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

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

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

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

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

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

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

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

17. 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

18. Retrograde Pedal Access: Dorsalis Pedis
Advancement of micropuncture needle into right DPA
Needle entering right Dorsalis Pedis Artery

19. Retrograde Pedal Access: Dorsalis Pedis
Successful vascular access of right Dorsalis Pedis Artery

20. Retrograde Pedal Access of Dorsalis Pedis A.
Peroneal DP
Right DPA

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

22. 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

23. 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

24. Retrograde Pedal Artery Access: Hemostasis
Manual compression (external)
??compromise distal outflow

25. 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

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

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

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

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

30. 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

31. 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

32. 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).

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