Novel Small-Bore Preshaped Guiding Sheath for Transradial Anterior Circulation Interventions: A New Device and Technique

Abstract

BACKGROUND AND IMPORTANCE:

The transradial approach is increasingly used for neurointerventions; nevertheless, a large-bore system can lead to access site complications. To reduce these risks, we developed a novel radial-specific small-bore guiding sheath, the 4F Axcelguide Stiff-J-20. Here, we present the first case and technique using this device for an anterior circulation aneurysm.

CLINICAL PRESENTATION:

In this study, we used the 4F Axcelguide Stiff-J-20 guiding sheath (outer diameter, 2.03 mm/0.080″; inner diameter, 1.65 mm/0.065″; usable length, 115 cm) for 2 patients. This sheath features a 20-cm Simmonds-shaped bending zone, allowing catheterization of the high cervical internal carotid artery. Coil embolization was performed for 2 patients: a 59-year-old man with an unruptured right middle cerebral artery bifurcation aneurysm and 52-year-old man with an unruptured left ICA-posterior communicating artery aneurysm. After the 4F Axcelguide Stiff-J-20 was engaged in the target internal carotid artery, a triaxial system (4F Axcelguide Stiff-J-20/3.2F Tactics Intermediate Catheter/Single Microcatheter) was constructed. Coil embolization was performed using a simple technique. Intraprocedural system instability and catheter kinking did not occur. No patient experienced access-site complications, and the postprocedural course was uneventful.

CONCLUSION:

The 4F Axcelguide Stiff-J-20 guiding sheath can achieve sufficient stability and kink resistance, while reducing the risk of access site complications. This device could be a useful therapeutic option for neurointervention.

ABBREVIATIONS:

RAO

radial artery occlusion

RAS

radial artery spasm

TRA

transradial approach.

Traditionally, the transfemoral approach is the primary vascular access method for neurointerventions. However, transfemoral approach can be challenging in patients with unfavorable anatomy of the target common carotid artery (CCA) or aortic arch. Furthermore, this approach carries the risk of life-threatening access site complications, including retroperitoneal hematoma, pseudoaneurysm, and deep venous thrombosis, due to postprocedural access-site compression.^1,2 By contrast, the transradial approach (TRA) has been developed as an alternative, offering a lower risk of access-site complications, greater patient comfort, and immediate ambulation. Recent reports have highlighted the usefulness of a preshaped guiding sheath in enhancing intraprocedural system stability and preventing catheter kinking.^3-6 However, large-bore systems pose a risk of access site complications, including radial artery spasm (RAS), radial artery occlusion (RAO), and radial pseudoaneurysms.^7,8 To reduce these complications while maintaining intraprocedural system stability and kink resistance, we developed a small-bore preshaped guiding sheath. Here, we present the first case and technique using this device for a patient with an anterior circulation aneurysm.

CLINICAL PRESENTATION

Use of 4F Axcelguide Stiff-J-20 Guiding Sheath

In this study, a transradial triaxial system was created using the 4F Axcelguide Stiff-J-20 (outer diameter, 2.03 mm/0.080″; inner diameter, 1.65 mm/0.065″; usable length, 115 cm; Medikit) and 3.2F Tactics distal access catheter (distal outer diameter, 1.07 mm; proximal outer diameter, 1.14 mm; inner diameter, 0.035″; usable length, 130 cm; Technocrat Corporation). The 4F Axcelguide Stiff-J-20 is a radial-specific, small-bore preshaped guiding sheath, which is used for sheathless navigation (Figure 1A). Its distal end features a 20-cm reversed curve specially designed for high cervical internal carotid artery (ICA) cannulation. The preshaped bending zone provides kink resistance. The guiding sheath was packaged using a dedicated dilator (Figure 1B).

FIGURE 1.

4F Axcelguide Stiff-J-20 guiding sheath (outer diameter, 2.03 mm/0.080″; inner diameter, 1.65 mm/0.065″; usable length, 115 cm; Medikit) designed for the transradial approach. The sheath features a 20-cm preshaped bending zone. A, View of 4F Axcelguide Stiff-J-20 guiding sheath. B, View of 4F Axcelguide Stiff-J-20 guiding sheath with accessory dilator.

