Popliteal and Pedal Vascular
Access and Hemostasis
Tak W. Kwan, MD, FAHA, FACC, FACP, FSCAI
Clinical Professor of Medicine...
I have nothing to disclosure.
Rational for Retrograde Access
▶ SFA CTO
– Often total occlusions that can’t be crossed from
above can easily be traversed...
Popliteal Artery Access
Popliteal Artery Access
▶ The popliteal approach was developed
to cross occluded SFA’s from below but
it has many disadvan...
Popliteal Artery Access
▶ Palpation
▶ Ultrasound guidance
▶ Angiographic guidance
7
Angiographic guidance from radial artery
injection
Hemostasis of Popliteal Access
▶ Manuel compression
▶ Bed rest
▶ Closing devices
– Anecdotal cases
– No outcome study
Transpedal Access: Why
▶ CTO of SFA
– Dual access, antegrade from femoral artery, retrograde from pedal
artery to perform ...
Avoidance of classic femoral
artery access site complication
Kwan T, et al. Journal Invasive Cardiology 2015
Routine use of Pedal Access for lower
extremity Angiography and Interventi...
Kwan T, et al. Journal Invasive Cardiology 2015
Results
SCAI 2015 Annual Scientific Meeting
▶ Pedal access successful rate in these
studies
• 90% (Kwan T, et al. JIC 2015)
• 92.7% (Shah S and Kwan T et al. SCAI 201...
How to do Pedal Puncture?
15
Transpedal Access: Ultrasound Guided
▶ The most feasible technique for accessing the
pedal/tibial vessels.
▶ Color flow to...
Ultrasound Guided
▶ Short axis
– Prefer in AT artery access
– Easy to puncture
– Needle tends to be more vertical
– Need t...
The needle closes to the middle of the
ultrasound probe. The deeper the vessel,
the more vertical is the needle.
Difficult to insert guidewire, be aware of vessel wall, branches After fine adjustment of needle to more co-axial,
then ad...
Ultrasound
▶ Identified the vessels and size
– Prediction difficulty
– No access failure >1.5mm
– Avoid hitting the vein, ...
Normal AT artery
PT artery with veins nearby
Peroneal artery with diseases
AT artery, calcification
AT CTO, reconstitution, with collaterals
Transpedal Puncture: Other Techniques
▶ Fluoroscopic guidance alone
– Can be done directly in heavily calcified vessels ba...
The leg is rotated and the
camera in 30˚. The peroneal
artery lies between the V.
Angiographic guidance
transpedal punctur...
Which Pedal Vessel to Access?
▶ Dorsalis Pedis artery/AT artery
(pedal access of choice)
– Easy to puncture
– Easy to hemo...
▶ Once the sheath is in
place
– Heparinized
– Antispasm cocktail
(NTG, Verapamil)
– Angiogram
• To make sure it is in
the ...
Case Report #1:
S/PAAA Stent Graft
Severe stenosis of the AT artery
Orbital Atherectomy with 1.25 burr and
2.5 mm x 220 mm balloon via the 4F sheath
Post atherectomy and ballooning of AT artery.
Case Example #2
TP trunk CTO
PT artery puncture
PT Access Total TP Trunk Guidewire and balloon were
easily performed.
Case Example #3
SFA CTO
AT CTO
AT access
Totally occluded AT artery Totally occluded SFA
Balloon inflation of AT artery
0.018” guidewire with microcatheter to
reentry into true lumen
Stenting of SFA
Case Example #4:
CTO Iliac Stenting via AT
access
Case Example #5
AT
PT
Peroneal
Case Example #6
Dual Pedal Access
AT CTO
Reversed CART FROM
PERONEAL
Total occluded AT artery, advance 0.018”
glidewire with loop technique.
Subintimal dissection of AT artery.
0.018” Loop wi...
Second pedal access from peroneal artery.
Then, another 3.5 x 150 mm
from peroneal artery to AT
artery (true to false)
(reversed CART).
