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Pedal Access in Critical Limb Ischemia

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.

R.S. Dieter et al. (eds.), Endovascular Interventions, 805


DOI 10.1007/978-1-4614-7312-1_65, Springer Science+Business Media New York 2014
806 C.M. Walker

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.

Technique Description: 13 Steps of Transpedal


and Tibial Access

Step 1: Access is obtained from above (this can be antegrade)


with a 6 or 7F sheath, contralateral femoral with a crossover
sheath or rarely brachial or axillary access (Fig. 65.1).
Step 2: Vasodilators (200400 mg) of nitroglycerin adminis- Fig. 65.2 Angiography showing the infrapopliteal arteries
tered via the antegrade sheath.
Step 3: An angiogram is taken from above to image the ves-
sel (Fig. 65.2).

Fig. 65.3 Local anesthesia utilizing a 50/50 mixture of lidocaine and


Fig. 65.1 Antegrade femoral artery sheath Tridil (NTG)
65 Pedal Access in Critical Limb Ischemia 807

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. 65.4 Micropuncture of tibial vessel utilizing angiographic guidance

Fig. 65.6 Placement of microsheath

Fig. 65.7 Administration of drug cocktail consisting of full dose of


Fig. 65.5 Advancement of either a .014 or .018 guidewire into the anticoagulant, nitroglycerin, and calcium channel blocker to avoid
tibial vessel spasm and clot
808 C.M. Walker

Fig. 65.9 Wire steered into the femoral sheath and externalized

been advanced into normal vessel above the occlusion.)


(Fig. 65.9)
Step 10: The microcatheter is withdrawn from the pedal ves-
sel then reintroduced over the externalized wire via the
antegrade sheath from above across all occlusions to
above the pedal entry site (Fig. 65.10).
Step 11: The .014 or .018 guidewire is removed then is
advanced with the flexible end distally into the foot distal
to the pedal puncture. It is important to avoid wire dissec-
Fig. 65.8 Wire advanced across the occlusion
tion when navigating around the tibial microcatheter
access site (Fig. 65.11).
will often facilitate wire passage from below. Once the Step 12: The pedal microcatheter is removed from below and
wire has crossed, the microcatheter is advanced over the light pressure applied over the pedal entry site to prevent bleed-
wire and across the lesion into a normal vessel segment ing (typically rapid hemostasis is achieved with full anti-
(Fig. 65.8). coagulation and antiplatelet therapy) (Figs. 65.12 and 65.13).
Step 9: The wire is steered or snared into the sheath above, Step 13: Deliver final therapy. Careful attention should be
and the wire is then externalized via the antegrade sheath. given to evaluate the entry site angiographically. If there
(Steering the wire often requires reshaping the wire after is evidence of dissection, then low-pressure balloon dila-
the occlusion has been crossed and the microcatheter has tion may be useful.
65 Pedal Access in Critical Limb Ischemia 809

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. 65.15 Wire advanced through micropuncture needle into the


posterior tibial artery

Fig. 65.17 Delivery of therapy (in this case, laser atherectomy fol-
lowed by angioplasty)

Fig. 65.16 Tibial microsheath removed and pressure applied for


23 min micropuncture sheath and advanced to the occlusion. The
guidewire easily crossed the occluded proximal posterior
The 2.8F micropuncture sheath (Cook) was then placed tibial and popliteal occlusion into the patent SFA below
over the wire into the posterior tibial artery and a hemo- the tip of the antegrade femoral sheath following which
static valve attached (Fig. 65.16). the microcatheter was advanced to that point
Following these, 5,000 units of heparin, 200 mg of (Fig. 65.17).
Tridil, and 100 mg of verapamil were administered into The guidewire was then removed, reshaped, then rein-
the posterior tibial artery. A .014 microcatheter and .014 troduced and steered into the femoral sheath
Confianza Pro guidewire were then placed through the (Fig. 65.18).
812 C.M. Walker

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

PTA was then performed with a 4 mm balloon at 4 atm


for 3 min (Fig. 65.21).
Completion angiography showed a widely patent ves-
sel with brisk flow to the foot (Fig. 65.22).

