The Relationship Between the Global Limb Anatomic Staging System (GLASS) and Midterm Outcomes of Retrograde Tibiopedal Access After Failure of Antegrade Recanalisation for Chronic Limb Threatening Ischaemia.

OBJECTIVE: To examine the relationship between the Global Limb Anatomic Staging System (GLASS) and midterm limb and survival related outcomes of retrograde tibiopedal access, after failed recanalisation of infrainguinal chronic total occlusions (CTOs) using the antegrade approach, in patients with chronic limb threatening ischaemia (CLTI). METHODS: This prospective, observational study was conducted between January 2017 and April 2019, and included 213 patients (29 GLASS I, 53 GLASS II, and 131 GLASS III lesions) with infrainguinal CTO in whom a percutaneous tibiopedal access was attempted following failed recanalisation using an antegrade approach. Multivariable Cox proportional hazard regression was performed to assess possible predictors of midterm clinical outcomes. Kaplan-Meier survival curves were used to estimate limb based patency (LBP), limb salvage, amputation free survival (AFS), and overall survival. RESULTS: The study reported access, crossing, and treatment success of 92.5%, 89.2%, and 89.2% of all tibiopedal access attempts, respectively. In comparison with GLASS I, GLASS stage III was associated with statistically significantly worse midterm LBP (p = .005), overall survival (p = .037), limb salvage (p = .021), and AFS (p < .001). CONCLUSION: Retrograde tibiopedal access for recanalisation of infrainguinal CTOs in patients with CLTI is associated with high access, crossing, and treatment success, and low complication rates. The study suggests that GLASS stage may be a useful predictor of midterm limb and survival related outcomes of this approach. In comparison with GLASS I, GLASS III anatomy is associated with a statistically significantly worse LBP, limb salvage, AFS, and overall survival.

Functional hemodynamics assessment during endovascular Tibio-pedal retrograde intervention of peripheral arterial disease.

OBJECTIVE: We sought to use a novel technique to measure the functional hemodynamics of peripheral arterial lesions during endovascular interventions. BACKGROUND: Functional hemodynamics has not been thoroughly evaluated during endovascular interventions. The aim of our study is to evaluate the feasibility and the potential benefits of pedal pressures measurements from tibio-pedal access. METHODS: We retrospectively reviewed 100 consecutive patients who underwent endovascular interventions via tibio-pedal artery access between October 3, 2018 and December 15, 2018. Baseline and postintervention pedal pressures from the pedal sheaths were measured. We also evaluated the pedal-brachial index (PBI) which is defined as the pedal sheath pressure divided by the simultaneously brachial cuff pressure. We compared baseline pedal pressures, postintervention pedal pressures, baseline PBI, postintervention PBI, % change of PBI ([postintervention PBI minus baseline PBI]/baseline PBI), and resting ankle-brachial index (ABI) versus baseline PBI in this cohort of patients. RESULTS: All 100 patients had successful tibio-pedal artery access. Baseline pedal pressure was 70 + 30 mmHg with post intervention pedal pressure of 133 + 27 mmHg (p < .001). Baseline PBI was 0.75 + 0.24 with post intervention PBI of 1.09 + 0.19 (p < .001). The correlation coefficient of resting ABI vs. baseline PBI was 0.55. The % change of PBI was 63.2 + 52.4%. There was significant improvement of postintervention PBI when compared to baseline PBI in the majority of patients. CONCLUSIONS: Obtaining pedal pressures and PBI from tibio-pedal access can be a feasible tool for endovascular interventions. This simple technique can provide us important functional hemodynamics information before and after peripheral revascularization.

Transradial versus tibiopedal access approach for endovascular intervention of superficial femoral artery chronic total occlusion.

