Below-the-Ankle Antegrade Teleferic Technique: New Approach for Below-the-Ankle Revascularization in Challenging Cases of Chronic Limb-Threatening Ischemia.

PURPOSE: To describe a novel bailout technique to approach below-the-ankle (BTA) chronic total occlusions or plantar-arch severe disease where the balloon/catheter is unable to follow the crossing guidewire and no other described recanalization approach is feasible. TECHNIQUE: When facing a complex BTA revascularization, if the guidewire crosses but the balloon cannot progress due to a lack of pushability, an antegrade puncture of the infrapopliteal vessel where the tip of the guidewire lays is performed. The guidewire is then carefully navigated through this distal BTA vessel into the needle to achieve its rendezvous and externalization. A low-profile balloon is inserted through the femoral access and advanced till the non-crossable point of the BTA vessels. A torque device is then attached to the proximal hub of the balloon, and the through-and-through guidewire is subsequently pulled from the new distal access, allowing the balloon to be dragged across the lesion together with the wire. CONCLUSION: The below-the-ankle antegrade teleferic (BAT) technique may be considered for highly complex BTA revascularization procedures where the wire crosses the lesion, but no other device can be tracked over it. CLINICAL IMPACT: The clinical impact of this article lies in the description of a bailout technique for BTA revascularization where the guidewire crosses, but no device can be advanced. This technique can be helpful in scenarios where failure to achieve success could result in limb loss. The BAT technique provides a solution in extremely challenging cases, enhancing technical success, improving outcomes and potentially preserving the limbs of patients who would otherwise face amputation, if not revascularized.The video shows the BAT technique performed with a support catheter under fluoroscopy: antegrate puncture of the DP, advancement of the support catheter over the wire, rendezvous of the guidewire in the catheter and subsequent externalization of the wire.

Tips and Tricks for Simple and Complex Below-the-Ankle Punctures.

CLINICAL IMPACT: When the standard endovascular crossing maneuvers have failed during CLTI recanalization procedures and the distal below-the-knee or proximal below-the-ankle retrograde access is not possible due to chronic occlusion of the vessels, mastering the more distal and complex retrograde BTA punctures may be advantageous.There are scanty reports regarding the retrograde puncture of the mid and forefoot vessels. The aim of this article is to review different tips and tricks related to these techniques to help operators to apply them in specific scenarios to eventually improve procedural success rate.

Balloon-Assisted Retrograde Puncture of Distal Vessels in Patients Unsuitable for a Conventional Transpedal Approach.

PURPOSE: To describe a novel bailout technique to approach below-the-knee chronic total occlusions after a failed bidirectional recanalization attempt using the plantar loop maneuver in patients who are poor candidates for a retrograde puncture. TECHNIQUE: After a failure of recanalization of the opposite tibial artery using the plantar loop maneuver, an assisted direct retrograde transpedal approach can be performed regardless of poor vessel caliber or even arterial occlusion. After crossing the plantar arch, a low profile angioplasty balloon is used as a landmark for the pedal puncture and to give guidance for the wire advancement from the new access. CONCLUSION: A balloon-assisted retrograde transpedal approach may be considered for below-the-knee recanalization after standard plantar loop technique failure in patients who are not candidates for conventional retrograde puncture.

Retrograde Balloon-Assisted Approach to Prevent Distal Embolization During Complex Recanalization Procedures.

PURPOSE: The purpose of the study is to describe a bailout technical strategy to prevent below-the-knee (BTK) distal embolization during procedures with increased inherent risk using universally-available "off-the-shelf" devices. TECHNIQUE: A conventional retrograde access is obtained of the BTK target vessel where embolization protection is sought. Before starting any potential proximal maneuver with an associated significant risk of distal embolization (eg, atherectomy and mechanical thrombectomy), a low-profile balloon is inserted and inflated through the distal retrograde access, so that any debris resulting from the recanalization procedure is blocked by the stagnant column of blood generated by the inflated balloon. Once the revascularization procedure has been completed, a 4F curved catheter is antegradely advanced down to the distally-inflated balloon, and in case of distal embolization the debris is aspirated in a standard fashion way. CONCLUSION: A retrograde balloon-assisted "off-the-shelf" embolic protection approach may be considered for BTK revascularization procedures where there is an inherent increased risk of distal trash, especially in the presence of distal single-vessel runoff. CLINICAL IMPACT: Distal embolization following endovascular procedures can have devastating consequences and there is a general recommendation for selective use of EPDs in high-risk-scenarios. The increased cost and low availability of the current EPD devices for BTK/BTA arteries have prohibited their widespread use. The retrograde balloon-assisted "off-the-shelf" EPD prevents distal embolization during procedures with increased risk of distal trash using inexpensive, nonspecific equipment available in any basic endovascular suite.