Radial Artery Cannulation

Under general anesthesia, a 4F 7-cm radial sheath (Medikit) was introduced through the right TRA. Using roadmap guidance, a 4F Simmons catheter was advanced over a 0.035″ hydrophilic standard guidewire into the proximal right subclavian artery. The guidewire was replaced with a 0.035″ hydrophilic stiff guidewire, and both the 4F Simmons catheter and the 4F radial sheath were removed. A 4F Axcelguide Stiff-J-20, preloaded with its dilator, was advanced over the stiff guidewire into the proximal right subclavian artery through the sheathless TRA.

Carotid Artery Cannulation

The 4F Simmons catheter was introduced into the target CCA through the 4F Axcelguide Stiff-J-20 (Figure 2A and 2B). Under roadmap guidance, the 4F Simmons catheter was advanced over a 0.035 hydrophilic standard guidewire into the external carotid artery (Figure 2C). After exchanging the guidewire for a 0.035″ hydrophilic stiff guidewire, the 4F Axcelguide Stiff-J-20 was tracked into the distal CCA (Figure 2D), and both the 4F Simmons catheter and the guidewire were removed (Figure 2E). Subsequently, a 4F straight-tip hydrophilic-coated catheter (usable length, 133 cm; 4F Cerulean G; Medikit), which integrates both flexible and supportive segments over a 0.035″ hydrophilic standard guidewire, was introduced into the high cervical ICA (Figure 2F). Finally, the 4F Axcelguide Stiff-J-20 was delivered into the high cervical ICA (Figure 2G and 2H), with its tip positioned 20 cm from the CCA origin, based on preprocedural computed tomographic angiography.

FIGURE 2.

Cannulation technique of a 4F Axcelguide Stiff-J-20 (outer diameter, 2.03 mm/0.080″; inner diameter, 1.65 mm/0.065″; usable length, 115 cm; Medikit) guiding sheath. A, 4F Simmons catheter was advanced through the 4F Axcelguide Stiff-J-20 guiding sheath and turned up in the ascending aorta. B, 4F Simmons catheter was introduced into the target CCA. C, 4F Simmons catheter was advanced over the 0.035″ hydrophilic standard guidewire (length, 180 cm; Radifocus guidewire M standard type; MicroVention-Terumo) into the external carotid artery. D, 4F Axcelguide Stiff-J-20 guiding sheath was tracked into the distal CCA after the guidewire was exchanged for the 0.035″ hydrophilic stiff guidewire (length, 260 cm; Radifocus guidewire M stiff type; MicroVention-Terumo). E, 4F Simmons catheter and the guidewire were removed. F, 4F straight-tip hydrophilic-coated catheter (usable length, 133 cm; 4F Cerulean G; Medikit) over the 0.035″ hydrophilic standard guidewire was introduced into the high cervical ICA. G, 4F Axcelguide Stiff-J-20 guiding sheath was tracked into the high cervical ICA. H, 4F straight-tip hydrophilic-coated catheter and the guidewire were removed. ©2025, Takuya Nakamura. All rights reserved. CCA, common carotid artery; ICA, internal carotid artery.

Endovascular Procedure

Under roadmap guidance, a 3.2F Tactics was advanced over a microcatheter and a 0.014″ microguidewire was advanced into the supraclinoid or cavernous segment of the ICA through the 4F Axcelguide Stiff-J-20 positioned in the high cervical ICA. Thus, the endovascular procedure was performed using this transradial triaxial system (4F Axcelguide Stiff-J-20, 3.2F Tactics, microcatheter).

Case 1

A 59-year-old man underwent coil embolization of an unruptured right middle cerebral artery bifurcation aneurysm with its size 3.3 mm by 3.2 mm (Figure 3A). The target right CCA originated at a steep angle from the right subclavian artery without significant tortuosity (Figure 3B). The 4F Axcelguide Stiff-J-20 was used because straight-shaped catheter had possibility of catheter kinking and system prolapse during the procedure. Therefore, the triaxial system was developed using the 4F Axcelguide Stiff-J-20, 3.2F Tactics and a 1.6F Headway Duo microcatheter (MicroVention-Terumo) through distal TRA (Figure 3C-3J). Simple coiling with a diameter of 3 mm was successfully achieved without catheter kinking or systemic instability (Figure 3K). Although postprocedural radial artery angiography revealed RAS, no complications, including catheter entrapment or postprocedural patient discomfort, were observed (Figure 3L). The postprocedural course was uneventful with no complications or RAO.

FIGURE 3.

