6/6/2016. Pedal Loop Reconstruction: A Crash Course in 60 minutes. Pedal-Plantar Anatomy. Anand Prasad, MD, FACC, FSCAI, RPVI.
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1 6/6/2016 Pedal Loop Reconstruction: A Crash Course in 60 minutes Pedal-Plantar Anatomy Anand Prasad, MD, FACC, FSCAI, RPVI Associate Professor of Medicine Freeman Heart Association Endowed Professor in Cardiovascular Disease Associate Program Director Cardiovascular Diseases Fellowship Program Associate Editor Catheterization and Cardiovascular Interventions Interventional Cardiology and Vascular Medicine University of Texas Health Science Center San Antonio Disclosures Research Funding: Osprey Medical Mike Hogg Fund Freeman Heart Association Medtronic Speaking Honoraria: St Jude Medical AstraZeneca Gilead Why is it important to know tibial and pedal anatomy? Implications for targeting angiosome guided therapy. Understanding anatomic variants which may be congenital and non-pathologic Avoiding confusing branches or collaterals with true vessels which may lead to complications. Intact pedal plantar loop allows for the most robust filling of the distal vessels. Rates of healing appear to be higher with an intact pedal plantar loop (Rashid H et al J of Vasc Surgery 57(5): , and Manzi M et al J Cardiovasc Surg, 50(3):331-7,2009.) 1
2 6/6/2016 Tibial and Popliteal Anatomy: Implications for the Pedal Circulation Tibial anatomy Pedal Anatomy Vast majority of individuals have (at birth) three primary tibial vessels: Anterior tibial artery anterior circulation Lateral originating vessel represents first branch off of P3 segment of popliteal artery. Superiorly passes through tibialisanterior and extensor hallicus longus muscles. Lies in the anterior compartment therefore perforations have implications for compartment syndrome. At the level of the ankle, crosses under extensor retinaculum and supplies dorsum of the foot at the dorsalis pedis. Posterior tibial artery posterior circulation Originates off tibo-peroneal trunk. Lies in the deep posterior compartment. Traverses behind the medial malleolus and then divides into medial and lateral plantar vessels. Peroneal artery communicating branches to the primary tibial vessels, calcaneal perfusion Originates off tibo-peroneal trunk. Lies in the deep posterior compartment but supplies blood to the lateral compartment. Important source of collaterals when primary tibial vessels are occluded. Mousa et al. JANUARY 2012 I SUPPLEMENT TO ENDOVASCULAR TODAY Tibial anatomic variations Normal Tibial shared origin Tibial high take off Kim D et al. Ann. Surg. - December
3 6/6/2016 Tibial anatomic variations Congenitally hypoplastic tibial vessels Kim D et al. Ann. Surg. - December 1989 Pedal Anatomy Pedal-Plantar Loop Deep plantar arch: Receives supply from the anterior circulation (dorsalis pedis) And the posterior circulation (lateral plantar artery) Foot Posterior Tibial Artery. Source: classconnection.s3.amazonaws.com 3
4 6/6/2016 Pedal-Plantar Loop Anatomy of Left Foot and Ankle. Source: Posterior Circulation Authors: Rick Buckley, Andrew Sands, Anterior Circulation Lateral tarsal artery and plantar arteries have communications Authors: Rick Buckley, Andrew Sands, 4
5 Manzi et al. RadioGraphics 2011; 31: Manzi et al. RadioGraphics 2011; 31: /6/2016 Lateral Oblique View Posterior Tibial Anterior Tibial Malleolar arteries Dorsalis Pedis Calcaneal Medial Plantar Lateral Tarsal Lateral Plantar Communication 5 th Meta-tarsal bone must be separated Anterior Posterior View Lateral Plantar Medial Plantar Dorsalis Pedis Lateral Tarsal 1 st Metatarsal space must be visible Metatarsal access 5
6 Manzi et al. RadioGraphics 2011; 31: Manzi et al. RadioGraphics 2011; 31: /6/2016 Pedal Anatomy: Occlusions, Collaterals, Variations Pedal Plantar Loop: Connections and Collaterals Posterior Tibial Anterior Tibial Dorsalis Pedis Calcaneal Medial Plantar Lateral Tarsal Lateral Plantar Superficial Branch of Medial Plantar Pedal Plantar Loop: Connections and Collaterals Medial Plantar fills Lateral Tarsal and anterior pedal circulation Anterior circulation is occluded and the medial plantar provides sole pedal blood flow. 6