A 0.014” wire advanced
from ...
Case Example #7
Dual Pedal Access (Pedal and
Radial)
SFA CTO (CART)
Transpedal Angiography via ATA
Transpedal angiography of SFA CTO
Attempt was made to cross using 0.035 Aquatrak wire and crossed via subintimal
plane up ...
Radial Antegrade Approach
4 Fr radial sheath- left radial puncture and cocktail of heparin/nitro/verapamil; use
IMA cathet...
Transpedal Subintimal Approach & Antegrade Angiography
From our pedal access, Aquatrak wire advanced using vertebral cathe...
Pedal-Radial CART Technique
Radial Antegrade
Wire
Pedal Retrograde
Wire
CTO
Lesion
Stented CTO
Externalized
Antegrade Wire...
Transpedal Subintimal Approach & Transradial Dissection Entry
▶ Balloon angioplasty was performed within the distal
true l...
snare
sheath
SFA Stent #1 SFA Stent #2
Post-Intervention SFA
Post-intervention angiogram demonstrates excellent
results were obtained.
Post-Intervention
Outflow at level of TP trunk showing three vessel
runoff
Post-Intevention
Patent AT post intervention
▶ Femoral access is not needed for
complex (TASC D) SFA CTO
interventions
▶ Radial and pedal access can be used
for CART t...
Patent Hemostasis
Patent Hemostasis
TR Band on radial and pedal access site x 2 hours. Patent hemostasis demonstrated by Doppler US of dorsa...
79
TRBand totally occluded distal flow--avoid
TRBand with patent distal flow Vasostat with patent distal flow
Complications
▶ Access site
– Most likely similar to radial artery
– Low risk of bleeding, hematoma
– Perforation, easy to...
Pseudoaneurysm
Access or non-access site related
Pseudoaneurysm 1 week after PT access Failed Long TRBand Compression,
The...
Perforation
Non-access site related
83
Embolization
Non-access site related
AV fistula from CTO or from recannalization?
Non-access site related
86
Vein cannulation (accident)
Transpedal Access Learning Curve
– Transpedal access perceived as
more difficult to learn than
trans-femoral
• Small sized...
Conclusions
▶ Avoid classical femoral access complications
▶ It is particularly useful when the popliteal and infrapoplite...
Conclusions
▶ However, there is still debate about the safety in
routine approach especially in 1-vessel runoff
– Risk and...
Thank You
Puncture site
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
Popliteal and Pedal Vascular Access and Hemostasis
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Popliteal and Pedal Vascular Access and Hemostasis

Tak W. Kwan, MD, FAHA, FACC, FACP, FSCAI Clinical Professor of Medicine Icahn School of Medicine at Mount Sinai Executive Chief of the Asian Services Center Co-Director, Asian Cardiac Services Senior Associate Director of Cardiac Catheterization Laboratory and Interventional Cardiology Mount Sinai Beth Israel, New York City, USA
Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Popliteal and Pedal Vascular Access and Hemostasis

  • 1. Popliteal and Pedal Vascular Access and Hemostasis Tak W. Kwan, MD, FAHA, FACC, FACP, FSCAI Clinical Professor of Medicine Icahn School of Medicine at Mount Sinai Executive Chief of the Asian Services Center Co-Director, Asian Cardiac Services 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 ▶ SFA 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. Popliteal Artery Access
  • 5. Popliteal Artery Access ▶ The popliteal approach was developed to cross occluded SFA’s from below but it has many disadvantages – Patient typically must be prone – There must be a patent popliteal artery – Can’t treat concomitant infrapopliteal disease – Risk of bleeding, AV fistula, and/or pseudoaneurysm – Access site closural is a problem
  • 6. Popliteal Artery Access ▶ Palpation ▶ Ultrasound guidance ▶ Angiographic guidance
  • 7. 7 Angiographic guidance from radial artery injection
  • 8. Hemostasis of Popliteal Access ▶ Manuel compression ▶ Bed rest ▶ Closing devices – Anecdotal cases – No outcome study
  • 9. 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 9
  • 10. Avoidance of classic femoral artery access site complication
  • 11. Kwan T, et al. Journal Invasive Cardiology 2015 Routine use of Pedal Access for lower extremity Angiography and Intervention
  • 12. Kwan T, et al. Journal Invasive Cardiology 2015 Results
  • 13. SCAI 2015 Annual Scientific Meeting
  • 14. ▶ Pedal access successful rate in these studies • 90% (Kwan T, et al. JIC 2015) • 92.7% (Shah S and Kwan T et al. SCAI 2015 abstract) – Once pedal access is in, the success of intervention is very high 163/164 (99%) • (Shah S and Kwan T, et al, SCAI 2015 abstract)
  • 15. How to do Pedal Puncture? 15
  • 16. 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
  • 17. Ultrasound Guided ▶ Short axis – Prefer in AT artery access – 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 – Prefer in PT artery access – Needle is more coaxial – Easier to advance the guidewire
  • 18. The needle closes to the middle of the ultrasound probe. The deeper the vessel, the more vertical is the needle.