BACKGROUND: Improved equipment and techniques have resulted in transition from surgical bypass to endovascular intervention to treat superficial femoral artery (SFA) chronic total occlusions (CTO). A change in access site to radial (TRA) or tibiopedal (TPA) artery for the treatment of these SFA CTO has been reported. The feasibility, efficacy and safety of these two access sites for treatment of SFA CTO have not been reported. METHODS: We performed an as treated analysis of 184 SFA CTO interventions in 161 patients from 01/2014 to 09/2016 using either primary TRA or TPA (operator discretion) at two institutions. Primary end point was 30 day major adverse event (MAE) - death, amputation or target vessel revascularization, secondary endpoint was success of procedure. RESULTS: Primary TRA was used in 46 patients with 47 CTO lesions .Primary TPA was used in 115 patients with 137 CTO lesions. Primary crossing success rate was higher with TRA compared to TPA (74% vs 54%, P = 0.01). Dual TRA-TPA was required in 72 prior uncrossed lesions resulting in a crossing and procedural success of 99% and 96% respectively. The overall crossing and procedural success rate using either of these approaches was 99% and 98% respectively. The 30 day MAE was 5% in TRA arm, 0% in TPA arm and 2% in dual TRA-TPA arm, P = 0.08. All access sites were patent, confirmed by ultrasound. CONCLUSION: The treatment of SFA CTO is feasible and safe using both TRA or TPA approach providing high success rates and no access site complications.

Chronic Total Occlusion Crossing Approach Based on Plaque Cap Morphology: The CTOP Classification.

PURPOSE: To present the chronic total occlusion (CTO) crossing approach based on plaque cap morphology (CTOP) classification system and assess its ability to predict successful lesion crossing. METHODS: A retrospective analysis was conducted of imaging and procedure data from 114 consecutive symptomatic patients (mean age 69±11 years; 84 men) with claudication (Rutherford category 3) or critical limb ischemia (Rutherford category 4-6) who underwent endovascular interventions for 142 CTOs. CTO cap morphology was determined from a review of angiography and duplex ultrasonography and classified into 4 types (I, II, III, or IV) based on the concave or convex shape of the proximal and distal caps. RESULTS: Statistically significant differences among groups were found in patients with rest pain, lesion length, and severe calcification. CTOP type II CTOs were most common and type III lesions the least common. Type I CTOs were most likely to be crossed antegrade and had a lower incidence of severe calcification. Type IV lesions were more likely to be crossed retrograde from a tibiopedal approach. CTOP type IV was least likely to be crossed in an antegrade fashion. Access conversion, or need for an alternate access, was commonly seen in types II, III, and IV lesions. Distinctive predictors of access conversion were CTO types II and III, lesion length, and severe calcification. CONCLUSION: CTOP type I lesions were easiest to cross in antegrade fashion and type IV the most difficult. Lesion length >10 cm, severe calcification, and CTO types II, III, and IV benefited from the addition of retrograde tibiopedal access.

Innovations in the Endovascular Management of Critical Limb Ischemia: Retrograde Tibiopedal Access and Advanced Percutaneous Techniques.

PURPOSE OF REVIEW: Retrograde tibiopedal access and interventions have contributed to advance of endovascular techniques to treat critical limb ischemia (CLI) patients. This review encompasses the spectrum from advanced diagnostic imaging and technical therapeutic approaches for infrapopliteal occlusions, to a discussion of current standards and future directions. RECENT FINDINGS: Contemporary studies of infrapopliteal angioplasty show suboptimal short-term and 1-year clinical outcomes. Comparative data is needed to shift the focus from PTA to disruptive treatment modalities that can further improve outcomes. Retrograde pedal access has emerged as an important tool to facilitate successfully percutaneous revascularization and limb salvage in patients with CLI. To efficiently approach the complexity of CLI, new thought processes are needed to change the reigning paradigms. Retrograde tibial-pedal access has shown improvement in the rate of successful revascularizations and is an important tool in the amputation-prevention armamentarium. Additional technologies may further improve success rates. Drug-eluting stents have shown better outcomes than PTA in patients with focal infrapopliteal lesions. Registry data have demonstrated the advantage of several atherectomy devices in the tibial arteries. More recently, bioresorbable vascular scaffolds have been used successfully, and further studies with drug-coated balloons are underway. Interventional operators are now even working in the inframalleolar space to reconstitute the plantar arch. Well-conducted studies are needed to generate high-quality evidence in the field of critical limb ischemia management.

Tibiopedal Access for Crossing of Infrainguinal Artery Occlusions: A Prospective Multicenter Observational Study.

