Retrograde Pedal Artery Access Primer to Percutaneous Endovascular Intervention February 5, 2012 Retrograde Pedal Artery Access Nelson Lim Bernardo, MD Washington Hospital Center

Nelson L. Bernardo, MD Honoraria Abbott Vascular Cook Medical Cordis Endovascular Covidien Medtronic Terumo Medical Corporation

Role of Endovascular Intervention in 2012: Percutaneous endovascular intervention (PEI) for treating PAD has significantly evolved in the past 2-3 decades Acceptance of treatment option “New” devices and techniques improving success PEI of below-the-knee (BTK) arterial occlusive disease, especially in critical limb ischemia (CLI), has also been gaining a lot of ground Growing patient population – DM, awareness Utility/success of PEI in limb salvage/preservation

PEI in BTK disease: Tackling CTOs of BTK arteries is the rule in the endovascular treatment of patients with CLI Approximately 15-20% of patients with complex tibio-peroneal arterial occlusive disease cannot be crossed with an antegrade approach using vascular access from the common femoral artery Retrograde pedal access is an alternative: Failure of antegrade access – dissection/subintimal Unfavorable anatomy – ‘flushed’ occluded Also in Tx of femoro-popliteal artery disease

Retrograde Pedal Artery Access: Lower Extremity-Pedal Artery Access: Dorsalis pedis artery (distal anterior tibial A) Distal posterior tibial artery Distal peroneal artery (through interosseous ligament) Techniques 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’ to guide needle insertion Peroneal DP Cons: The artery is entered ‘blindly’ Radiation, + Contrast agent Needle

Retrograde Pedal Access: Duplex Ultrasound Real time ultrasound (US)-guided vascular access Allows real time visualization of vessel anatomy and the advancement of needle into the lumen Real time/Dynamic imaging: Vascular probe in sterile sleeve + US machine Imaging views for needle ‘entry’: Transverse Longitudinal

Retrograde Pedal Access: Duplex Ultrasound Real time ultrasound (US)-guided vascular access Allows real time visualization of vessel anatomy and the advancement of needle into the lumen Real time/Dynamic imaging: Vascular probe in sterile sleeve + US machine Imaging views for needle ‘entry’: Transverse Longitudinal

Real Time Ultrasound Guidance: The goal of real time US-guided access is to show the needle tip in the image and follow its course as it enters the lumen of the vessel Improves ‘safety’ & ‘success’ of vascular access (especially in veins) Arterial success – ‘makes sense’, ??data Only routine use of real time US vascular access technique could achieve 100% success rate with no complications

US-guided Pedal Access: Equipments Vascular probe + US machine

US-guided Pedal Access: Equipments Vascular probe + US machine 4F micropuncture kit + Tuohy-Borst/Copilot control valve

Equipments for Retrograde Pedal Access 4F micropuncture kit + Tuohy-Borst/Copilot control valve 21G Echogenic Tip Needle 4F Micropuncture Sheath 21G Micropuncture Needle

Retrograde Pedal Access: Dorsalis Pedis Ultrasound-guided access of Right Dorsalis Pedis artery

Retrograde Pedal Access: Dorsalis Pedis Peroneal DP Ultrasound-guided access of Right Dorsalis Pedis artery

Retrograde Pedal Access: US guidance 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 Peroneal DP Ultrasound-guided access of Right Dorsalis Pedis artery Doppler – Arterial flow

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 DP Access: Sheath Mgt 21G Micropuncture needle in right DP artery 4F Micropuncture sheath + Tuohy-Borst/Co-pilot in right DP artery

Retrograde Pedal Artery Access: Access with the first puncture to prevent spasm “Anti-spasm” cocktail Nitroglycerin Heparin Ca++ channel blocker – Verapamil Dedicated 4F pedal access kit ** Micropuncture introducer inner diameter = 2.9F ** ‘Bare-back’ balloon catheter

Wire into R Popliteal Artery Retrograde DP Access: Sheath Mgt 4F Micropuncture sheath + Co-pilot Guidewire advanced using 0.018” Support Catheter (Cook CXI) through 4F micropuncture sheath Wire into R Popliteal Artery

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

Retrograde Pedal Artery Access: TR-Band Courtesy of Dr. J. Wang

Balloon inflation x 5 minutes Retrograde Pedal Artery Access: Hemostasis Balloon occlusion (internal) 2.0-mm diameter Balloon catheter Balloon inflation x 5 minutes

Balloon inflation x 5 minutes Retrograde Pedal Artery Access: Hemostasis Balloon occlusion (internal) 2.0-mm diameter Balloon catheter Balloon inflation x 5 minutes

using internal balloon occlusion Retrograde Pedal Artery Access: Hemostasis Good hemostasis using internal balloon occlusion Post: 2-vessel run-off

Real Time US Guidance for Vascular Access Advantage: Direct visualization of artery Anatomy – bifurcation Vessel wall – calcified diseased segment Anterior stick Visualization of track of needle entry

Real Time US Guidance for Vascular Access Routine application or only with infrequently accessed vessels Pedal arteries Proximal segment of tibial arteries Popliteal artery SFA CFA Axillary artery Brachial artery Radial artery Ulnar artery

Conclusions: Use of retrograde pedal artery access is clearly an innovative technique and is a valuable tool to have in an interventionalist’s armamentarium needed for the percutaneous treatment of lower extremity arterial occlusive disease/critical limb ischemia. Case selection, operator experience (i.e. real-time ultrasound guidance) and appropriate technique are essential for optimal procedural and clinical success and avoid complication(s).

Thank you. Have a Good Day! On the road to Mount Everest Yamdro Yumtso Lake