  • 19. Difficult to insert guidewire, be aware of vessel wall, branches After fine adjustment of needle to more co-axial, then advance the guidewire.
  • 20. 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
  • 21. Normal AT artery
  • 22. PT artery with veins nearby
  • 23. Peroneal artery with diseases
  • 24. AT artery, calcification
  • 25. AT CTO, reconstitution, with collaterals
  • 26. Transpedal Puncture: Other Techniques ▶ 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. ▶ Palpation – Most patients have poor distal pulse ▶ Peroneal artery puncture – Fluroscopy V sign
  • 27. The leg is rotated and the camera in 30˚. The peroneal artery lies between the V. Angiographic guidance transpedal puncture.
  • 28. 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
  • 29. ▶ 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
  • 30. Case Report #1: S/PAAA Stent Graft
  • 31. Severe stenosis of the AT artery
  • 32. Orbital Atherectomy with 1.25 burr and 2.5 mm x 220 mm balloon via the 4F sheath
  • 33. Post atherectomy and ballooning of AT artery.
  • 34. Case Example #2 TP trunk CTO PT artery puncture
  • 35. PT Access Total TP Trunk Guidewire and balloon were easily performed.
  • 36. Case Example #3 SFA CTO AT CTO AT access
  • 37. Totally occluded AT artery Totally occluded SFA
  • 38. Balloon inflation of AT artery 0.018” guidewire with microcatheter to reentry into true lumen
  • 39. Stenting of SFA
  • 40. Case Example #4: CTO Iliac Stenting via AT access
  • 41. Case Example #5 AT PT Peroneal
  • 42. Case Example #6 Dual Pedal Access AT CTO Reversed CART FROM PERONEAL
  • 43. Total occluded AT artery, advance 0.018” glidewire with loop technique. Subintimal dissection of AT artery. 0.018” Loop wire
  • 44. Second pedal access from peroneal artery.
  • 45. Then, another 3.5 x 150 mm from peroneal artery to AT artery (true to false) (reversed CART). A 0.014” wire advanced from AT artery into the true lumen. 3.5 x 220 mm balloon inflation.
  • 46. Case Example #7 Dual Pedal Access (Pedal and Radial) SFA CTO (CART)
  • 47. Transpedal Angiography via ATA
  • 48. Transpedal angiography of SFA CTO Attempt was made to cross using 0.035 Aquatrak wire and crossed via subintimal plane up to proximal SFA. At this point, we were concerned that further advances would not enter the true lumen of the common femoral artery. To avoid this risk, Controlled Antegrade Retrograde Subintimal Tracking technique was pursued.
  • 49. Radial Antegrade Approach 4 Fr radial sheath- left radial puncture and cocktail of heparin/nitro/verapamil; use IMA catheter and 0.035 Aquatrack wire to traverse subclavian/descending aorta, then exchange IMA for 4 Fr 150cm terumo multicurve catheter.
