in practice for 25 years, who's done five times, 10 times, maybe 100 times more than you've done. And I think they're opinion and absolutely matter matter. Shay, your structural is as well. You do structural work, correct? Yeah, I do a tavre as well. Yeah. Are there any role for real to proffel in the structural world? Oh, I love it. Yeah, Sam, this is actually what Another really nice benefit is when you have, and this actually happened recently, and you'll see this not, hopefully not too often, but you have a patient who had a recent femoral procedure, likely large borer, even hemodynamic support, where there's an issue, whether it's bleeding, whether it's a decreased flow, clotication after the procedure, a plug that plugged the whole tube good. So we see that quite a bit, and so radial to peripherals, a great technique, to get those treated well. I've used it, so I'll say, one is post large borer axis for a valvular cases, where there's been a growing issue, and great technique, because especially if the groin's been accessed within the, like last week or two, I really don't wanna stick that same groin, especially if there's echamosis, hematoma, a lot of different things in that, in that, and really not knowing kind of what's been going on, you don't wanna stick that side. Some of these cases, if you're using bilateral groins, such as trans catheter valves, both of them have been stuck. Sometimes with a plug that you really don't wanna hit, then you're going above or below. So the radial, really R2P in those cases is excellent. Another strategy I've used in patients that are larger, severe obesity that have, for instance, an impella catheter. So if you wanna employ dry closure, I do that all the time, where we will place the, take the impella out, and I'll have a dry closure technique from balloon from the radial, and then I'll be able to inflate the balloon, make sure we have time to really fix the groin, especially in shock, where you don't have pre-close or pre-close already deployed. It's a nice access point where you don't have to, again, hit another femoral artery, and then deal with closing that femoral artery. So it's another technique, but I've been using radial to peripheral, in those cases, many times. And I think that's a nice utilization for what we do. - So I'd love to pick your brain on equipment, technical stuff. We have probably 15 more minutes at left. So what should people have on their shelf from a micro-catheter length standpoint, length, a wire length, and obviously balloons stance? And we know that thrombectomy and atherectomy is a little impediment, but I'm sure Sam can give us his long experience with laser and CSI, et cetera. - Yeah, absolutely. I mean, I think just before I talked about what you should have, one of the limitations that I've been pretty vocal about is imaging. I think anything proximal SFA and below from the radial approach is very tough to do intravascular imaging OCT. We still don't have that in which I'd really love 'cause I do image everything I can, especially in the coronary and the periphery if possible. So imaging still is a problem, but we do now have wires that are 400 length. There are, obviously we used to use the Vipro wire a lot because that was a long wire. And even if we didn't do CSI, we would use it if we had to do especially monorail things. But now we have a lot of options in the RX. So there's balloons, there's Stenst, there's DCB. You can do IVL into 150 shaft. There are some specialty balloons, cutting balloon technology that goes to 150. You do have the ability to do laser threctomy as well as orbital atherectomy on these longer segments. But I think 400 a millimeter length wire is very helpful as well as having the longer shaft balloons and DCBs. And obviously the R2P sheath goes from the 75 centimeter to all the way up to 149 centimeter length. And then from there you're able to use those to kind of rail your equipment. But I think the game changer has been the addition of balloons and DCBs on longer shaft. And I'm sure there's more to come, but I think DCB on a longer shaft was very helpful. - Sam, from your experience between laser atherectomy and orbital atherectomy which are available in 200 centimeter shafts, do you feel like there's any other lesion subsets you cannot do from the radio? - I think the one subset that are two subsets that I would say away from an radio is thrombus. Even with a laser atherectomy I think we're more comfortable doing thrombectomy. The largest laser we have is 1.5 Excel from Ariane. Yes, it's indicated for thrombus, but like I did a recent, yes last week actually an L-VAD patient, previous PT stand that thrombose, I was very comfortable putting a laser there, deliver energy ballooned, it looked great. But if I'm having a fempa bypass occlusion with thrombus, if I'm having a stuff like that, I'll be out say away from that. The second thing when you wanna use an abyobso will scaffold below the knee, that's you