Division of Endovascular Interventions Mount Sinai Hospital New York 08/15/2018

Presents with 1-2 Block claudication with Left>>R Case presentation 71 year old male HTN, DM, dyslipidemia, CAD s/p 3V CABG (1995), Ex smoker, s/p AAA repair (2006), Aorto-bifemoral bypass with mutilple PTA Presents with 1-2 Block claudication with Left>>R Medications: ASA, plavix, Lipitor, Lisinopril, Imdur, Metoprolol Hb- 11.5, INR- 1.0, Creatinine- 1.1

Inflow Iliac angiogram

BTK RUNOFF LLE

Popliteal lesion

Left subclavian tortuosity

STRATEGY Left pedal access with micro access and right radial for visualization 4/5 vs 5/6 cm crossover sheath Therapeutic anticoagulation- Angiomax vs heparin Atherectomy? PTA followed by DCB

Alternate access for peripheral interventions Who should be considered: No option for traditional retrograte CFA access (previous aorto-bifemoral bypass graft, previous endovascular repair of abdominal aortic aneurysms, extreme angulations of the aorto-iliac bifurcation, iliac artery occlusion Or for ipsilateral antegrade CFA access (morbid obesity, infected groin, extensive groin scars, patients with hip contractures)

Alternate access points Antegrade femoral Trans-radial Trans-pedal Brachial

Radial access for peripherals

Interventional Cardiology (2015) Volume 7, Issue 1

Access- radial sheaths

Dedicated peripheral radial equipment

Dedicated Radial Peripheral balloons

Transpedal access- pro

Transpedal access

Pedal Access Ultrasound guidance preferred Micropuncture® Pedal Access Set consists of a 21-gage, 4-cm echogenic needle 7-cm Micropuncture® introducer engineered to increase control while gaining retrograde infrapopliteal access; and a 0.018-inch nitinol wire guide and hemostasis valve Check-Flo® hemostasis valve attaches directly to the Micropuncture introducer, allowing it to be used as an interventional introducer with a 2.9-F inner diameter Nitro, heparin and verapamil for IA cocktail

Transpedal