  • 50. Transpedal Subintimal Approach & Antegrade Angiography From our pedal access, Aquatrak wire advanced using vertebral catheter for support and performed controlled retrograde subintimal dissection entry. Cannulated the left common femoral artery from the radial approach with multicurve catheter.
  • 51. Pedal-Radial CART Technique Radial Antegrade Wire Pedal Retrograde Wire CTO Lesion Stented CTO Externalized Antegrade Wire Subintimal Retrograde Subintimal Balloon Subintimal Antegrade Wire
  • 52. Transpedal Subintimal Approach & Transradial Dissection Entry ▶ Balloon angioplasty was performed within the distal true lumen into the subintimal false lumen using 5.0mm x 100mm at 10 atmosphere to expand the neo lumen. ▶ We completed the CART technique using an antegrade aquatrack wire in the SFA true lumen to enter the now balloon-dilated SFA false lumen, traverse the false lumen and re-enter the distal SFA true lumen. ▶ The antegrade wire was advanced, snared in the anterior tibial artery, and externalized at the pedal access point. ▶ The pedal sheath was upsized to a Terumo 6Fr Slender sheath in preparation for intervention. Antegrade wire Retrograde wire and balloon
  • 53. snare sheath
  • 54. SFA Stent #1 SFA Stent #2
  • 55. Post-Intervention SFA Post-intervention angiogram demonstrates excellent results were obtained.
  • 56. Post-Intervention Outflow at level of TP trunk showing three vessel runoff
  • 57. Post-Intevention Patent AT post intervention
  • 58. ▶ Femoral access is not needed for complex (TASC D) SFA CTO interventions ▶ Radial and pedal access can be used for CART technique
  • 59. Patent Hemostasis
  • 60. Patent Hemostasis TR Band on radial and pedal access site x 2 hours. Patent hemostasis demonstrated by Doppler US of dorsalis pedis artery with TR band. Radial artery hemostasis achieved with “classic patent hemostasis technique” with pulse oximetry after TR Band placement.
  • 61. 79 TRBand totally occluded distal flow--avoid
  • 62. TRBand with patent distal flow Vasostat with patent distal flow
  • 63. Complications ▶ Access site – Most likely similar to radial artery – Low risk of bleeding, hematoma – Perforation, easy to compress – AV fistula, from CTO intervention (easy to seal with balloon inflation) – Pseudoaneurysm • from inadequate compression, PT/peroneal artery? – Access site occlusion • Using heparin, vasodilator, small hydrophilic sheath, patent hemostasis technique • At 1-month, 1.0% from 302 pts (ultrasound)
  • 64. Pseudoaneurysm Access or non-access site related Pseudoaneurysm 1 week after PT access Failed Long TRBand Compression, Then closed after Thrombin Injection.
  • 65. Perforation Non-access site related 83
  • 66. Embolization Non-access site related
  • 67. AV fistula from CTO or from recannalization? Non-access site related
  • 68. 86 Vein cannulation (accident)
  • 69. 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 3 months, 51pts, conversion to femoral 8 pts (16%) – Nowadays, 302 pts, conversion to other access 2.6% (femoral 1%, radial 1.7%)
  • 70. Conclusions ▶ Avoid classical femoral access complications ▶ It is particularly useful when the popliteal and infrapopliteal vessels are occluded ▶ Perfect for outpatient procedure – Early dischage, QOL, nursing staffs sastifications ▶ 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 and aspiration of the pedal sheath creates a continuous flow. It should decrease the no reflow, thrombus formation etc. There are only 2 cases of thrombus formation in >300 consecutive cases of intervention and easily treated.
  • 71. Conclusions ▶ However, there is still debate about the safety in routine approach especially in 1-vessel runoff – Risk and benefit ratio in claudication vs. ischemic limb ▶ Mirror the early stage of Transradial in PCI—difficult to accept ▶ Need further large number and multicenter study 89
  • 72. Thank You Puncture site

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