Retrograde Distal Pedal Artery Access A Primer to Percutaneous Endovascular intervention Retrograde Distal Pedal Artery Access Nelson Lim Bernardo, MD Director, Peripheral Vascular Laboratory Medstar Heart Institute at Washington Hospital Center Washington, D.C.
Terumo Cardiovascular Systems Group Nelson L. Bernardo, MD Honoraria: Abbott Vascular Cook Group Incorporated Cordis Corporation Covidien Medtronic, Inc. Terumo Cardiovascular Systems Group
Faculty Disclosure Abbott Vascular – Training Site Cook Medical – Training Site Cordis Endovascular – Training Site Covidien/eV3 – Training Site Medtronic – Training Site No conflict of interest related to this presentation Non-IFU use of devices will be discussed
PEI of Infra-inguinal Occlusions: Approximately 15-20% of patients with complex infra-inguinal arterial occlusive disease cannot be ‘crossed’ with an antegrade approach using vascular access from the common femoral artery Retrograde pedal artery access is an alternative to allow successful ‘crossing’ of the lesion and eventual recanalization
Retrograde Pedal Artery Access: Retrograde pedal access in percutaneous endovascular intervention: Failure of antegrade access – dissection/subintimal course of guidewire Unfavorable anatomy – ‘flushed’ occlusion Treatment of femoro-popliteal artery disease not amenable to ‘usual’ antegrade approach
Retrograde Pedal Artery Access: Retrograde pedal access in percutaneous endovascular intervention: Failure of antegrade access – dissection/subintimal course of guidewire Unfavorable anatomy – ‘flushed’ occlusion Treatment of femoro-popliteal artery disease not amenable to ‘usual’ antegrade approach
Retrograde Pedal Artery Access: Retrograde pedal access in percutaneous endovascular intervention: Failure of antegrade access – dissection/subintimal course of guidewire Unfavorable anatomy – ‘flushed’ occlusion Treatment of femoro-popliteal artery disease not amenable to ‘usual’ antegrade approach Popliteal A. ?? AT artery PT Peroneal
Retrograde Pedal Artery Access: Retrograde pedal access in percutaneous endovascular intervention: Failure of antegrade access – dissection/subintimal course of guidewire Unfavorable anatomy – ‘flushed’ occlusion Treatment of femoro-popliteal artery disease not amenable to ‘usual’ antegrade approach
Retrograde BTK - Pedal Artery Access: Anterior tibial artery Dorsalis pedis artery (distal anterior tibial A) Proximal anterior tibial artery Posterior tibial artery Distal (proximal segment of plantar vessels) Mid segment of the vessel Distal peroneal artery (+/- through interosseous ligament)
Vasculature of the L.E.: Arterial System Arterial System Venous System
Retrograde BTK - Pedal Artery Access: Techniques - ‘Imaging’ guidance for Pedal Artery Access: Surgical - ‘Open’ cutdown X-ray Fluoroscopy - Angiography, Roadmapping Duplex Ultrasound guidance
Retrograde Pedal Access: Surgical ‘Open’ surgical cutdown Cutdown - direct visualization of the artery Direct puncture of the artery, i.e. dorsalis pedis artery Cons: Surgical incision site to manage ??hemostasis Right Foot
Retrograde Pedal Access: Fluoro guidance X-ray Fluoroscopy guidance Angiography +/- ‘road-map’ Vessel wall calcification Peroneal DP Cons: The artery is entered ‘blindly’ Radiation, + Contrast agent Needle
Retrograde Pedal Access: Ultrasound guidance Real time ultrasound (US)-guided vascular access Allows real time visualization of vessel anatomy and the advancement of needle into the lumen of the vessel
Retrograde Pedal Access: Ultrasound guidance Real time ultrasound (US)-guided vascular access Allows real time visualization of vessel anatomy and the advancement of needle into the lumen of the vessel Major Advantage over the Fluoroscopy-guided technique The vessel is NOT entered BLINDLY
Retrograde Pedal Access: Ultrasound guidance In the lower extremity, each artery is accompanied by corresponding two (2) veins These structures (artery + 2 veins) are easily dileneated by vascular duplex imaging study Ultrasound - shows the structure of the vessel Doppler - shows the movement of red blood cells (flow through the structure) Allows real time visualization of vessel anatomy and flow during vascular access
Retrograde Pedal Access: Ultrasound guidance BTK - Pedal Artery Access: Front wall stick Access with the first puncture to prevent spasm to avoid vascular injury Avoid cannulating the vein Imaging views for needle ‘entry’: Transverse Longitudinal
Retrograde Pedal Access: Ultrasound guidance BTK - Pedal Artery Access: Front wall stick Access with the first puncture to prevent spasm to avoid vascular injury Avoid cannulating the vein Imaging views for needle ‘entry’: Transverse Longitudinal
US-guided Pedal Access: Equipment Vascular probe + US machine
US-guided Pedal Access: Equipment Vascular probe + US machine Linear Array 2.5 - 8.0 MHz “Hockey Stick” ~18 MHz
US-guided Pedal Access: Equipment Vascular probe + US machine 4F micropuncture kit + Tuohy-Borst/Copilot control valve
Retrograde Pedal Access: Access Needle Cook 4F micropuncture kit + Tuohy-Borst/Copilot control valve An echogenic tip needle is not essential can also ‘score’ needle tip 21G Echogenic Tip Needle 21G Micropuncture Needle