PURPOSE: To report a prospective, multicenter, observational study (ClinicalTrials.gov identifier NCT01609621) of the safety and effectiveness of tibiopedal access and retrograde crossing in the treatment of infrainguinal chronic total occlusions (CTOs). METHODS: Twelve sites around the world prospectively enrolled 197 patients (mean age 71±11 years, range 41-93; 129 men) from May 2012 to July 2013 who met the inclusion criterion of at least one CTO for which a retrograde crossing procedure was planned or became necessary. The population consisted of 64 (32.5%) claudicants (Rutherford categories 2/3) and 133 (67.5%) patients with critical limb ischemia (Rutherford category ≥4). A primary antegrade attempt to cross had been made prior to the tibiopedal attempt in 132 (67.0%) cases. Techniques used for access, retrograde lesion crossing, and treatment were at the operator's discretion. Follow-up data were obtained 30 days after the procedure. RESULTS: Technical tibiopedal access success was achieved in 184 (93.4%) of 197 patients and technical occlusion crossing success in 157 (85.3%) of the 184 successful tibial accesses. Failed access attempts were more common in women (9 of 13 failures). The rate of successful crossing was roughly equivalent between sexes [84.7% (50/59) women compared to 85.6% (107/125) men]. Technical success did not differ significantly based on a prior failed antegrade attempt: the access success rate was 92.4% (122/132) after a failed antegrade access vs 95.4% (62/65) in those with a primary tibiopedal attempt (p=0.55). Similarly, crossing success was achieved in 82.8% (101/122) after a failed antegrade access vs 90.3% (56/62) for patients with no prior antegrade attempt (p=0.19). Minor complications related to the access site occurred in 11 (5.6%) cases; no patient had access vessel thrombosis, compartment syndrome, or surgical revascularization. CONCLUSION: Tibiopedal access appears to be safe and can be used effectively for the crossing of infrainguinal lesions in patients with severe lower limb ischemia.

Combined Radial-Pedal Access Strategy and Radial-Pedal Rendezvous in the Revascularization of Complex Total Occlusions of the Superficial Femoral Artery (the "No Femoral Access" Strategy).

PURPOSE: To describe the combined use of radial-pedal access for recanalization of complex superficial femoral artery (SFA) occlusions unsuitable for transfemoral recanalization. TECHNIQUE: Patients are selected for this strategy if they have a long (≥ 10 cm) SFA occlusion with unfavorable aortoiliac anatomy, an absent ostial stump, or severely diseased and calcified distal reconstitution. Left radial artery and distal anterior or posterior tibial artery are accessed with 6-F and 4-F sheaths, respectively. The SFA lesion is crossed retrogradely with a 0.035-inch wire system. If retrograde crossing is not immediately successful, transradial subintimal tracking and radial-pedal subintimal rendezvous are used to allow retrograde reentry. Fifteen patients (mean age 62 ± 5 years; 11 men) have been treated in this fashion, and frequently stented, through the tibiopedal access. Seven patients required radial-pedal rendezvous to facilitate retrograde reentry. Two patients underwent transradial iliac stenting during the same session, and 1 patient underwent transradial kissing angioplasty of the profunda. No major complication occurred in any patient. After the procedure, the pulse across the accessed tibial artery was palpable in all patients. CONCLUSION: In patients with long and complex SFA occlusion unsuitable for transfemoral recanalization, a radial-pedal strategy can overcome revascularization obstacles.

Short-Term Outcomes After Retrograde Versus Antegrade Crossing Approaches for Femoropopliteal Occlusive Disease.

OBJECTIVE: To compare short- and mid-term outcomes of patients with femoropopliteal (FP) occlusive disease treated with a retrograde vs antegrade crossing strategy. BACKGROUND: Few studies have directly compared procedural details and outcomes after retrograde vs antegrade crossing of FP lesions. METHODS: Patients undergoing retrograde approaches to FP lesions were identified from the multicenter Excellence in Peripheral Artery Disease (XLPAD) registry between 2007 and 2015. These patients were matched 1:1 to patients treated with antegrade crossing strategies based on age, gender, comorbidities, indication for procedure, and lesion characteristics. Technical success, major adverse limb events (MALEs), and overall device cost were compared between retrograde and antegrade-only crossing. RESULTS: A total of 116 patients (58 antegrade and 58 retrograde) were included. The retrograde group had higher prevalence of coronary artery disease and presence of chronic total occlusions. The retrograde approach was associated with significantly longer procedural time (186 ± 70 minutes vs 124.4 ± 60 minutes; P<.001), but similar technical success (91.4% vs 96.6%; P=.24). There was no significant difference in perioperative morbidity. Patients treated with a retrograde approach had a lower total amputation rate (8.6% vs 22.4%; P=.04) and no difference in overall mortality (8.6% vs 5.2%; P=.47). Mean procedural costs were similar in the antegrade and retrograde groups. CONCLUSION: In patients with similar disease characteristics, a retrograde approach to FP occlusive disease was associated with longer procedural time, but improved limb salvage, without significant difference in procedural cost.