definitely need either into great axis or up and over or pedal just because of the shaft length. The laser atherectomy really made a significant improvement of what things we can do. I used to not liking to treat instant arrestinosis to be a radial for two reason. One, I didn't have any true atherectomy, I can use a CSI or a bit of atherectomy. The laser changed that because that's one of the indication. And to the DCB, so recently we didn't have any DCB that's 200 shaft and metronic came with their over the wire 200, three years ago and now we have a ranger from Boston, which is a rapid exchange. Things are changing. I think the challenge is that each company working separately, they're not communicating. They're like, you get a company who does the atherectomy but they don't do the micro-cather. Then the company does the micro-cather but they don't make the wire. And when they make the wire, they don't ask people what characteristic of the wire we have. So right now we have glide wire that's 400, that's O35. We have the F18, O18. There's a company in the metronic, bought recently, so it's a metronic now. There's an O18 and you have the Viper, the most favorite, my favorite wire of all time, actually I don't like it at all, of joke. But it's a 475, my staff always joke, they're gonna work on the other room. But I think in general, again, do you have to do complex, complex cases? But a case wouldn't have an L-vad on inter-cregulation with an IonR of 3.1 that needs it. I've them below the knee cases with laser and blue and an adjuoplasty. Things like that, absolutely it's not for all cases. But honestly, PIDL is not for all cases. And groin is not for all cases. You definitely need to be selective. - Yeah, so as Sam was saying, actually, we do have a micro catheter through, with Tarummo, they have the NaviCross 200, which is a nice utilization of that. I've used that quite a bit. I like the NaviCross subsets, which I use, they have the different platforms. So I use that. And now I do have the F14 and F18 wires that are longer through Metronik, through the Japanese company. So there are some options, but the micro catheter now being at 200 is really helpful for those in the SFA, public teal lesions that are still tortuous and tough to navigate. It also gives you the ability to, as you know, take some pictures and reset, take a different wire change. If you need to do athrectomy, as we said, I used to use the Viper wire for everything. That's always kind of not a great wire to work over if you're not doing orbit or athrectomy, but that's obvious. But I think now with these wires, you're able to use a lot and remember some of the things that you need. The other thing to remember is that, depending on what you're using, it utilizes a different size. So for instance, Shockwave, 014, if you wanted to IVE as something proximal, and you had 014, 018, then you have to understand your size metrics and to the devices and things you're using. And so sometimes it's nice to have the micro catheter be able to exchange out and then know what you're getting into and then base your wire based on that so that you're not switching your wires out a lot just for the purposes of getting two different devices. So, Shay, you mentioned the utilization of radial to peripheral and I think the impella is a great, great example. And I think it's important why, you know, to match cardio, it should know basic peripheral because cases like impella and taver. I'm actually, I know you're the guest, but I'm gonna ask Hadi a question. - Yeah, yeah. - I know he does some, you know, some complex visceral and renalz. Are you a radial to mesenteric renalz or are you-- - 100%. - So what would that, well, do you think we have the equipment to do it? I'm the answer from Easy As, but for the audience, we ask you, do we have that equipment to do mesenteric and renalz for your radial? - Like he said, the companies don't talk to each other and that's not gonna happen, but because of that, we have to put things together from different companies. So I found out very early and of course, all of us know the angle of takeoff of those vests was so favorable from a radial standpoint. about the issue that you run into is the fact that you're going to be able to see the benefits of the situation. that most of the stents are 150 or 135 cm shaft. So you're barely exiting the guide or the sheath, and that's a problem because if you have a toey, whatever you use, that's an extra 7 cm. So what I learned early on out of Tal and Eder is to remove the toey and place the cook valve. It literally saves you 7 cm. And then most of those are osteol lesions. So when you exit the guide, you're literally right there, so you don't need any length. So you don't run in the mesenteric and renal space. You don't run into length issues as long as you solve that issue. And I've been very impressed with the Tarumo sling guide, which is not very much used. The 7-French sling guide sheathless that