THE RETROGRADE APPROACH FOR BELOW-THE- KNEE ANGIOPLASTIES:

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1 THE RETROGRADE APPROACH FOR BELOW-THE- KNEE ANGIOPLASTIES: Massimiliano Fusaro, MD Interventional Cardiologist Hemodynamics and Cardiovascular Interventions Service San Pellegrino Hospital Castiglione delle Stiviere, Italy And Abano Terme Hospital

2 CONFLICT OF INTEREST Within the past 12 months, me or my spouse/partner have NOT a financial interest/arrangement or affiliation with the organization(s).

3 LIMITATION OF BTK ANGIOPLASTY Limited patency of treated vessels Applicability: failure of procedure >20% also in experienced hands (limitation of wiring of long occlusion; limited crossing of ballons and device) Crucial point: how I can increase the applicability of angioplasty expecially in tibial arteries occlusions?

4 THE RETROGRADE APPROACH FOR BELOW- THE- KNEE ANGIOPLASTIES: WHEN: failure of standard antegrade crossing of the wire because of perforation and/or dissection of target vessel 2006: SHEATLESS RETROGRADE PEDAL ARTERY ACCESS 2008: PEDAL-PLANTAR PLANTAR LOOP TECHNIQUE

5 SHEATHLESS RETROGRADE PEDAL ARTERY ACCESS: Materials: 18G needle, and/or CTO dedicated guidewire, OTW dedicated BTK balloons Methods: Needs patency of the pedal and/or plantar artery Retrograde wiring of the occlusion with the support of the OTW balloon inserted through the skin in a direct manner ( sheathless technique)

6 The Retrograde approach for below the knee angioplasty

7 Limitations and risks of direct puncture approach Perforation and/or dissection of pedal artery with needle and/or guide wire Thrombosis of pedal artery (reduced in sheathless approach) Impossibility to puncture the pedal artery (occlusion pedal vessels, echo guided puncture) Impossibility to cross retrogradely the occlusion The real risk is to damage the pedal artery, a vessel suitable for by-pass graft.

8 The Pedal Plantar Plantar LOOP Technique In order to avoid the risks and limitations of retrograde pedal artery access, a novel approach to below the knee occlusions was developed. The pedal plantar loop technique is based on the creation of a loop with a guide wire from a tibial artery to another by means of guide wire tracking through the foot collaterals (thus the name pedal plantar loop ).

9 0.014 retrograde wire antegrade wire retrograde wire

10 retrograde ballooning

11 Limitations of the loop technique Occlusion of both, pedal and plantar arteries with/without the occlusion of the pedalplantar arch. Limited control of the retrograde wire. Limited crossing of the retrograde balloons trhough the pedal plantar arch. Experienced operator (0.014 wire).

12 THE RETROGRADE APPROACH in 2008 Standard antegrade approach: 70% Retrograde approach: 30% direct puncture: 2% of retrograde loop technique : 25 30% In patient affected by diabetic foot, the patency of the plantar arch (2 pedal vessels opened) reduce the time in TMA healing (unpublished data).

13 CONCLUSIONS: The direct access performed limiting the risk of local artery trauma by means of sheathless technique, appears effective and safe in selected patients. Nevertheless the risk of perforation and/or dissection of a vessel suitable for grafting remains. The pedal plantar loop technique,d,eveloped to reduce the trauma of direct puncture may become a new important tool in the armamentarium of interventionalists facing challenging patients with critical limb ischemia.