1. 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

2. 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

3. 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.

4. 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.

5. 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

7. 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.

8. 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.

9. 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.

10. 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

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

12. 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

13. Angiogram done afterward showed good outcome.

14. 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.

15. 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.

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

17. references
Bosiers M, Hart JP, Deloose K, Verbist J, Peeters P. Endovascular therapy as the primary approach for limb salvage in patients with critical limb ischemia: experience with 443 infrapopliteal procedures. Vascular. 2006 Mar-Apr;14(2):63–9.
Rogers RK, Dattilo PB, Garcia JA, Tsai T, Casserly IP. Retrograde approach to recanalization of complex tibial disease. Catheter Cardiovasc Interv. 2011 May 1;77(6):915–25. 
Iyer SS, Dorros G, Zaitoun R, Lewin RF. Retrograde recanalization of an occluded posterior tibial artery by using a posterior tibial cutdown: two case reports. Cathet Cardiovasc Diagn. 1990 Aug;20(4):251–3.
Spinosa DJ, Leung DA, Harthun NL, Cage DL, Fritz Angle J, Hagspiel KD, et al. Simultaneous antegrade and retrograde access for subintimal recanalization of peripheral arterial occlusion. J Vasc Interv Radiol. 2003 Nov;14(11):1449–54.
Downer J, Uberoi R. Percutaneous retrograde tibial access in the endovascular treatment of acute limb ischaemia: a case report. Eur J Vasc Endovasc Surg. 2007 Sep;34(3):350–2. 
Walker C. Durability of PTAs using pedal artery approaches. 37th Annual VEITH Symposium; November 18th 2010; New York City, NY 2010.

18. QUESTIONS?