allows you to really use a lot of equipment over it. What's your experience, Jay? Yeah, I think that we've approached plenty of renal through the radial. I think that's been an approach. I did start the renal denervation program at Lehigh Valley as well. So we've been doing that. And I always think about, you know, while that's a femoral procedure currently, there needs to be radial procedure for the renal because that actually will be a game changer as well for these patients. But yeah, I think that it's definitely favorable. And I think you had just, like you said, the watch out is having enough length and really being able to navigate some of the erratic tortuosity just like you would anyway. I think the major other thing is understanding what size sheath you would need based on what where you're going to troubleshoot in the target lesion because if you take too long of a sheath, then you're going to either go past it or be outside the hand. And then, so really getting kind of really a great visual. And sometimes what I'll do is I'll take that smaller micro catheter wire and actually judge the distance based on that. And then I'll take the sheath, the longer sheath based on that. I do that actually in the periphery too. What I'll do is I'll put the short sheath, take like the JR4 or the pig tail, and then I'll take that 150 or 200 centimeter micro catheter and kind of judge. I'll do a little test. And then I'll see where I'm at with distance just because some of these older patients in the tortuosity, you lose length more than you would know. So I judge those distances before really going in with the sheath of choice. And do you use any guides 125 centimeter coronary guides for some of those interventions? Yeah, occasionally. And what is available in your experience and what do you have on the shelf? Yeah, so we have some of the sheathless guides. I haven't used a lot of them because I've been able to do a lot just from the R2P sheets. But I think that, you know, if that is something you're going to do a lot of, we actually don't in the coronary lab. We end up most of our mesenterics and things like that are done by interventional radiology at our practice. So they're doing a majority of those. So I believe they do have all the flavors of the sheathless guides. But we don't carry all of them in the coronary lab. Sam, do you use the 125? Yeah, no, I have the 110 JR4 guide. And I think most of the time it's reached nicely. In the cases that they didn't reach, I actually used the 85 R2P, which straightened the arch or I can go left radio and that's where I get the call. Then centimeter. A car you write someone has told me it actually works very nicely for mesenteric. I've never used I have it, but I've never used it. I don't think a short person. Yeah, for sure. And it sure. Exactly. Exactly, which not very common where I live. Everybody's very tall. I think, you know, I don't have any of the 120 guide. We use it, you know, we use it for diagnostic. The other option I've used before is using a 105 radio to peripheral. I put my JR4 diagnostic or avert and use it as selective pictures. Then put a wire. The wire will straighten the cathode towards the OSTM. Just a little bit difficult in that scenario. And I think that's where I think we still missing some of the equipment. And based on that, I'm going to ask Shay, I'm going to ask Hadi, part of you guys. You have Santa wish list. You have two products that if you say today, the company is going to just within a month and going to make it happen. What are the two products that you're looking to have in radio to peripheral that we don't have today? Shay, what's that with you? Okay. I think since, you know, kind of, we were discussing earlier some of the distal disease in the SFA, pop, platyl, and below, having the ability to image those patients from the radio. So for me, imaging is a huge part of what I do. I think an imaging catheter that gets down there would be great. The other thing is is having an IVL option more than 150. We know that, you know, it's very obvious what IVL has done for our practice in the periphery and the coronary. I think that that would be another really nice option for us. So for me, it would be a longer IVL and a longer imaging catheter. For me, obviously adding to what you just said from back to me, options six French compatible. You'll be surprised how much you can get done with six French from an arterial side. Of course, Venus is completely different animal, but just the 200 cm shaft that's all we're asking for. Just make it longer for simple minded physicians like us. I just don't understand why they don't do it. But say we're getting close to an hour now. I wanted to ask you, so you've done your intervention. Now you're going to pull the sheet out. Walk us through the specific things that you make sure you're doing. Absolutely. I think this is just as important. So going over this is key. Number one, understanding that depending on time