On-Site-Modified Sheath to Overcome the Undesirable Catheterization of the Profunda Femoris Artery During Antegrade Femoral Access.

Purpose: To present a simple method to avoid favored passage of a guidewire into the profunda femoris artery (PFA) after antegrade puncture of the common femoral artery. Technique: A 6-F conventional introducer sheath with a radiopaque distal marker is placed on the nurse's table with its side port orientated to the 12 o'clock position. A small (2-2.5 mm) oval fenestration is created on the superior aspect of the sheath about 3 cm from its tip with a size 11 surgical blade. The modified introducer is passed over the angled 0.035-inch guidewire into the PFA and gently retrieved until the tip marker is ~3 cm from the femoral bifurcation. The dilator is removed, and the guidewire is withdrawn to the level of the fenestration, manipulated through it, and advanced further into the superficial femoral artery under fluoroscopic guidance. Conclusion: When repeated passage of the guidewire down the PFA persists despite conventional manipulation of the wire or needle, an on-site modification of the sheath is an easy alternative approach for the catheterization of the superficial femoral artery.

Homemade Device to Facilitate Percutaneous Venous Arterialization in Patients With No-Option Critical Limb Ischemia.

PURPOSE: To describe a maneuver to facilitate percutaneous arteriovenous fistula creation during venous arterialization procedures in patients with no-option critical limb ischemia. TECHNIQUE: Following a failed arterial recanalization attempt, a balloon catheter is passed up to the tip of the guidewire. Venous access is gained distally, a 4-F sheath is antegradely passed, and a 4-mm GooseNeck snare is advanced through it. A fluoroscopic view that overlaps the snare and the inflated balloon is obtained. If the vein remains anterior with respect to the artery, a needle is inserted across the vein, passing through the snare loop and puncturing the intra-arterial balloon. A wire is inserted and placed inside the punctured balloon. The balloon is retrieved and the wire externalized through the femoral access. A catheter is advanced antegradely over this wire from the artery into the vein. If the vein remains posterior to the artery, a needle is inserted, puncturing the balloon and thereafter the vein (crossing through the snare). A wire is inserted, captured by the snare, and externalized through the vein sheath. A catheter is finally advanced over this wire from the vein into the artery. CONCLUSION: This maneuver is a simple alternative to create an arteriovenous fistula during venous arterialization procedures in patients with no-option critical limb ischemia.

A Modified Syringe Plunger Device Significantly Reduces Guidewire Threading Time Regardless of Experience Level or the Presence of Presbyopia.

PURPOSE: To evaluate the efficacy of a new guidewire threading instrument (GTI) in reducing guidewire threading times compared with the traditional freehand method. MATERIALS AND METHODS: This prospective, controlled, single-center study recruited 100 subjects (mean age 45.2±11.3 years; 43 men) and divided them into 2 groups depending on their professional background: 50 experienced medical personnel (performed or assisted in >50 catheter-based procedures) and 50 medical personnel with no experience in endovascular techniques (inexperienced group). The threading time of both groups was recorded using the conventional freehand method and with the GTI for both 0.035- and 0.014-inch platforms. Users of eyeglasses for presbyopia were tested with and without glasses. Median values are reported with the interquartile range (IQR; Q1, Q3) in parentheses. RESULTS: The mean insertion times with both the 0.035-inch and 0.014-inch guidewires in the overall study group were significantly better with the use of the GTI compared with the traditional freehand method (p<0.001). Both the experienced and the inexperienced participants improved their insertion times using the GTI with both guidewire platforms (p<0.001). The threading time with the new device was also significantly reduced (p<0.001) for both participants with presbyopia and those without. When comparing the median absolute time improvement (difference between freehand/GTI insertion times) for the 0.014-inch platform, the inexperienced group showed a greater improvement in their performance [3.52 seconds (IQR 2.76, 5.12)] compared with the experienced group [1.87 seconds (IQR 1.37, 2.66), p<0.001]. The median "absolute time improvement" was also significantly greater for the presbyopic group [5.75 seconds (IQR 3.14, 8.20)] vs the group without age-related visual impairment [2.64 seconds (IQR 1.65, 3.36), p<0.001]. CONCLUSION: This simple and inexpensive homemade device facilitates wire threading of low-profile catheters and seems to be especially helpful for trainees with no experience and presbyopic operators.

