Transpedal approach for peripheral intervention

1. Transpedal Approach for
Peripheral Intervention
Tak W. Kwan, MD, FAHA, FACC, FACP, FSCAI
Clinical Professor of Medicine
Icahn School of Medicine at Mount Sinai
President, Chinatown Cardiology, P.C.
Senior Associate Director of Cardiac Catheterization
Laboratory and Interventional Cardiology
Mount Sinai Beth Israel, New York City, USA

2. I have nothing to disclosure.

3. Rational for Retrograde Access
▶ Rationals for recannalization of CTO
– Often total occlusions that can’t be crossed from
above can easily be traversed intraluminally from
below.
– Distal cap of occlusion may be softer than the
proximal cap

4. Transpedal Access: Why
▶ CTO of SFA
– Dual access, antegrade from femoral artery, retrograde from pedal
artery to perform complex intervention.
• Botti CF, Jr., Ansel GM, Silver MJ, Barker BJ, South S. Percutaneous retrograde tibial access in
limb salvage. J Endovasc Ther 2003;10:614-8.
• Spinosa DJ, et al. Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI)
for subintimal recanalization to treat chronic critical limb ischemia. J Vasc Interv Radiol. 2005
Jan;16(1):37-44
• Montero-Baker M, Schmidt A, Braunlich S, et al. Retrograde approach for complex popliteal
and tibioperoneal occlusions. J Endovasc Ther 2008;15:594-604.
• Rogers RK, Dattilo PB, Garcia JA, Tsai T, Casserly IP. Retrograde approach to recanalization of
complex tibial disease. Catheter Cardiovasc Interv 2011;77:915-25.
• Mustapha JA, Saab F, McGoff T, et al. Tibio-pedal arterial minimally invasive retrograde
revascularization in patients with advanced peripheral vascular disease: the TAMI technique,
original case series. Catheter Cardiovasc Interv 2014;83:987-94.
• Walker C. Pedal access in critical limb ischemia. J Cardiovasc Surg (Torino) 2014;55:225-7.
• Ruzsa Z, Transpedal access after failed anterograde recanalization of complex below-the-knee
and femoropoliteal occlusions in critical limb ischemia. Catheter Cardiovasc Interv. 2014 May
1;83(6):997-1007
4

5. Avoidance of classic femoral
artery access site complication

6. Routine Use of Primary Pedal Access for Lower Extremity Angiography and
Intervention
▶ Evidence for feasibility and safety
– 80 pts for peripheral angiography and interventions
– All with severe claudication and 10% RC 4
– Successful pedal access (93%)
– Conversion to femoral access (10%)
– Patency of access site by ultrasound at 1 month (100%)
6
Kwan T, et al. Journal Invasive Cardiology 2015

7. Lower Extremities Interventions via Sole Pedal Access-A Novel Approach
▶ 177 pts for peripheral interventions
▶ CLI 36.6%
▶ Pedal access successful rate 92.7%
▶ Average fluoroscopy time 467.5+398.2 sec
▶ Average radiation exposure (air-kerma) 32.8+30.17 mGy
▶ Average contrast used 44+10 ml
▶ One access site closure at 1-month follow-up by
ultrasound
Shah S, Kwan T et al. CCI 2015

8. ▶ Pedal access successful rate in these
studies
• 90% (Kwan T, et al. JIC 2015)
• 92.7% (Shah S and Kwan T et al. CCI 2015)

9. The Evolution of Therapy For Infrainguinal Arterial Occlusive Disease:
Improvement in Quality of Life With Endovascular Interventions via Transpedal
Access
▶ Prospective analysis was
performed of 150 consecutive
patients with symptomatic
PAD who underwent
endovascular intervention via
transpedal access alone.
▶ The validated Walking
Impairment Questionnaire
(WIQ) was completed by all
patients at baseline and 30
days after treatment.
Patel A, Kwan T. et al. TCT 2016

10. A Single Center Experience of Transpedal vs. Transfemoral Approach for
Infrainguinal Endovascular Interventions
▶ Retrospective analysis
▶ Transpedal 204 pts; Transfemoral 199
pts
▶ Access successful rates
– Transpedal 94%; transfemoral 100%
▶ In transfemoral group
– 13 large hematomas (6.5%)
– 1 retroperitoneal bleed requiring
transfusion
▶ In transpedal group
– No major access site complication
– Less contrast dose, less radiation,
less fluoro time
– Access site patency 100% by
ultrasound
10Shah S, Kwan T, et al, TCT 2016