Retrograde Pedal Access: Step-by-Step Have a dedicated RVT hold the probe and guide you (2-person operation): Size of the vessel ‘Short’ landing zone Ultrasound-guided access of Right Dorsalis Pedis artery
Retrograde Pedal Access: Dorsalis Pedis Imaging – Longitudinal Axis Peroneal DP Ultrasound-guided access of Right Dorsalis Pedis artery
Retrograde Pedal Access: US guidance Imaging – Longitudinal Axis Peroneal DP Ultrasound-guided access of Right Dorsalis Pedis artery Doppler – Arterial flow
Retrograde Pedal Access: US guidance Confirm arterial doppler-flow signal to avoid cannulating the accompanying vein Imaging – Longitudinal Axis Peroneal DP Ultrasound-guided access of Right Dorsalis Pedis artery Doppler – Arterial flow
US-guidance: Delineating the artery/vein Things to look for on duplex ultrasound: Vessel wall - calcification of the arterial wall (if present) Doppler flow (including color flow doppler) Arterial flow vs Venous flow signal Manuever to alter ‘flow state’ Venous augmentation
Augmentation of Venous color flow doppler signal US-guidance: Delineating the artery/vein Augmentation of Venous color flow doppler signal
Retrograde Pedal Access: Dorsalis Pedis Advancement of micropuncture needle into right DPA Needle entering right Dorsalis Pedis Artery
Retrograde Pedal Access: Dorsalis Pedis Successful vascular access of right Dorsalis Pedis Artery
Retrograde Pedal Access of Dorsalis Pedis A. Peroneal DP Right DPA
Retrograde Pedal Access: Foot Positioning ‘Frog-leg’ position + Dorsiflexion Plantar Flexion PT artery Dorsalis pedis, distal AT artery ‘Frog-leg’ position PT artery, Peroneal artery
Retrograde Pedal Access: Posterior Tibial A. Artery Vein
Retrograde PT Artery Access: Technique Confirmed arterial doppler-flow signal
Retrograde PT Artery Access: Technique Application of local anesthesia Confirmed arterial doppler-flow signal Insertion of micropuncture needle
Look for “Tenting” of the vessel wall Retrograde PT Artery Access: Technique Look for “Tenting” of the vessel wall Needle approaching Posterior Tibial Artery
Retrograde PT Artery Access: Technique Needle entering Posterior Tibial Artery Blood return - micropuncture needle
Retrograde PT Artery Access: Technique Needle entering Posterior Tibial Artery Advancement of guidewire into vessel lumen
Retrograde Pedal Artery Access: Access with the first puncture to prevent spasm to avoid vascular injury Adequate anti-coagulation (i.e. Heparin) “Anti-spasm” cocktail Nitroglycerin Ca++ channel blocker – Verapamil, Nicardipine
Retrograde DP Access: Sheath Mgt 21G Micropuncture needle in right DP artery 4F Micropuncture sheath + Tuohy-Borst/Co-pilot in right DP artery
Retrograde Pedal Access: Access Site Mgt Management of Access Site-Sheath Options: ‘Bare-back’ over guidewire with balloon catheter or support catheter Vessel wall trauma with repeated entry
Retrograde Pedal Access: Access Site Mgt Management of Access Site-Sheath Options: ‘Bare-back’ over guidewire with balloon catheter or support catheter Vessel wall trauma with repeated entry Use of the Micropuncture introducer sheath No need to exchange out; attach Tuohy- Borst/Copilot control valve Inner diameter = 2.9F (can accommodate the entire length of Cook CXI 0.018” support catheter)
Retrograde Pedal Access: Access Site Mgt Management of Access Site-Sheath Options: ‘Bare-back’ over guidewire with balloon catheter or support catheter Vessel wall trauma with repeated entry Use of the Micropuncture introducer sheath No need to exchange out; attach Tuohy- Borst/Copilot control valve Inner diameter = 2.9F (can accommodate the entire length of Cook CXI 0.018” support catheter)
Retrograde Pedal Access: Access Site Mgt Management of Access Site-Sheath Options: ‘Bare-back’ over guidewire with balloon catheter or support catheter Vessel wall trauma with repeated entry Use of the Micropuncture introducer sheath No need to exchange out; attach Tuohy- Borst/Copilot control valve Inner diameter = 2.9F (can accommodate the entire length of Cook CXI 0.018” support catheter) ‘Dedicated’ 3F pedal access sheath
Retrograde Pedal Artery Access: Hemostasis Manual compression (external) ??compromise distal outflow
Retrograde Pedal Artery Access: Hemostasis Manual compression (external) ??compromise distal outflow Mechanical compression (external) Use of blood pressure cuff Use of TR-band TR-band – Over left distal PT artery access site
Balloon inflation x 5 minutes Retrograde Pedal Access: Hemostasis Balloon occlusion (internal) 2.0-mm diameter Balloon catheter Balloon inflation x 5 minutes
Balloon inflation x 5 minutes Retrograde Pedal Access: Hemostasis Balloon occlusion (internal) 2.0-mm diameter Balloon catheter Balloon inflation x 5 minutes
KL: Successful CLI revascularization Good hemostasis Post: 2-vessel run-off
Retrograde Pedal Access Retrograde pedal access is a valuable technique to have in an interventionalist’s armamentarium needed for the percutaneous treatment of lower extremity arterial occlusive disease/critical limb ischemia. Real time ultrasound-guided pedal access requires training and experience to ensure good outcome & avoid complication(s).
A Primer to Percutaneous Endovascular intervention Thank You