Technique to Facilitate Retrograde Puncture of Mid to Upper Calf Tibial Vessels.

PURPOSE: To describe a simple maneuver to facilitate the retrograde puncture of challenging tibial vessels in the lower leg. TECHNIQUE: Because of the depth of the tibial vessels at the mid to upper calf, especially in obese or muscular patients, a 7- or 9-cm, 21-G micropuncture needle is often needed to reach the artery. However, the low profile of the needle contributes to its flexibility and therefore the tendency to bend as it progresses through the deep tissues, hindering access to the target vessel. To overcome this obstacle, a 4- to 5-cm, 18-G needle is initially placed pointing to the artery. The 21-G needle is advanced through it to the target site. This simple maneuver increases the support to the 21-G needle, preventing its bending and facilitating arterial puncture in the presence of calcified vessels. CONCLUSION: The telescoping needle technique may be considered as a bailout procedure in the retrograde tibial approach after failed attempts secondary to needle bending or calcified vessels.

Buddy Needle Technique to Facilitate Retrograde Puncture of Heavily Calcified Tibial Vessels.

PURPOSE: To describe a technical trick to overcome a prior failed retrograde puncture of the tibial vessels secondary to arterial calcification. TECHNIQUE: Following a prior failed retrograde puncture attempt, the needle is left in place next to the artery. The tip of the needle is then moved toward the artery as a lever so that the artery is fixed between the needle, the skin, and the surrounding tissues. With the artery fixed, a standard puncture procedure is performed. Alternatively, if additional support is needed, 2 micropuncture needles are inserted one on either side of the artery, crossing under the target vessel and hence trapping it between them, providing additional support and therefore enhancing the chance of successful arterial access. CONCLUSION: The buddy needle technique may be considered as an alternative procedure in a retrograde pedal/tibial approach after prior failed standard attempts in patients with heavily calcified vessels.

A new simple method of converting a retrograde femoral access to an antegrade catheterization.

Antegrade puncture is a routinely used technique of obtaining access to the common femoral artery to perform infrainguinal interventions. However, antegrade arterial access can be challenging in the presence of hostile, scarred groins, obesity, or a high common femoral artery bifurcation. A simple method of converting a retrograde femoral access to an antegrade catheterization using an inexpensive and universally available monofilament suture is presented.

Easy technique to overcome the undesirable catheterization of the profunda femoral artery during antegrade femoral access.

BACKGROUND: We describe a simple method to avoid favored passage of the wire into the profunda femoral artery (PFA) after antegrade puncture of the common femoral artery. METHODS: The method consists of placing a 3F Fogarty catheter into the origin of the PFA, which addresses the guidewire toward the superficial femoral artery. CONCLUSION: When a repeated passage of the guidewire down the PFA is experienced despite conventional manipulation of the wire or needle, the barrier technique is an easy alternative approach for the catheterization of the superficial femoral artery.

Easy technique for retro-antegrade superficial femoral artery catheterization.

The antegrade femoral approach is a routinely used technique for the percutaneous treatment of the lower extremities vascular disease. However, this approach can be challenging in case of obese patients or due to special anatomy of the femoral bifurcation. We present a simple and inexpensive alternative by means of the use of a Fogarty catheter to convert a retrograde femoral access to an antegrade catheterization.

Easy alternatives to difficult clamping of distal vessels of the leg.

Control of proximal and back bleeding following an arteriotomy can be challenging when tibial or pedal vessels are noncompressible owing to calcification. We present two easy, inexpensive, and available solutions using a simple intravenous cannula to facilitate clamping of the distal vessels during below-knee revascularization.

Thrombosed iliac venous aneurysm: a rare form of presentation of a congenital anomaly of the inferior vena cava.

Aneurysms of the iliac veins are extremely rare. We report a case of a 51-year-old male who was admitted for swelling of the lower right limb. Sonography and ascending phlebogram showed a complete occlusion of the right femoropopliteal veins, both iliacs and the inferior vena cava (IVC). A large collateral circulation throughout the paravertebral plexus and azygos system was also observed. The CT scan revealed a 5 x 9 cm thrombosed aneurysm of the right external iliac vein and a congenital hypoplasia of the infrarenal IVC. Anticoagulant treatment and compression with elastic stocking was started. The 3-month follow-up showed mild residual edema of the right lower limb. The literature on this pathology is extensively reviewed.