11. Tibiopedal Access for Crossing of Infrainguinal Artery Occlusions: A Prospective
Multicenter Observational Study
▶ Safety and effectiveness of tibiopedal access and retrograde crossing in
the treatment of infrainguinal CTO
– 197 patients (mean age 71±11 years)
– 12 sites
– Rutherford (2/3): 64 pts (32.5%)
– Critical limb ischemia (Rutherford ≥4):133 pts (67.5%)
– A primary antegrade attempt to cross had been made prior to the
tibiopedal attempt in 132 (67.0%) cases
– Follow-up data were obtained 30 days after the procedure.
11
Walker CM, et al. J Endovascular Ther. 2016 Aug. 24

12. ▶ Technical tibiopedal access success was achieved in 184 (93.4%) of 197
patients.
▶ Technical occlusion crossing success in 157 (85.3%) of the 184 successful
tibial accesses.
▶ Minor complications related to the access site:
– 11 (5.6%) cases
– no patient had access vessel thrombosis, compartment syndrome, or
surgical revascularization.
▶ Tibiopedal access appears to be safe and can be used effectively for the
crossing of infrainguinal lesions in patients with severe lower limb ischemia.
12
Walker CM, et al. J Endovascular Ther. 2016 Aug. 24

13. Potential Patient Benefits
▶ Reduced time to ambulation
▶ Reduced procedural access site complications
▶ Less Radiation exposure for peripheral
intervention
▶ Quality of life are improved by transpedal
approach
▶ More access to endovascular treatment options

14. How to do Pedal Puncture?
14

15. Transpedal Access: Ultrasound Guided
▶ The most feasible technique for accessing the pedal/tibial
vessels.
▶ Color flow to assess blood flow
▶ Gray scale to assess the position of the needle
▶ Use of echogenic micropuncture 21/19G tapered needles
▶ 4 Fr. Hydrophilic coated sheath
▶ 0.018” Nitinol Mandril wire

16. Ultrasound Guided
▶ Short axis
– Easy to puncture
– Needle tends to be more vertical
– Need to do some fine adjustment to advance the guidewire
• to make the needle more coaxial to the vessel
▶ Long Axis
– Needle is more coaxial
– Easier to advance the guidewire

19. The needle closes to the middle of the
ultrasound probe. The deeper the vessel,
the more vertical is the needle.

20. Difficult to insert guidewire, be aware of vessel wall, branches After fine adjustment of needle to more co-axial,
then advance the guidewire.

21. Ultrasound
▶ Identified the vessels and size
– Prediction difficulty
– No access failure >1.5mm
– Avoid hitting the vein, especially PT artery
▶ Gray scale
– Identify the calcium, plaque, healthy vessel
▶ Doppler flow
– Color flow
• Antegrade or reverse flow, CTO?
• Length of distal reconstitute portion (if >5cm?) in CTO
– Doppler
• Monophasic, biphasic etc

23. AT artery, calcification

26. AT CTO, reconstitution, with collaterals

29. Transpedal Puncture: Other Techniques
▶ Palpation
– Most patients have poor distal pulse
▶ Fluoroscopic guidance alone
– Can be done directly in heavily calcified vessels based
▶ Angiographic roadmapping
– This is aided by antegrade angiography from the
femoral access site to identify the pedal/tibial vessel
to be accessed.
▶ Peroneal artery puncture
– Fluoroscopy V sign

30. The leg is rotated and the
camera in 30˚. The peroneal
artery lies between the V.
Angiographic guidance
transpedal puncture.

31. Peroneal Artery

32. Which Pedal Vessel to Access?
▶ Dorsalis Pedis artery/AT artery
(pedal access of choice)
– Easy to puncture
– Easy to hemostasis, bone
underneath
▶ PT artery
– Moderate difficulty, deep,
nerve?
– Moderate difficult to
hemostasis
▶ Peroneal artery
– Difficult to be seen in
ultrasound
– Difficult to hemostasis, deep,
between bone

33. ▶ Once the sheath is in
place
– Heparinized
– Antispasm cocktail
(NTG, Verapamil)
– Angiogram
• To make sure it is in
the vessel and
assess the disease
burden of the artery

34. Patent Hemostasis

35. Patent Hemostasis
TR Band and Vasostat on pedal access site x 2 hours. Patent hemostasis demonstrated by Doppler of
distal vessel.

