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65
Craig M. Walker
Contents Introduction
Introduction ................................................................................... 805
Interventional therapy of critical limb ischemia has devel-
Technique Description: 13 Steps of Transpedal
and Tibial Access ........................................................................... 806
oped into first-line therapy. Successful intervention is depen-
dent on crossing obstructive lesions. Retrograde tibial access
Summary........................................................................................ 822
often allows successful crossing of lesions that cant be
References ...................................................................................... 822 crossed in antegrade manner. This increases the rate of suc-
cessful interventional treatment of critical limb ischemia.
Any interventionist can easily perform retrograde tibial
approach without the need for specialized equipment. With
careful attention, it can be performed with low risk of dam-
age to the pedal vessels, which may serve as future bypass
targets. Retrograde tibial access may also lessen the need for
reentry tools in certain cases, which may serve to lessen cost.
This chapter includes a simple 13-step process to achieve
access and avoid complications.
Endovascular and surgical techniques for treating periph-
eral arterial disease (PAD) have improved dramatically over
the last decade resulting in improved outcomes [1, 2]. Despite
these accomplishments, over 200,000 amputations are per-
formed worldwide annually as a result of critical limb isch-
emia (CLI) [3]. The incidence of CLI is increasing worldwide
as diabetic prevalence is higher and life expectancy is
increasing.
CLI represents the most severe spectrum of PAD. It poses
a particular clinical challenge as these patients are often aged
and have many comorbidities. The 1-year mortality rate
approaches 25 % and may be as high as 45 % in those who
have undergone amputations [3].
CLI commonly involves popliteal and infrapopliteal arte-
rial occlusions. Surgical revascularization may be limited by
(1) poor distal targets, (2) lack of autologous vein, and (3)
comorbid conditions. Endovascular therapy may be an option
even in this group of patients with no surgical options but is
C.M. Walker, MD
Terrebonne General Medical Center,
limited by the need to first cross these chronic total occlu-
225 Dunn Street, Houma, sions. Lesions that are uncrossable in antegrade fashion are
LA 70360, USA often easily crossed via retrograde approach.
The popliteal approach [413] was developed to cross Step 4: Local anesthesia using a 50:50 mixture of 1 % lidocaine
occluded SFAs from below, but it has many disadvantages in and Tridil given subcutaneously over intended pedal punc-
CLI including: ture site. The Tridil (nitroglycerin) lessens the risk of induc-
1. There must be a patent popliteal artery. ing vascular spasm during vessel puncture (Fig. 65.3).
2. One cant treat concomitant infrapopliteal disease.
3. The patient in most cases must be prone.
4. There is a risk of bleeding and AV fistulae.
5. The crossing and delivery of final therapy must usually be
via the popliteal artery where sheaths may be occlusive.
6. The physician is exposed to more radiation.
The pedal approach (via anterior or posterior tibial arteries
and rarely the peroneal artery) is a viable approach in limb
salvage interventions where occlusions cant be crossed from
above and may become a choice in treating severe claudication
as well [14, 15]. Advantages of a pedal approach include:
1. It can be used with popliteal and IP occlusions.
2. The patient is supine.
3. The interventionist can approach the lesion from above
and below simultaneously.
4. There is a higher incidence of luminal crossing.
5. There is a very low risk of bleeding.
6. The physician is exposed to less radiation.
Pedal access is more difficult as these vessels are small, may
be calcified, and the interventionist doesnt want to occlude
potential distal graft sites. Meticulous attention to avoid spasm,
clotting, dissection, and being occlusive is required.
Step 5: Micropuncture of the pedal vessel performed under which can lessen the amount of contrast needed.)
direct fluoroscopic visualization. The use of 10 s injec- (Figs. 65.4 and 65.5)
tions of 30 cc of contrast at a rate of 3 cc/s allows the Step 6: If pedal access is being used to cross only, then a .018
interventionist time to localize and puncture the artery. wire with or without a .018 microcatheter is advanced
(Ultrasound-guided access can be utilized if available, into the vessel (to lessen risk of vessel occlusion).
If pedal access is being used to cross and deliver ther-
apy (only special circumstances), a sheath is introduced.
Initially, a 4F sheath is used but can be upsized for stent-
ing or atherectomy once crossing has been accomplished
(Fig. 65.6).
Step 7: A drug cocktail is administered into the pedal ves-
sel including (1) a full dose of anticoagulant, (2) 200
400 mg of Tridil, and (3) a calcium channel blocker. These
agents are administered in bolus form to avoid spasm and
clot (Fig. 65.7).
Step 8: The occlusion is crossed with the .014 or .018 wire.