Transpedal and Tibiopedal Retrograde Revascularization for Peripheral Vascular Disease.

Peripheral vascular disease, or peripheral artery disease (PAD), is a chronic and debilitating disease that affects millions of people worldwide. PAD is associated with abnormal arterial narrowing, specifically outside of the heart and brain. PAD is primarily observed in the legs, but it can also affect the kidneys, arms, and neck. Patients with PAD often complain of acute leg pain that occurs when walking. However, the pain resolves with rest. The phenomenon of acute pain due to narrowed arteries is known as intermittent claudication. Common symptoms of PAD include abnormal hair and nail growth, bluish skin, skin ulcers, and cold skin. Untreated and unmanaged PAD can lead to serious complications such as tissue infection or necrosis, which in turn could lead to amputation. In rare cases, PAD may cause a stroke or coronary artery disease. Among all the management options available, the endovascular approach remains the recommended and the gold standard nowadays. In this paper, we examine and analyze the transpedal and tibiopedal retrograde revascularization in PAD patients in which the conventional antegrade approach is not successful intra-operatively with emphasis on the challenges and postoperative complications. It also correlates the different studies and its outcomes with an up-to-date worldwide results.

Tibio-pedal arterial pressure assessment during endovascular intervention to improve quality-of-life in patients with intermittent claudication.

Objective: The aim of this study is to compare the quality-of-life (QOL) outcomes and the tibio-pedal arterial pressure post-endovascular intervention. Background: Physiological assessment of peripheral arterial lesions is infrequently performed during endovascular interventions. Materials and methods: We retrospectively reviewed all 343 patients with intermittent claudication who underwent an endovascular intervention via tibio-pedal artery access from October 2018 to May 2021. The baseline and post-intervention tibio-pedal arterial pressures from the pedal sheaths were measured. QOL was assessed using a pre-validated Walking Impairment Questionnaire (WIQ) score before and at 30-day after intervention. We compared the baseline tibio-pedal arterial pressure, post-intervention tibio-pedal arterial pressure, delta pressure (post-intervention minus baseline), baseline WIQ scores, 30-day WIQ scores, and delta score (30-day minus baseline). Results: All 343 patients had successful tibio-pedal accesses. The average tibio-pedal arterial pressure at baseline was 87.0 ± 1.8 mmHg vs. 135.5 ± 1.7 mmHg post-intervention (p < 0.001). Average baseline and 30-day WIQ scores were summation (99.8 ± 3.3 vs. 115.0 ± 3.1, p < 0.001), walking distance (35.7 ± 1.3 vs. 42.5 ± 1.3, p < 0.001), walking speed (21.1 ± 0.9 vs. 23.6 ± 0.8, p = 0.036), stair climbing (4.7 ± 1.4 vs. 24.2 ± 1.4, p = 0.019), and symptoms (18.8 ± 0.2 vs. 20.1 ± 0.2, p < 0.001), respectively. When comparing the increased post-intervention tibio-pedal arterial pressure <60 mmHg vs. ≥60 mmHg, the average delta WIQ scores were all significantly improved with summation (10.0 ± 3.9 to 25.8 ± 5.5, p = 0.01), walking distance (4.1 ± 1.7 to 9.8 ± 2.5, p = 0.02), walking speed (1.5 ± 1.1 to 4.3 ± 1.5, p = 0.02), stair climbing (2.3 ± 1.8 to 9.4 ± 2.5, p = 0.02), and symptoms (1.0 ± 0.3 to 1.8 ± 0.4, p = 0.04), respectively. Conclusion: Increasing the post-intervention tibio-pedal arterial pressure by 60 mmHg can enhance QOL as suggested by improvement of WIQ scores.