Fig. 65.21 Widely patent popliteal artery


814 C.M. Walker

Fig. 65.22 Widely patent popliteal and posterior tibial artery


65 Pedal Access in Critical Limb Ischemia 815

Case 2 ral-popliteal bypasses were occluded and there was no


History proximal SFA stump (Fig. 65.23).
This 59-year-old male presented with an extensive history of Attempts at antegrade crossing of the SFA utilizing
peripheral vascular disease with prior aortobifemoral bypass, external ultrasound guidance as well as fluoroscopy were
complicated by prior left groin wound infection, and two unsuccessful. Following the administration of local anes-
prior right femoral to popliteal bypass procedures. He devel- thesia, direct micropuncture of the dorsal pedal artery was
oped true ischemic right leg rest pain and a nonhealing toe performed under direct fluoroscopic visualization during
ulcer. The ABI on the right was 0.3 with a skin perfusion a 10 s injection of 3 ml/s. of contrast via the axillary
pressure of 16 mmHg. Outside CTA showed a patent aorto- sheath. A 5F hydrophilic sheath was placed in this large
bifemoral graft with total right SFA occlusion at its origin and (>3.5 mm) artery to allow the use of .035 hydrophilic
reconstitution of the anterior tibial near its origin with this guidewires and long transport catheters. A bolus of biva-
vessel reaching the foot. The patient was tall (6 ft 10 in.). lirudin, nitroglycerin (400 mg), and verapamil (100 mg)
Procedural Technique were administered into the dorsal pedal artery. Following
It was elected to first obtain left axillary artery access with this, the occlusion was crossed via the anterior tibial
a 5F sheath to possibly allow treatment of the occlusion access with a .035 glidewire and a .035 135 cm long
from the antegrade approach as contralateral femoral and Quick-Cross catheter. Angiography via the Quick-Cross
antegrade femoral were not options nor was brachial as catheter confirmed intraluminal common femoral posi-
no devices have a shaft length long enough to reach the tion. A .014 guidewire was then placed into the distal
lesions in this patient. Following access, 200 mg of intra- aorta, as it was apparent that the patients height precluded
arterial nitroglycerin was administered then cineangiog- delivery of therapy via the axillary sheath, as distal part of
raphy performed. This confirmed the CTA findings of a the occlusion was approximately 180 cm from the sheath.
widely patent aortofemoral bypass and total right SFA Laser atherectomy was performed over the .014 wire uti-
occlusion with reconstitution of the anterior tibial, which lizing a 0.9 mm probe and two passes at 1 mm/s establish-
was a large vessel that reached the foot. The prior femo- ing a channel (Fig. 65.24).

Fig. 65.23 Patent aortofemoral bypass with total SFA occlusion and reconstitution of the anterior tibial artery
816 C.M. Walker

Fig. 65.24 Angiography post laser and PTA


65 Pedal Access in Critical Limb Ischemia 817

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).

Fig. 65.25 Angiography post stenting


818 C.M. Walker

Fig. 65.25 (continued)

Case 3 popliteal, tibioperoneal, and peroneal arteries 6 months


History prior to referral for severe recurrent claudication that had
This 78-year-old female was referred with a nonhealing relieved her symptoms for 4 months. Outside angiogra-
left foot ulcer and true rest pain (ABI 0.3 and skin perfu- phy showed the graft to be occluded with reconstitution
sion pressure 22 mmHg). There were gangrenous skin of the posterior tibial artery that reached the foot. The
changes at the tips of two toes. She had undergone femo- posterior tibial artery had been jailed by the prior stents
ral-popliteal bypass 8 years prior that had been compli- in the popliteal, tibioperoneal, and peroneal arteries.
cated by groin infection with resultant deep extensive Attempts at crossing the occluded segment had been suc-
groin scar. The patient had graft lysis and stenting of the cessful but lysis and angioplasty did not restore flow, as
65 Pedal Access in Critical Limb Ischemia 819

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

Fig. 65.27 Microsheath in posterior tibial artery

tibial access. Following administration of local anesthesia


consisting of 5 cc of a 50/50 mixture of 1 % lidocaine and
500 mg Tridil, the posterior tibial artery was punctured
with a microneedle utilizing fluoroscopic guidance and
angiography. A micropuncture sheath was then placed in
the artery over the .018 guidewire (Fig. 65.27).
Heparin 5,000 units, verapamil 100 mg, and Tridil
Fig. 65.28 Balloon across the jailed origin of the posterior tibial
200 mg were administered into the posterior tibial artery. artery
A 300 cm Confianza Pro guidewire was then introduced
through the micropuncture sheath to the proximal poste-
rior tibial artery. The micropuncture sheath was removed sions (wire tethering was required to cross the jailed
and a .014 Quick-Cross catheter advanced over the wire segment). The vessel was then dilated with this balloon
to the site of occlusion. Following this, the guidewire eas- and the graft dilated with a 5 mm balloon. A 3.5 mm bal-
ily crossed the proximal occlusion through the jailed loon-expandable stent was placed across the jailed seg-
area into the popliteal segment where it was steered into ment following which it was post-dilated with a
the .035 Quick-Cross catheters that had been placed via noncompliant balloon at 20 atm (Fig. 65.28).
the contralateral femoral sheath. The wire was then Laser atherectomy and PTA with a 5 mm balloon was
advanced through the catheter and externalized at the performed on the previously stented femoropopliteal graft
contralateral sheath. The .035 femoral Quick-Cross cath- and popliteal artery. An additional nitinol stent was placed
eters and the .014 tibial Quick-Cross catheters were then in the proximal graft. Subsequent angiography showed a
removed. A 10 cm long 2.5 mm diameter balloon was widely patent graft with brisk runoff via the posterior
then advanced from the femoral sheath across all occlu- tibial artery (Fig. 65.29).
65 Pedal Access in Critical Limb Ischemia 821

