Clinical outcomes of endovascular therapy for aortoiliac artery chronic total occlusion via the transradial approach

Background: Endovascular therapy (EVT) for the aortoiliac (AI) artery using the transradial approach (TRA) has become increasingly common with the availability of radial-specific devices. However, the feasibility of treating AI chronic total occlusion (CTO) via the TRA remains unclear. Methods: This was a single-center, retrospective study. From October 2019 to November 2024, among 105 cases of AI CTO treated with EVT, 46 procedures performed via the TRA were analyzed. The primary endpoint was clinical success. The secondary endpoints were 12-month freedom from clinically driven target lesion revascularization (CD-TLR), successful antegrade guidewire passage, procedure time, need for femoral sheath insertion, and procedural or perioperative complications. Results: The mean age was 74.4 ± 9.2 years. Mean lesion length was 121.9 ± 44.1 mm, and 80.4% were classified as Trans-Atlantic Inter-Society Consensus II type C/D. The left radial approach was used in 91.3% of cases. Stent implantation was successful in all patients. Bare nitinol stents were used in 78.3% and covered stents in 21.7%. Intravascular ultrasound was used in 97.8% of procedures. The TRA alone was performed in 34.8%, the TRA with sheathless femoral access in 13.0%, and femoral sheath insertion in 52.2%. The 12-month rate of freedom from CD-TLR was 94.7%. Mean procedure time was 97.2 ± 52.3 minutes. Successful antegrade guidewire passage was achieved in 56.5%. Procedural and perioperative complications each occurred in 6.6%. No cases of radial artery occlusion, cerebral infarction, or blue toe syndrome were observed. In the multivariable analysis, common-to-external iliac artery CTO (adjusted odds ratio 0.09, 95% confidence interval 0.02–0.53, p = 0.008) and common femoral artery involvement (adjusted odds ratio 0.05, 95% confidence interval 0.006–0.39, p = 0.005) were independently associated with unsuccessful antegrade guidewire passage. Conclusion: EVT for AI CTO via the TRA is feasible and achieves high procedural success; however, many cases required an additional bidirectional approach using the transfemoral route.