Tibiopedal Motion Following Tendo-Achilles Lengthening or Gastrocnemius Recession in Total Ankle Replacement: A Comparative Cohort Study.

BACKGROUND: End-stage ankle arthritis is a debilitating condition often necessitating total ankle replacement (TAR). Tendo-Achilles lengthening (TAL) and gastrocnemius recession (GR) are commonly performed with TAR to improve ankle dorsiflexion (DF). No studies to date have radiographically analyzed tibiopedal motion to guide surgical management. The purpose of this study is to determine the effect of a TAL or GR during TAR on radiographic tibiopedal range of motion (ROM). METHODS: A retrospective review of a prospectively maintained database was conducted followed by a propensity score-matched analysis of 110 patients who underwent TAL (n = 26), GR (n = 29), or no lengthening procedure (n = 55) with TAR. Minimum of 1-year ROM radiographic follow-up was required. Exclusion criteria included (1) calcaneal osteotomies, (2) simultaneous or previous hindfoot or midfoot arthrodesis, (3) prior ankle arthrodesis, or (4) revision TAR. Demographic data were extracted from the TAR database. Radiographic assessment included tibiopedal dorsiflexion (DF) and plantarflexion (PF). RESULTS: DF improved by 2.8 degrees (P = .0286) and by 6.0 degrees (P < .0001) in the TAL and GR cohorts, respectively, with no difference in the control group (+0.7 degrees, P = .3764). PF was decreased by 4.5 degrees (P = .0152) and by 7.2 degrees (P = .0002) in the TAL and GR cohorts, respectively, with no difference in the control group (-0.2 degrees, P = .8546). Minimal differences were observed for total arc of motion for all 3 groups (control 0.5 degrees, GR -1.2 degrees, TAL -1.7 degrees), all of which were nonsignificant (all P > .05). There was no between-group difference in the change in overall arc of motion between the groups (P = .3599). GR resulted in a greater increase in DF (6.0 vs 2.8 degrees; P = .1074), with a reciprocal greater decrease in PF (7.2 vs 4.5 degrees; P = .2416) compared with the TAL cohort. CONCLUSION: Both TAL and GR increased postoperative DF; however, this was accompanied by a reciprocal loss in PF. Minimal differences were observed for total arc of motion. Patients should be counseled that concomitant procedures performed to increase DF will do so at the expense of PF. LEVEL OF EVIDENCE: Level III, retrospective review of prospectively collected data.

Facilitated Intravascular Ultrasound-Guided Balloon-Assisted Re-Entry Technique for Complex Lower-Extremity Chronic Total Occlusions: The FIBRE Technique.

PURPOSE: To examine the efficacy and safety of the facilitated intravascular ultrasound (IVUS)-guided balloon assisted-re-entry (FIBRE) technique in the treatment of complex, chronic total occlusion (CTO) peripheral arterial lesions. METHODS: A retrospective analysis of 150 patients undergoing peripheral intervention for lower extremity CTO was performed from 2014 to 2017 at two institutions. From the selected population, 10 patients with complex CTOs were identified using the FIBRE technique. Procedural success, 30 day and 6 month patency rates, ankle brachial index improvement, and complications were analyzed. RESULTS: Ten out of 150 patients had the FIBRE technique utilized to attempt revascularization of a complex CTO of a femoropopliteal artery. Technical success was achieved in all 10 patients (100%). There were no intra-operative or peri-procedural complications reported including vessel perforation, bleeding, distal embolization, infrapopliteal vessel compromise, or infection. Arterial studies were obtained at 30 days and 6 months to assess patency in 9/10 patients (90%), with 1 patient being lost to follow up. Of the 9 patients, all 9 (100%) had documented arterial patency at both 30 days and 6 months. All patients reported improvement in symptoms. There were also no reports of re-intervention, amputation, or death at 6-month follow up. CONCLUSIONS: The FIBRE technique is a safe and feasible strategy with excellent technical success in experienced hands for revascularization of complex lower extremity CTO when conventional modalities fail.

Approach to Tibiopedal Retrograde Revascularization of Below-The-Knee Peripheral Arterial Diseases With or Without Transradial Guidance Peripheral Angiography.