and what you've done and how many things, number one is always making sure your sheet is flushed and there's no thrombus or clot in there or debris. So I'm always kind of retracting that, making sure it's flush. I do keep an ACT over 250 for these cases as well. And I do a ven reset and we do put the dilator back into the sheath. I put the dilator fully back into the sheath with a really stable wire. Whether, you know, for me, sometimes we use the advantage glide wire. I like the super core. There's other options. Obviously, as you know, that are more stable. The other thing is is walking that back and always watching because sometimes the sheath can actually come unarticulated. It can actually start to lengthen on you. So you have to be really careful about going around these tortuous anatomies. So it's slow and steady watching. I still floro most of the time, unless it's, you know, really coming out easy. And I started what we would do just because there's a lot going on almost two people need to be involved. I used to take it out and put it like the short sheet back in just so that everything my base of operations and then we could put the band on and all this stuff. Now we've done plenty of cases where we don't do that, but I don't think it's unreasonable. The other thing I noticed early on, I used to just prophylactically have two bands on just to make sure we have control definitely putting the dilator watching it, putting a supportive wire really nice retraction. If there's pain, stop, reassess using continuing sedation until really everything's out. Those are very important tips. The whole purpose of radial axis is to minimize access at complication. And if we don't pay attention to this, it can end up being a disaster. And just one thing for the audience, if you want to I personally still replace with the short sheet just because I need to go to something else where my staff can take care of the sheet, put the orders and stuff like that. You have to make sure you have an O1A wire, not the O3-5. So we use the dilator, stiff wire all the way to the arm. Whenever we get to the arm, you know, axially artery, we swipe it with the O1A and then we switch to a short sheet. And this way you can have that short sheet there and the staff can you could have cocktail if you want to or just take it out and put the band. Yeah, I'm sorry. So for just to kind of conclude, I'm an interventionist who've been doing profile vascular for quite a while. Now I'm going to pick like what Sam asked you at the beginning case selection. So walk us through the cases that you're going to pick for the first 20, 25 cases from a patient selection, anatomy selection and CTO versus not. Yeah, so I think one of the things as we know, the benefits are decreased bleeding risk, femoral complications bleeding from that site. So patients that have had multiple femoral problems, prior growing complications who are anti-quagulated, who have severe back pain, you already get an indication of some of these patients, you know, the peripheral population is a, is a comorbid population most of the time. And they've gone through some of these procedures, especially some of the patients who are say, am I going to have to stay flat for six hours or the other patients that which we didn't mention is patients that I'm not going to be really happy putting a plug or closing with per close. Or I think that that would not be a really good way to close or they would definitely need a manual compression and manual compression. would be very difficult depending on their anatomy. I'm also thinking about radial in those cases. First 25 cases personally, I wouldn't attack long calcified CTOs. I think that depending on obviously where you're at in your practice, I think that's something you can build up to and I have, but I think those cases are reserved. I think another strategy for those cases is a combo where you do radial and pietal. That's actually a really elegant way to fix some of these CTOs that are long. The other opportunity we already alluded on is the Iliac population. An Iliac CTO, like Sam said, is one of the best ways is from a radial approach. I think they anagrade you kind of find the channel. You find that you're actually able to fix these very nicely. So those are really nice cases which I didn't think would be really approachable from the radial approach, but actually can be done very nicely and safely through the radial approach. And of course, your lesions that have a channel that won't take CTO, but anything C-top maybe three or four again is non favorable from the cap. You know, it's going to be long. You may have to do some sort of card or reverse card. I think in the beginning is probably not ideal. But those are kind of the things I look out for. Sam, tell us about obviously, one of the things we also want to make sure the audience is aware of is how can they get to your course, Sam, unless also Dr. Singh has another course. But how do they