(One can actually work from above and below simultane-
ously if necessary.) If both wires become trapped subinti-
mally, then dilation of the vessel via the antegrade wire
Fig. 65.9 Wire steered into the femoral sheath and externalized
Fig. 65.11 Wire removed then placed with the soft tip distal to the
entry site
Fig. 65.10 Crossing catheter placed over the wire across the lesion
from the femoral access
Fig. 65.12 Microsheath removed and light digital pressure applied Fig. 65.13 Bleeding at microsheath insertion site after 1 min
810 C.M. Walker
Case 1 into the contralateral femoral artery via the right femoral
History artery, 400 mg of nitroglycerin as administered. Following
This 49-year-old female presented with severe claudication this, cineangiography was performed utilizing 20 cc of
and a nonhealing right foot plantar surface ulcer (1 cm contrast (5 ml/s) demonstrating total occlusion of the right
diameter). Angiography disclosed popliteal artery occlusion popliteal artery with reconstitution of a widely patent
with a patent posterior tibial artery that was patent to the posterior tibial artery to the foot (Fig. 65.14).
foot. The patient had no remaining autologous saphenous Multiple attempts at crossing the occluded popliteal
vein for distal bypass. Two prior attempts (one via contral- segment with wires were unsuccessful. Following subcu-
ateral femoral access and one via antegrade femoral access taneous administration of 10 cc of a 50/50 mix of 1 %
utilizing dedicated crossing tools) at crossing the total occlu- lidocaine and Tridil (200 mg/cc of NTG) at the ankle,
sion had been unsuccessful before the patient was referred. direct puncture of the posterior tibial artery was performed
During those procedures, the SFA had been stented. utilizing a micropuncture needle with a .018 wire under
Procedural Technique direct fluoroscopic guidance during a 10 s injection of
Following local anesthesia, antegrade left retrograde fem- 30 cc of contrast via the femoral sheath at 3 cc/s
oral access was obtained and a 7F sheath was advanced (Fig. 65.15).
Fig. 65.14 Angiogram showing occluded popliteal and proximal posterior tibial artery with distal posterior tibial reconstitution
65 Pedal Access in Critical Limb Ischemia 811
Fig. 65.17 Delivery of therapy (in this case, laser atherectomy fol-
lowed by angioplasty)
The guidewire was then advanced through the sheath from the left common femoral access into the posterior
and externalized. The .014 microcatheter was removed tibial artery distal to the site of prior access. The 2.8F
from the pedal sheath and reintroduced via the femoral sheath was then removed and light manual compression
sheath and advanced across the total occlusions into the applied over the access site for 2 min following, which
posterior tibial artery above the tip of the tibial sheath. there was hemostasis (Fig. 65.19).
Following this, the guidewire was removed and then Laser atherectomy was then performed on the occluded
advanced with the soft end distal via the microcatheter segment utilizing two passes (1 mm/s advancement speed)
with a 2 mm probe (Fig. 65.20).
Fig. 65.18 Guidewire advanced into the femoral Fig. 65.20 Laser atherectomy probe treating occluded segment
Fig. 65.19 Tibial mirosheath removed and light digital pressure applied for 2 min
65 Pedal Access in Critical Limb Ischemia 813
Fig. 65.23 Patent aortofemoral bypass with total SFA occlusion and reconstitution of the anterior tibial artery
816 C.M. Walker
Subsequent balloon angioplasty resulted in a subopti- The wire and pedal sheath were removed and light
mal result. The sheath was exchanged for a 6F sheath fol- pressure applied to the entry site for 8 min achieving
lowing which the vessel was stented with excellent result hemostasis.
(Fig. 65.25).
there was very little runoff via the peroneal. Attempts at which angiography was performed. Angiography showed
crossing into the posterior tibial were unsuccessful. a patent profunda, flush SFA occlusion, and occlusion of
Outside vascular surgical consultation was obtained. the femoropopliteal bypass graft at its origin. The poste-
Because of extensive groin scarring, lack of autologous rior tibial reconstituted and reached the foot with no filling
vein (patient had prior five-vessel CABG), and poor of the other infrapopliteal vessels (Fig. 65.26).
health (severe ischemic cardiomyopathy and COPD), it Attempts at crossing the occlusion from the contralat-
was decided that she was not a candidate for surgery. eral femoral sheath utilizing a .035 glidewire and a Quick-
Procedural Technique Cross support catheter were successful to the popliteal
Contralateral femoral access was obtained utilizing a 7F artery, but there was no success at crossing into the poste-
sheath. The patient was anticoagulated with heparin. Via rior tibial despite trying multiple guidewires and angu-
the sheath, 200 mg of Tridil was administered, following lated support catheters. It was decided to utilize posterior
Fig. 65.26 Occluded femoropopliteal bypass with distal posterior tibial reconstitution. The origin of the posterior tibial is jailed by a stent
into the peroneal
820 C.M. Walker