7 Manzi et al. RadioGraphics 2011; 31: Manzi et al. RadioGraphics 2011; 31: Manzi et al. RadioGraphics 2011; 31: /6/2016 Pedal Plantar Loop: Connections and Collaterals Posterior circulation is occluded but fills from anterior circulation Pedal Plantar Loop: Anatomic Variation Anatomic variation: No dorsalis pedis: Lateral tarsal artery is the dominant anterior vessel: 6-12% individuals. The arcuate artery which normally originates from the dorsalis pedis is missing: ~ 30% of individuals. Pedal Plantar Loop: Anatomic Variation Anatomic variation: Anterior and Posterior circulations do not communicate: ~ 10% of individuals. 7
8 6/6/2016 Summary Tibial and pedal anatomy in the majority of patients will be reproducible, however variations exist that can impact interpretation of angiograms. Identification of primary tibial vessels, perfusion to the wound angiosome, and understanding of collaterals is key to planning interventions. Important arteries and landmarks include the first metatarsal space, the medial and lateral plantar course, the lateral tarsal branch off of the dorsalis pedis, and the union of the lateral plantar with the dorsalis pedis to complete the pedal plantar loop THANK YOU 8
9 5/23/2016 With Pedal Loop Reconstruction, Any Need For Angiosome GuidedTherapy? John H. Rundback MD FAHA FSVM FSIR Medical Director, Interventional Institute Holy Name Medical Center, Teaneck, NJ Angiosomes First described by Taylor in 2007 Not specifically intended to describe pedal arch vessel In fact, the pedal arch is the terminal distribution of the named angiosomes The extent of name pedal vessels is limited Alexandrescu. J Endovasc Ther 2011 Angiographosomes A better term for angiographically mediated revascularization Requires distal injections, vasodilator, AP and lateral projections Goal is to assess regional and wound specific PERFUSION Most pedal wounds are watershed Multivessel contribution including pedal arch branches supply ischemic tissue 1
10 5/23/2016 Angiographosome AP LAT PT LAT DP Case 1 Lateral calcaneal foot ulcer Prior posterior tibial intervention Normal posterior tibial ABI, normal hallux TBI 2
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14 5/23/2016 PRE POST Case 2 Distal hallux wound in March revascularized peroneal with PT continuation, and AT PTA with sluggish flow. Had Distal hallux amp with plantar flap Presents with Regional Ischemia, rest pain, cellulitis on dorsum of foot 6
15 5/23/2016 Prior angio 7
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18 5/23/2016 Complete plantar arch Case 3. Pedal Arch wound supply Partial arch dorsalis pedis Partial arch plantar artery P=0.012 Absent plantar arch Case 4. Wound blush watershed multivessel contribution methylene blue angiography ANT TIB INJECTION POST TIB INJECTION (PROX TO COLLATS) Conclusion ANGIOGRAPHOSOMES angiographically mediated revascularization remains relevant for pedal arch interventions Wound blush is the main objective measure Methylene blue or indocyanine green (Luna systems) can further define patterns of pedal arch perfusion Evolving perfusion systems will provide more optimized determination of real time interventional success 10
19 5/23/2016 2D Perfusion -time -AUC -opacification 11
20 Pedal loop reconstruction: what are the tools? Lawrence A. Garcia, MD Chief, Section Interventional Cardiology and Vascular Interventions Director, Vascular Medicine St. Elizabeth s Medical Center Tufts University School of Medicine Boston, MA Case PT 88 year old female with history HTN, HLP, DM and PVD with L great toe ulceration and chronic pain with infection at site with MRSA Non-invasive work-up included ABI/duplex with non-compressible. Pre-occlusive Doppler in all tibial vessels distally with outflow appearing to be PT Angiography planned and images taken 1
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22 Access tools Sheaths Wires Support catheters Ballloons Non-DCB DCB Stents Balloon expandable SES DES Athrectomy What do you need? Access and bear back your wire and support catheter Can use angiocath Simple IV catheter Cook systems checkflo 4 Fr Larger sheaths have been used (5-6 Fr) Access tools Wires Depends on your tastes rarely used in the tibial circulation useful and supportive most commonly used 3
23 Industry Name Support Tip Wt Use Abbott SpartaCore Strong <1.0 gm WorkHorse Command/Winn series Medium Up to 10 gm Crossing Connect Strong Up to 30 g Crossing SteelCore Strong <1.0 gm WorkHorse Asahi Regalia Low 1.0 gm Crossing Astato 20 Medium 20 gm Crossing GrandSlam High <1.0 gm Position Treasure/Astato 30 Medium 12-30gm Crossing BSC V14 High 3 gm Crossing V18 Medium 3-6 gm Crossing Victory 14/18 Medium 12,18,25,30 g Crossing Support catheters Either for position or increase force of distal wire and systems most often used Straight or angled Devices Balloons POBA DCB? Stents DES SES (BMS/DES) Atherectomy Directional Orbital Rotational 4