Fig. 65.29 Final angiogram post stenting


822 C.M. Walker

Summary 5. Nice C, Timmons G, Bartholemew P, et al. Retrograde vs. ante-


grade puncture for infra-inguinal angioplasty. Cardiovasc Intervent
Radiol. 2003;26:3704.
Tibial and pedal access is useful in limb salvage angioplasty 6. Spinosa DJ, Leung DA, Harthun NL, et al. Simultaneous antegrade
when conventional antegrade approach is unsuccessful. and retrograde access for subintimal recanalization of peripheral
Many factors may play a role in making crossing in retro- arterial occlusion. J Vasc Interv Radiol. 2003;14:144954.
7. Villas PA, Cohen G, Goyal A, et al. The merits of percutaneous
grade manner possible when antegrade attempts fail. These transluminal angioplasty of a superficial femoral artery stenosis via
include (1) avoidance of collateral vessels, (2) a softer distal a retrograde popliteal artery approach. J Vasc Interv Radiol.
cap of the occlusion, and (3) hibernating vascular seg- 1999;10:3258.
ments unrecognized during angiography. Tibial and pedal 8. Yilmaz S, Sindel T, Lulci E. The merits of percutaneous translumi-
nal angioplasty of a superficial femoral artery stenosis via a retro-
access can be performed safely without expensive equipment grade popliteal approach. J Vasc Interv Radiol. 2001;12:14578.
in any interventional suite. 9. Tonnesen KH, Sager P, Karle A, et al. Percutaneous transluminal
angioplasty of the superficial femoral artery by retrograde catheter-
ization via the popliteal artery. Cardiovasc Intervent Radiol.
1988;11:12731.
References 10. Cutress ML, Blanshard K, Shaw M, et al. Retrograde subintimal
angioplasty via a popliteal artery approach. Eur J Vasc Endovasc
1. Ramsey SD et al. Incidence, outcomes and cost of foot ulcers in Surg. 2002;23:2756.
patients with diabetes. Diabetes Care. 1999;22:3827. [Conversion 11. McCullough KM. Retrograde transpopliteal salvage of the failed
from 1995 to 2011 medical costs at: http://www.halfhill.com/ antegrade transfemoral angioplasty. Australas Radiol. 1993;37:
inflation.html. Accessed 14 Feb 2011]. 32931.
2. Faglia E et al. New ulceration, new major amputation, and survival 12. Creasy TS, Tonnesen KH. Retrograde femoral angioplasty: a new
rates in diabetic subjects hospitalized for foot ulceration from 1990 technique. Br J Surg. 1992;79:710.
to 1993. Diabetes Care. 2001;24:7883. 13. Yilmaz S, Sindel T, Luleci E. Ultrasound-guided retrograde
3. Allie DE, Walker CM, et al. Critical limb ischemia: a global epi- popliteal artery catheterization: experience in 174 consecutive
demic. A critical analysis of current treatment unmasks the clinical patients. J Endovasc Ther. 2005;12:71422.
and economic costs of CLI. EuroIntervention. 2005;1(1):7584. 14. Montero-Baker M, Schmidt A, et al. Retrograde approach for com-
ISSN 1774-024X. plex popliteal and tibioperoneal occlusions. J Endovasc Ther.
4. Saha S, Gibson M, Magee TR, et al. Early results of retrograde 2008;15(5):594604. doi:10.1583/08-2440.1.
transpopliteal angioplasty of iliofemoral lesions. Cardiovasc 15. Botti Jr CF et al. Percutaneous retrograde tibial access in limb sal-
Intervent Radiol. 2001;24:37882. vage. J Endovasc Ther. 2003;10:6148.

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