Vascular imaging of the foot: the first step toward endovascular recanalization.

In the past 5 years, with the introduction of new techniques and dedicated materials, endovascular recanalization of distal tibial and pedal vessels has become a valid alternative to inframalleolar bypass for limb salvage in patients with severe arterial occlusive disease, particularly diabetics. Revascularization of the foot is now often performed by using percutaneous transluminal angioplasty; over a 4-year period, the authors performed more than 2500 antegrade interventional procedures in patients with critical limb ischemia, diabetes, and infrainguinal arterial disease. Intraprocedural angiography of the foot is crucial for successful planning and guidance of percutaneous transluminal angioplasty in tibial and pedal arteries, and its effective use requires both anatomic knowledge and technical skill. To select the best revascularization strategy and obtain optimal clinical results, interventional radiologists, cardiologists, and vascular surgeons performing below-the-knee endovascular procedures also must be familiar with the functional aspects of circulation in the foot. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.316115511/-/DC1.

Mastering the antegrade femoral artery access in patients with symptomatic lower limb ischemia: learning curve, complications, and technical tips and tricks.

BACKGROUND: Antegrade femoral access is fraught by technical challenges and steeper learning curve, in comparison with retrograde contralateral femoral access. We appraised learning curve, complications, and technical aspects inherent in the adoption of antegrade approach. METHODS: Consecutive cases in which antegrade access was attempted by a cardiologist experienced in retrograde access, but inexperienced in antegrade, under supervision of an operator with anterograde expertise, were collected. The primary end-point was the occurrence of antegrade access failure or local complications. Major complications were defined as those life-threatening, requiring transfusion, percutaneous, or surgical repair. RESULTS: Anterograde access was attempted in 120 patients. The primary end-point occurred in 14 (11.6%) cases, but according to the learning curve, in 12 (20%) for first 60 cases vs 2 (3.3%) for the last 60 cases (P = 0.008). Access failure in the hands of the in-training operator was similarly found in all cases but one during the first 60 cases. No major complications occurred, while minor complications were found in 9 (7.5%) patients, again with all but two of them occurring in the first 60 cases. These included peri-adventitial extravasation in 8 patients (6.7%), and perforation of a small branch in one (0.8%); all these complications were conservatively and successfully managed. Obesity was the only significant predictor of access failure/complication (P = 0.004). CONCLUSIONS: This work, the first to report on the learning curve of the antegrade approach, supports the feasibility and safety of this access site even for an in-training operator, if supervised. A minimum caseload of 60 procedures is likely needed to master this technique.