24 To date there are no meaningful data regarding outcomes with atherectomy in the pedal loop Definitive LE 78% patency 6 cm LL CLI LIBERTY 360 To be presented 2016 Primary Patency in Subgroups Subgroup Claudicants (n=743) CLI (n=279) Patency (PSVR < 2.4) Lesion Length (cm) Patency (PSVR < 2.4) Lesion Length (cm) All (n=1022) 78% % 7.2 By Lesion Length < 4 cm (n=318) 81% % cm (n=418) 83% % cm (n=283) 67% % 15.1 SFA Only By Lesion Length < 4 cm (n=184) 78% % cm (n=253) 83% % cm (n=232) 65% % 15.5 Primary Patency in Subgroups Subgroup Claudicants (n=743) CLI (n=279) Patency (PSVR < 2.4) Lesion Length (cm) Patency (PSVR < 2.4) Lesion Length (cm) All (n=1022) 78% % 7.2 Lesion type Stenoses (n=806) 81% % 5.8 Occlusions (n=211) 64% % 10.3 Lesion Location SFA (n=671) 75% % 8.6 Popliteal (n=162) 77% % 5.4 Infrapopliteal (n=189) 90% % 6.0 5
25 LIBERTY 360 Prospective, observational, multi-center clinical study to evaluate acute and long-term clinical, functional and economic outcomes of endovascular device intervention in patients with distal outflow peripheral arterial disease (PAD) No inclusion and exclusion Independent core laboratory analyses and adjudications Angiographic Duplex Ultrasound Six Minute Walk Test Health Economics Includes separate analyses for Claudicants Critical limb ischemia (RB4 and 5) Critical limb ischemia (RB6) Conclusions Pedal loop reconstruction is an attractive intervention for limb salvage and foot preservation Devices and selection of method of intervention remain at the discretion of the operator Access and contemporary interventional approach allows a myriad of technologies and devices for ultimate revascularization Issues that remain Still may be too aggressive to the pedal loop without current long term data seems an important issue Is drug elution/delivery an important part of the intervention? 6
26 6/6/2016 Pedal Loop Reconstruction Step by Step Case Presentation Fadi Saab MD, FACC,FASE,FSCAI Associate Director of Cardiovascular Laboratories Co-Director of Pulmonary Embolism and Deep Venous Thrombosis Services Clinical Assistant Professor-Michigan State University School of Medicine Metro Heart and Vascular Metro Health Hospital Disclosures Bard Peripheral Vascular - Research, Consultant, Cardiovascular Systems, Inc. - Research, Consultant, Cook Medical - Research, Consulting Covidien Consulting Terumo Consulting Spectranetics Research, Consulting 1
27 6/6/2016 Advantage of Retrograde Tibial Access Increase success rate of crossing Shorten treated segment Preserve options of therapy : Surgery, atherectomy Utilize hibernating lumen Preserve tibial vessels flow Saab et al Pedal Loop Reconstruction Antegrade Approach Retrograde Approach Critical Limb Ischemia patients Patients with Short Pedal CTO s Requires at Least 5 Fr Sheath Adequate Flow through the opposite vessel (PT or AT) Usually for longer CTO s Requires a Tri-Axial system Usually safer At least a 6 Fr sheath Retrograde crossing under Flouroscopy with a loop technique Saab et al Pedal Loop Reconstruction Wires Journey Wire (BSCN) Regalia Wire (Asahi) Glide Advantage (0.014) (Terumo) Runthrough (Terumo) Gladius (Asahi) Saab et al 2
28 6/6/2016 Case Presentation 69 year old that presented with a non healing wound over the Plantar and dorsal aspect of the great toe Risk factors include: HTN, DM, Ischemic cardiomyopathy with an EF of 40% Despite 6 months of wound care, no healing Non compressible ABI s Antegrade VS Retrograde? 3
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30 6/6/2016 Visual Illusion 5
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32 6/6/2016 Retrograde Crossing 7
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34 6/6/2016 Another Option 9
35 6/6/2016 Conclusion Pedal Loop reconstruction is the next phase in CLI therapy Current available plaque modification technology for the pedal loop is expanding. Current technologies include Laser atherectomy, Orbital atherectomy and Phoenix atherectomy Long term benefits will need to be tracked and documented in trials and registries (PRIME Registry)
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