Preprocedural and intraprocedural imaging of case 1. A, Preprocedural three-dimensional rotational angiography showed the right middle cerebral artery bifurcation aneurysm (white asterisks). B, Magnetic resonance angiography showed a steep angulation between the right subclavian artery and CCA. C, Radial artery angiography revealed the brachioradial artery with a small diameter (black arrowheads). D, Right anterior oblique view of the right CCA angiography. A 4F Simmons catheter (white arrow) was introduced into the right CCA via a 4F Axcelguide Stiff-J-20 (outer diameter, 2.03 mm/0.080″; inner diameter, 1.65 mm/0.065″; usable length, 115 cm; Medikit) (black arrow). E, Right anterior oblique view of roadmap imaging based on the right CCA angiography. The 4F Simmons catheter (white arrow) over a 0.035″ hydrophilic standard guidewire (length, 180 cm; Radifocus guidewire M standard type; MicroVention-Terumo) was advanced into the right external carotid artery. The guidewire was exchanged for a 0.035″ hydrophilic stiff guidewire (length, 260 cm; Radifocus guidewire M stiff type; MicroVention-Terumo). F, 4F Axcelguide Stiff-J-20 (black arrow) was tracked into the distal CCA, and the 4F Simmons catheter (white arrow) and guidewire were removed. G, 4F straight-tip hydrophilic-coated catheter (usable length, 133 cm; 4F Cerulean G; Medikit) (white dotted arrow) over the 0.035″ hydrophilic standard guidewire was introduced into the high cervical ICA via the 4F Axcelguide Stiff-J-20 (black arrow). H, 4F Axcelguide Stiff-J-20 (black arrow) was delivered into the high cervical ICA. I, Working projection of the right ICA injection for coil embolization. J, 3.2F Tactics intermediate catheter (distal outer diameter, 1.07 mm/0.042″; proximal outer diameter, 1.14 mm/0.045″; inner diameter, 0.89 mm/0.035″; usable length, 130 cm; Technocrat Corporation, Aichi, Japan) (black dotted arrow) and a Headway Duo microcatheter (distal outer diameter, 0.53 mm; proximal outer diameter, 0.7 mm; inner diameter, 0.0165″; usable length, 156 cm; MicroVention-Terumo) (white arrowhead) via the 4F Axcelguide Stiff-J-20 (black arrow) were advanced into the supraclinoid segment of the ICA and aneurysm, respectively. K, Working projection after coil embolization demonstrated no complications, such as vessel occlusion or aneurysmal perforation. L, Postprocedural radial artery angiography revealed radial artery spasm without any symptoms. CCA, common carotid artery; ICA, internal carotid artery.

Case 2

A 52-year-old man underwent coil embolization for an unruptured left ICA-posterior communicating artery aneurysm with its size 3.0 mm by 2.5 mm (Figure 4A). The target left CCA was associated with a nonbovine arch without significant tortuosity (Figure 4B). A triaxial system was established using the 4F Axcelguide Stiff-J-20, 3.2F Tactics, and a 1.7F Excelsior SL-10 microcatheter (Stryker) through the distal TRA (Figure 4C-4F). Simple coiling with a diameter of 3 mm was accomplished without catheter kinking or system prolapse (Figure 4G-4I). Postprocedural radial artery angiography revealed an intact radial artery (Figure 4J). The postprocedural course was uneventful with no complications or RAO.

FIGURE 4.