OBJECTIVE: We sought to compare the use of transradial peripheral angiography to guide retrograde revascularization of below-the-knee (BTK) lesions using tibiopedal access (TPA). BACKGROUND: Tibiopedal retrograde revascularization of BTK lesions is an emerging technique in peripheral interventions. METHODS: We performed an observational cohort study of 194 consecutive adult patients with critical limb ischemia (CLI) who underwent endovascular intervention for BTK diseases using peripheral angiography and primary TPA access with vs without transradial (TR) guidance at 2 centers (New York, USA and Budapest, Hungary). The primary endpoints were procedure success, 30-day major adverse event rate, 30-day access-site complication rate, and 30-day access-site patency rate by ultrasound. Secondary endpoints were periprocedural complications, fluoroscopy time, procedure length, and crossover rate to femoral access. RESULTS: There were 78 patients in the TR-guidance group and 116 patients in the non-TR guidance group. Overall procedure success rates with TR guidance vs without TR guidance were 97% and 98%, respectively. Fluoroscopy times (732.8 ± 615.7 seconds vs 769.8 ± 565.8 seconds; P=NS) and procedure times (46.5 ± 24.4 minutes vs 55.4 ± 12.6 minutes; P=NS) were similar in the TR-guidance group vs the non-TR guidance group, but contrast volumes were higher in the TR-guidance group (100.0 ± 60.1 mL vs 43.8 ± 10.2 mL in the non-TR guidance group; P<.05). There was no difference in 30-day major adverse events, other than higher amputation rate in the TR-guidance group (15.3%), which was attributed to severe baseline complex CLI status in this patient group. There was 1 case of arteriovenous fistula, 1 case of pseudoaneurysm, and 1 case of tibiopedal artery occlusion at 30 days in the group without TR guidance. There were 3 cases (3.8%) of radial artery occlusion in the TR-guidance group. CONCLUSIONS: The treatment of CLI with BTK lesions is feasible and safe, with a high procedural success rate and low access-site complication rate using the TPA approach regardless of whether or not TR guidance is utilized.

Primary Retrograde Tibio-Pedal Approach for Endovascular Intervention of Femoropopliteal Disease with Chronic Total Occlusion.

OBJECTIVES: This study investigated the feasibility, safety, and the acute outcome of primary retrograde tibio pedal approach (TPA) in the treatment of peripheral arterial disease (PAD) with femoropopliteal (FP) chronic total occlusion (CTO). BACKGROUND: With maturing in endovascular technology and further development in new devices, endovascular therapy has become a comparable and preferred treatment for patients with PAD. The retrograde TPA has not been studied to treat FP CTO extensively. METHODS: We performed a retrospective analysis of 98 consecutive patients who underwent peripheral angiogram and intervention of 123 FP CTO lesions from June 1st, 2016 to June 30th, 2018 in a single center. Peripheral angiography and percutaneous balloon angioplasty was done primarily via retrograde TPA. Demographic data, procedural success rate, peri-procedural major adverse complications, and 30-day outcomes were recorded. RESULTS: Out of 123 procedures, the dorsalis pedis artery/distal anterior tibial artery was the most common TPA site (59%) followed by the posterior tibial artery in 27% patients and peroneal artery in 14% patients. In 40 (33%) FP CTO lesions, additional transradial accesses were needed for controlled antegrade and retrograde tracking (CART) technique. Overall procedural success was achieved in 122 FP CTO (99%) lesions. No patients had significant access site bleeding, hematoma, worsening kidney dysfunction or acute limb ischemia within 30-day following this procedure. CONCLUSIONS: The primary retrograde TPA for FP CTO lesions is safe and feasible. With a combination of tibio pedal and transradial approach, our procedural success rate is very high for FP CTO intervention.

Diagnostic and Therapeutic Approaches in the Management of Infrapopliteal Arterial Disease.

Chronic limb-threatening ischemia represents end-stage peripheral artery disease. It is underdiagnosed; it relies on clinical symptoms and traditional noninvasive tests, which significantly underestimate the severity of disease. Innovative techniques, approaches, technologies, and risk-assessment tools have significantly improved our ability to treat these patients and to better understand their complex disease process. For patients with chronic limb-threatening ischemia considered without options, the reengineering of deep venous arterialization procedures has shown promising results. Finally, the creation of interactive and multidisciplinary teams in centers of excellence is of paramount importance to significantly improve the care and outcomes of these patients.