36. 36
TRBand totally occluded distal flow--avoid

37. TRBand with patent distal flow Vasostat with patent distal flow

38. Complications
▶ Access site
– Most likely similar to radial artery
– Low risk of bleeding, hematoma
– Perforation, easy to compress
– AV fistula (may be sealed with external compression)
– Pseudoaneurysm
• Most likely from inadequate compression, PT/peroneal artery?
• Can be treated with thrombin injection
– Access site occlusion
• Using heparin, vasodilator, small hydrophilic sheath, patent
hemostasis technique
• No acute occlusion
• At 1-month, 1.0% from 308 pts (ultrasound) (most 4F sheath)
▶ No retroperitoneal bleeding, blood transfusion, compartment syndrome,
surgical revascularization, or mortality from pedal access

39. Pseudoaneurysm
Access or non-access site related
Pseudoaneurysm 1 week after PT access Failed Long TRBand Compression,
Then closed after Thrombin Injection.

40. 40
Pseudoaneursym of the PTA
Resolution of the pseudoaneurysm
after thrombin injection

41. Perforation
Non-access site related
41

42. Embolization
Non-access site related

43. AV fistula from CTO or from recannalization?
Non-access site related

44. Vein cannulation (accident)

45. Transpedal Access Learning Curve
– Transpedal access perceived as
more difficult to learn than
trans-femoral
• Small sized vessel
• More diseased vessel
• Lack of dedicated
introducer sheath
– First 50 pts, conversion to
femoral access 10%
– After 300 pts, conversion to
femoral access 2.6%

46. Popliteal Artery Aneurysm
46

47. ▶ 80 y.o. male
▶ History of
smoking, HTN,
CAD
▶ S/p AAA stent
graft
▶ Now ischemic
rest pain R> L

48. Right Distal AT Doppler

49. 49

54. Attempted to recannulate from above but failed.

55. 55

57. Proximal pop
Distal pop

58. Decision is to insert DES (Zilver PTX) 7x100mm (three) to treat the SFA
CTO, and one Covered stent (Viabahn 7 x 100mm) to treat the popliteal
aneurysm

62. General Limitation for Transradial Approach to PAD
▶ Technical challenges for long sheaths or
guiding catheters
– small RA
– RA spasm
– radial and brachial tortuosities, loops
– subclavian tortuosities
– dilated and distorted aortic arch
▶ Lack of dedicated hardware
– Length
– SFA, in very tall patients
– Left radial approach and high puncture

63. Staniloe C et al CCI 2013;7:1194-203

64. Conclusions
▶ In compared to Transradial approach for PAD intervention
• No need to modified present peripheral equipment (length)
• Avoid radial loop, subclavian tortuosity, inadvertently cannulated
and perforated intra-abdominal vessel.
• Perfect for tibial vessels as difficult to transmit torque, push from
transradial approach.
• Treatment of outflow tibial vessels first and aspiration of the pedal
sheath creates a continuous flow. It should decrease the no reflow,
thrombus formation etc. Very rarely to see thrombus formation in
pedal approach.
64

65. Conclusions
▶ Access site closure can be more worrisome in Transpedal than
Transradial
– Lack of dedicated Transpedal equipments, sheath, closing
devices etc.
– Extensive collaterals in Radial occlusions
– Smaller diameter of Pedal arteries than radial artery
– More diseases burden in Pedal arteries
– Radial occlusion is a benign phenomenon in extensive
studies
▶ However, access site complications are still very low in our
and others experiences
▶ No one developed acute limb ischemia in Pedal access
65

66. Conclusions
▶ Transpedal
– Good for femoral-popliteal, and infrapopliteal
– Avoid iliac artery tortuosity
– It is particularly useful when the popliteal and
infrapopliteal vessels are occluded
– Perfect for outpatient procedure
– Early discharge, QOL, nursing staffs satisfications
– Mirror the early stage of Transradial in PCI—difficult to
accept
– Need further large number and multicenter study

67. Thank You
Puncture site