Preprocedural and intraprocedural imaging of case 2. A, Preprocedural three-dimensional rotational angiography showed the left ICA-posterior communicating artery aneurysm (white asterisks). B, Magnetic resonance angiography showed a nonbovine aortic arch. C, Sheath angiography revealed a radial artery with a small diameter (black arrowheads). D, Left anterior oblique view of the left CCA angiography. A 4F Simmons catheter (white arrow) was introduced into the left CCA via a 4F Axcelguide Stiff-J-20 (outer diameter, 2.03 mm/0.080″; inner diameter, 1.65 mm/0.065″; usable length, 115 cm; Medikit) (black arrow). E, After the 4F Simmons catheter was advanced over a 0.035″ hydrophilic standard guidewire (length, 180 cm; Radifocus guidewire M standard type; MicroVention-Terumo) into the right external carotid artery, the guidewire was exchanged for a 0.035″ hydrophilic stiff guidewire (length, 260 cm; Radifocus guidewire M stiff type; MicroVention-Terumo), and the 4F Axcelguide Stiff-J-20 (black arrow) was tracked into the distal CCA. F, After a 4F straight-tip hydrophilic-coated catheter (usable length, 133 cm; 4F Cerulean G; Medikit) over the 0.035″ hydrophilic standard guidewire was introduced into the high cervical ICA, the 4F Axcelguide Stiff-J-20 (black arrow) was advanced into the high cervical ICA. G, Working projection of the left ICA injection for coil embolization. H, 3.2F Tactics intermediate catheter (distal outer diameter, 1.07 mm/0.042″; proximal outer diameter, 1.14 mm/0.045″; inner diameter, 0.89 mm/0.035″; usable length, 130 cm; Technocrat Corporation) (black dotted arrow) and an Excelsior SL-10 microcatheter (distal outer diameter, 0.56 mm; proximal outer diameter, 0.79 mm; inner diameter, 0.0165″; usable length, 150 cm; Stryker) (white arrowhead) via the 4F Axcelguide Stiff-J-20 (black arrow) were advanced into the cavernous segment of the ICA and aneurysm, respectively. I, Working projection after coil embolization demonstrated no complications, such as vessel occlusion or aneurysmal perforation. J, Postprocedural radial artery angiography revealed no complications, including radial artery spasm or radial artery occlusion. CCA, common carotid artery; ICA, internal carotid artery.

Data availability

Data and materials are available from the corresponding author on reasonable request.

Ethics Approval

This study was approved by the ethics committee (The Committee for Medical Ethics of Shinshu University School of Medicine 4754) and was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments.

Informed Consent

Written informed consent for publication was obtained from the patients.

DISCUSSION

Right TRA with a straight-tip guiding catheter/sheath can be technically challenging in patients with an unfavorable takeoff of the target CCA, such as a right CCA with steep angulation from the right subclavian artery or a left CCA with a nonbovine origin. These anatomic variations increase the risk of catheter prolapse into the aortic arch or catheter kinking.^9,10 Recent reports have described the use of TRA with a 6F preshaped Simmons guiding sheath (6F Axcelguide Stiff-J guiding sheath; outer diameter, 2.70 mm/0.106″; inner diameter, 2.24 mm/0.088″; usable length, 90 cm; Medikit) as an effective therapeutic option for anterior circulation interventions, including such challenging cases. The preshaped bending zone of the 6F Simmons guiding sheath offers kink resistance and system stability during the procedure.^3-6 However, large-bore sheaths increase the risk of access-site complications, such as RAS, RAO, and radial pseudoaneurysms.^7,8 RAS is among the most frequent access-site complications associated with TRA.^7-9 Furthermore, RAS can cause to rare but serious access-site complications, including dissection, or avulsion of the radial artery, catheter/sheath entrapment, and forearm hematoma, resulting in compartment syndrome.^9,10 RAO occasionally occurs after TRA; however, most RAO cases are asymptomatic. Maintaining radial artery patency is important, as RAO prevents future use of vascular access in TRA, as a donor vessel in coronary bypass surgery, or for the construction of arteriovenous fistulae in patients with end-stage renal failure.^11,12 Radial pseudoaneurysm is a rare but can cause rupture associated with massive bleeding, necessitating urgent surgical intervention.^7,9

To reduce access site complications while ensuring system stability, we developed a new small-bore preshaped guiding sheath, the 4F Axcelguide Stiff-J-20. Sheathless TRA enable smaller-bore catheter systems and reduce the risk of access-site complications.^13-15 The 4F Axcelguide Stiff-J-20 features a smaller bore than the 6F Axcelguide Stiff-J, reducing the outer diameter from 2.70 mm to 2.03 mm. Although both illustrative cases had an unfavorable takeoff of the target CCA, simple coiling was accomplished without catheter kinking, system prolapse, crossover to the transfemoral access, and/or access site complications. Intraoperative ICA angiography can be performed directly through the guiding sheath placed in the high cervical ICA, thus enabling updated roadmap imaging. In addition, the 4F Axcelguide Stiff-J-20 (inner diameter, 1.65 mm/0.065″) can potentially be applied to dual microcatheter manipulation, including double-catheter, balloon-assisted, and stent-assisted coiling using jailing techniques.

Further investigation is required to clarify the usefulness, potential risks, and limitations of this device and system.

CONCLUSION

The 4F Axcelguide Stiff-J-20 can achieve sufficient stability and kink resistance while reducing the risk of access site complications. This device could be a useful therapeutic option in the field of TRA neurointervention.

Funding

This study did not receive any funding or financial support.

Disclosures

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.