A Novel Patent Hemostasis Protocol - Prevention of Pseudoaneurysm after Tibiopedal Arterial Access for Evaluation and Treatment of Peripheral Arterial Disease.

BACKGROUND: Pseudoaneurysm (PSA) is a rare complication (0.2%) after transpedal arterial access (TPA) for endovascular treatment of peripheral arterial disease, occurring only in the posterior tibial artery (PTA) likely related to the anatomy of the vessel leading to unfavorable circumstances for adequate hemostasis. We describe a novel patent hemostasis protocol for TPA access to avoid PSA. METHODS: We prospectively studied 586 patients with symptomatic PAD who underwent 1038 peripheral procedures between 02/2016 and 02/2017 via TPA (dorsalis pedis artery (DP)/anterior tibial artery (ATA), PTA or peroneal artery (PA)). Hemostasis for the DP/ATA was achieved with the Vasostat™ device, while TR Band™ was used for PTA/PA, as per our new protocol (figure). Patent hemostasis technique was confirmed using Doppler. RESULTS: Of the 1038 procedures, 733 (88% interventional) were done via the DP/ATA, 176 (92% interventional) were done via the PTA and 129 (64% interventional) were via the PA. The incidence of PSA related to any access site was 0.0%. All access sites were patent on Doppler ultrasound at 30 day follow up. CONCLUSION: PSA associated with TPA is very rare, it can be easily prevented with the above described patent hemostasis protocol while preserving the patency of the access site. CONDENSED ABSTRACT: Pseudoaneurysm (PSA) is a rare complication (0.2%) after transpedal arterial access (TPA). We describe a novel patent hemostasis protocol for TPA access to avoid PSA. We prospectively studied 586 patients with symptomatic PAD who underwent 1038 endovascular procedures via TPA (dorsalis pedis artery (DP)/anterior tibial artery (ATA), PTA or peroneal artery (PA)). Hemostasis for the DP/ATA was achieved with the Vasostat™ device, while TR Band™ was used for PTA/PA, as per our new protocol (figure). Patent hemostasis technique was confirmed using Doppler. The incidence of PSA related to any access site was 0.0%. All access sites were patent on Doppler ultrasound at 30 day follow up. PSA associated with TPA is very rare, it can be easily prevented with the above described patent hemostasis protocol while preserving the patency of the access site.

Retrograde Tibiopedal Access for the Treatment of Critical Limb Ischemia.

Critical limb ischemia (CLI) is associated with high rates of morbidity and mortality. Many patients with CLI are poor surgical candidates. Endovascular therapy has been shown to be an effective technique to improve arterial perfusion for patients with CLI. In patients with isolated infrapopliteal occlusive disease, endovascular therapy may be more effective than conventional bypass surgery. When antegrade endovascular revascularization fails, an understanding of tibiopedal access and retrograde crossing techniques is essential to re-establish flow to aid in tissue healing, provide symptomatic relief, and avoid amputation.

Tibiopedal access for lower extremity arterial intervention: when to use and how to perform.

Tibiopedal artery access is being used with increasing frequency as an alternative access to facilitate procedural success in lower extremity arterial intervention. This technique is usually employed in the setting of critical limb ischemia and tibial artery intervention, but it may offer potential practical advantages for popliteal artery and even superficial femoral artery intervention in unique situations. As in all cases of lower extremity arterial intervention, consideration of access is important not only for initial approach to any obstructing lesion but also for exit strategy. The dorsalis pedis artery and posterior tibial artery can be readily accessed if necessary owing to their relatively superficial position in the foot or the ankle, yet their normal diameter and the presence of significant calcification (a common finding in patients with tibial occlusive disease and critical limb ischemia) can pose difficulties as well. In addition, the peroneal artery in the lower leg can be accessed percutaneously; however, its size and depth may present additional challenges. Meticulous attention to detail is paramount in avoiding complications in what may be the only distal vessel supplying the foot. This article describes common techniques in using tibiopedal artery access as a means of alternative access for successful infrainguinal intervention.