get through that? Is it through the company? And I'm sure there are a lot of people who are interested about that. Yeah. I mean, so the way I look at some of the technologies completely different, though, what I recommend, the way I do it, I just go all in. And I learn by, you know, because if someone tell you this cat it works for every single case, and my first five cases that's all come or it doesn't work, they mean they're not truthful. But I don't think there's a right way when you're learning new technology. What Shay has mentioned, I think, is very important. If you are not going to invest in radial to peripheral equipment and you want to just get the sheet, then you're limited to do LA comment femoral and maybe very proximal SFA and nothing complicated. You know, you can do coming up like a conclusion with all the equipment you have on the shelf right now. The only thing you need is the sheet. If you want to commit it to the radial to peripheral, there are three companies who make straight-up to peripheral equipment, different, you know, they'll have sheet, some have wires, microgatherers, balloons, things like that. So it's important to kind of make a list of how you and approach a radial to peripheral. Shay mentioned briefly, I think, very nice way to look at them from wire to catheter, et cetera. And then go from there. I think it's important to build your cases. If you are not comfortable doing radial access, I think so would 10 diagnostic. Even if you are an interventional cardiologist who does real to coronary every single day, I also recommend the first 10 cases. It's to be diagnostic. You build a type A legion, simple SFA, simple Iliac. You finish 25 cases, then you start challenging yourself. Regarding the conference, the conference has picked the steam really recently because the appetite for interventional cardiologists to learn peripheral. I think it's important now as part of the job requirement. And if you are very experienced doing radial for coronary, you really, really quickly can pick it up. We have it at least quarterly, the way they can reach out to us directly to me directly or through any of the companies we work with. They support this. And definitely we love to have anybody who is interested in doing it. And even if reaching out offline, asking questions, happy to reach out any time. This is a field that's, I think, we are right now in the radial to peripheral where we were in radial to coronary 15 years ago. So it's exciting, challenging. You've seen it, Chad, and on the conference work together with someone bring radial to peripheral, people like you guys are crazy. Oh, not doing this. Yeah. It's very exciting. I'm happy to be the crazy one who bring it along your size, guys. So happy to have a group of crazy people together. But I will actually just interject. And I want to say the course that I went to was Sam's course. And it was excellent. It gave me the confidence to take it to that next step because you want to be-- I think you need to-- I'm a visual learner. And if I was there with a hands-on fashion, and I saw really good results and the ability to do it, it gives you that confidence. So thank you, Sam. And for having that course, and I think it's a fantastic course. So I would really recommend it as well. Say, just final comments. First of all, really, thank you for your time. It's a Sunday today. So we're taking the time from your family. So this is really very helpful. We're looking forward for future episodes. But final comments, especially for people who are considering this and transitioning to that. Yeah, absolutely. Thank you so much for having me and the kind invitation. But I think as we've kind of outlined in essence, the importance is understanding that this is another way to treat patients. It's another thing to have in your bag because a lot of patients are going to have subsets, anatomy, concern, safety issues. This gives you the opportunity to help them, I think, in a safer manner that as a interventional cardiologist you're used to in the radial. And you will find by kind of doing things in a stepwise approach that this is going to continue to evolve with industry helping us deliver those tools to us, where we can fix more patients and help them through the radial artery with safer outcomes, faster ambulation, getting them home quicker, with a lot more success and a better experience. So I think this was a fantastic discussion. And thank you so much, Heidi and Sam, for the great discussion. And I'm looking forward to more in the future. [MUSIC PLAYING] Thank you so much for joining us on Backtable Cariology. If you have not already, be sure to follow and subscribe. Rate the show five stars and share with a friend. If you have any questions or comments, direct messages at underscore Backtable Cargs on Instagram, LinkedIn, X, TikTok, Blue Sky, or YouTube. Backtable is hosted by Hadi Lisha and Sammy Saifel. 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