ALAA GABI, MD SUPERVISOR: MEHIAR EL-HAMDANI, MD Combined Radio-Pedal Access is being Used as an Alternative Approach for Peripheral Intervention. ALAA GABI, MD SUPERVISOR: MEHIAR EL-HAMDANI, MD

CASE REPORT 55 YO female patient presented with bilateral progressive claudication. PMH: HTN,HLD,PVD PSH: RT External Iliac artery stent, right femoral to left femoral bypass graft and left femoral to left popliteal graft. SH: Heavy smoker

Ct aNGIOGRAM Right Patent RCI. Occluded Rt external iliac. Reconstituition at the level of Rt SFA and profunda femoris. Good 3 vessel run-off distally.

Ct aNGIOGRAM Left Patent LCI. High grade stenosis of lt external iliac. Diminutive left common femoral artery Occluded Left SFA. Reconstitution at the level of left popliteal artery. Good 3-vessel run off.

procedure Due to bilateral severe femoral disease, radial artery access sheath was used to gain arterial access. Through a radial access, aortogram and bilateral lower extremity peripheral angiograms were obtained. On the right side, the right common iliac artery was patent, there was a stent extending across the right external iliac with a total occlusion in the distal part

The femoral artery was occluded as well as the proximal portion of the SFA with reconstitutes at the level of the middle part of the SFA The popliteal artery was patent with good distal 3 vessels run-off.

On the left side the left common iliac, external and internal iliac were patent. The left common femoral had high grade stenosis in its proximal part, profunda femoris was patent, SFA was totally occluded in it's proximal portion with reconstitution distally via collaterals at the beginning of the popliteal artery with good distal 3 vessel run-off.

It was decided to start with angioplasty on the right side and do a staged angioplasty on the left side at a different session.   Through the radial access multiple attempts to recanalize the right Common Femoral Artery (CFA) failed due to selective advancement of the wire to collateral branches. So, right pedal access was obtained with ultrasound guidance.

A Glidewire was advanced through the pedal access with successful canalization of right CFA. Balloon was inserted and inflated in the CFA and proximal SFA at different levels

Angiogram showed successful restoration of blood flow in the right CFA and SFA. Angiogram also showed high grade osteal disease in the profunda Femoris

A wire was advanced through the left radial access and passed into the profunda.   A balloon was inserted to the proximal profunda and another balloon was inserted through the pedal access to the common femoral. Both balloons were inflated simultaneously in kissing fashion

Angiogram done afterward showed good outcome.

discussion Using pedal and radial access is mainly important when femoral access is not possible. It is associated with a quicker recovery. Avoidance of trans-femoral access complications, like femoral pseudoanerysm and retroperitoneal bleeding.

The small diameter of the dorsalis pedis and radial artery enhances the control and pushabilty of devices during angioplasty. Studies have shown that crossing totally occluded peripheral vessels from the lower cap is usually more successful. Of importance also is through retrograde approach there is less chance of entering unwanted branches given the caudal fashion of collateral branching in peripheral vessels.

conclusion In conclusion, radial and pedal access could represent a good alternative approach to the traditional femoral approach.

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