Retrograde dorsalis pedis and posterior tibial artery access after failed antegrade angioplasty

Transcription

1 Retrograde dorsalis pedis and posterior tibial artery access after failed antegrade angioplasty Poster No.: C-2067 Congress: ECR 2010 Type: Topic: Authors: Keywords: DOI: Scientific Exhibit Interventional Radiology E. Kashef, S. Shah, A. Loh, R. Bird, A. Marcus, A. Saini, K. Lotzof; London/UK Retrograde angioplasty, Posterior tibial artery, Dorsalis pedis /ecr2010/C-2067 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 21

2 Purpose 1. To report our initial experience of retrograde anterior and posterior tibial artery access for angioplasty in patients with severe peripheral vascular disease, following failed antegrade approaches 2. To demonstrate that this is an appropriate technique in selected patients with critical limb ischaemia who are poor surgical candidates and where limb loss is inevitable Background Percutaneous subintimal angioplasty is part of the mainstay of treatment of peripheral vascular disease Many interventional techniques have been described for the treatment of critical limb ischaemia Conventional access options include contralateral or ipsilateral approaches; for the latter this can be via antegrade femoral or retrograde popliteal puncture Recently, simultaneous antegrade femoral and retrograde popliteal punctures have been reported, where the lesion is crossed from above and below using a 'rendezvous' technique Failure to cross a lesion usually occurs due to long distance occlusion or heavy calcification of the plaque. These difficulties are usually overcome with use of stiff wires or re-entry from the distal end of the plaque Retrograde access via the anterior or posterior tibial artery is a recognised technique but not yet routine endovascular practice Methods and Materials Page 2 of 21

3 Retrospective review of electronic patient record and radiological reports of patients who underwent peripheral angiograms between November 2008 and August 2009 at Barnet and Chase Farm NHS Trust, UK 9 cases of critical limb ischaemia were referred for angioplasty after failed attempts at angioplasty via an antegrade femoral approach None of the patients were suitable candidates for surgical management All patients underwent retrograde access via anterior or posterior tibial or dorsalis pedis arteries +/- simultaenous femoral artery puncture Procedure Punctures performed under US guidance 22G single part needle 4 Fr micro-puncture vascular access sheath (Cook) 0.018" guidewire - used for manipulation Subintimal technique used to re-canalise occluded vessels, followed by balloon angioplasty Rendezvous procedure (Figures 1-2) with simultaneous antegrade femoral artery puncture performed when necessary Images for this section: Page 3 of 21

4 Page 4 of 21

5 Fig. 1: Rendezvous technique - guidewires in situ via retrograde tibial and antegrade femoral access Page 5 of 21

6 Page 6 of 21

7 Fig. 2: Rendezvous technique - balloon catheters in situ via retrograde tibial and antegrade femoral access Page 7 of 21

8 Results Rendezvous procedure performed in 4 cases (Figures 1-2) Successful re-establishment of flow after angioplasty (primary patency) in 8 out of 9 cases (89%) No immediate adverse events reported post procedure in 8 out of 9 cases (e.g. arterial occlusion, bleeding or compartment syndrome at the puncture site) Absent flow within the anterior tibial artery distal to the site of puncture in 1 case suggestive of acute arterial occlusion, requiring emergency surgical intervention Therefore 7 technical/radiological successes without immediate complications (Figures 3-6) 4/7 cases demonstrated improvement in ulcer healing, symptoms or anklebrachial pressure indices on follow up 3/7 cases showed no clinical improvement or required amputation within 2 weeks of the retrograde tibial procedure Images for this section: Page 8 of 21

9 Page 9 of 21

10 Fig. 1: Distal superficial femoral artery (SFA) occlusion. Pre rendezvous angioplasty. Page 10 of 21

11 Page 11 of 21

12 Fig. 2: Distal SFA occlusion. Post rendezvous angioplasty. Fig. 3: Case 1 - Long distal SFA/popliteal occlsion. Pre angioplasty. Page 12 of 21

13 Page 13 of 21

14 Fig. 4: Case 1 - Long distal SFA/popliteal occlsion. Post angioplasty. Page 14 of 21

15 Page 15 of 21

16 Fig. 5: Case 2 - Distal SFA occlsion. Pre angioplasty. Page 16 of 21

17 Page 17 of 21

18 Fig. 6: Case 2 - Distal SFA occlsion. Post angioplasty. Page 18 of 21

19 Conclusion Many reports of the technique described above have been anecdotal 1 Recently however, larger numbers have been reported: Technical Tips and Results of Transpedal Approach for Revascularizing Tibial Artery Occlusions Which Cannot be Crossed from Above. A Schmidt Scientific presentation- abstract, VEITH symposium October September 2009 >80 cases of trans-pedal puncture All cases had failed angioplasty from above the lesion (femoral approach) In difficult cases "double balloon" technique was used to cross the lesion from above and below Good long term patency rate No acute occlusion or long term stenosis of the pedal artery noted Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) 3 SAFARI technique is now an Most reported approaches include popliteal as well as PTA and ATA punctures 4 The technique involves puncture of these vessels in cases where conventional femoral approach has failed The occlusion is "flossed" from below and above until a continuous tract is established Summary Although this technique is not used as first line treatment, retrograde tibial punctures are increasingly utilised in cases where patients have threatened limb loss and/or are not fit for surgery Despite the good success rate, 13-24% are associated with failure and subsequent limb loss: -increased force required to cross the lesion -difficulty in guiding the direction of the subintimal tract Page 19 of 21

20 Our technical success with this procedure is very good, and the authors therefore recommend this technique as a "salvage treatment" in cases where limb loss is inevitable References 1. Fusaro M et al. Retrograde pedal artery access for below the knee percutaneous revascularisation. J Cardiovasc Med 2007; 8: Schmidt A. Technical Tips and Results of Transpedal Approach for Revascularizing Tibial Artery Occlusions Which Cannot be Crossed from Above. Scientific presentation- abstract, VEITH symposium Spinosa DJ et al. Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) for subintimal recanalization to treat chronic critical limb ischemia. J Vasc Intervent Radiol 2005; 16: Gandini R et al. The ''Safari'' Technique to Perform Difficult Subintimal Infragenicular Vessels. Cardiovasc Intervent Radiol 2007; 30: Personal Information Kevin Lotzof Consultant Interventional Radiologist Barnet Hospital Barnet and Chase farm NHS Trust Wellhouse Lane Barnet EN5 3DJ Page 20 of 21

21 UK Page 21 of 21