Radial Techniques for Treatment of PAD

Disclosures: Orlando Marrero reports he is a consultant for Boston Scientific. Dr. Zaheed Tai reports the following: Terumo (proctor for transradial course), Spectranetics (proctor for laser course, speaker, advisory board member), The Medicines Company (speakers bureau). 

Orlando Marrero, RCIS, MBA, can be contacted at orlm8597@icloud.com. 

Dr. Zaheed Tai can be contacted at zaheedtai@gmail.com

Case

This is an 80-year-old gentleman with a history of chronic obstructive pulmonary disease, hyperlipidemia, hypertension, gastroesophageal reflux disease, diabetes, obesity, renal insufficiency and right lower extremity claudication with a small slow healing ulceration of the first digit. He had inconclusive noninvasive studies. He underwent peripheral angiography from a radial approach demonstrating a right occluded popliteal across the knee joint (Figure 1) as well as tibioperoneal (TP) trunk occlusion andcollateral filling of the anterior tibial (Figure 2). In addition, the patient had a calcified tortous aortic bifurcation. He was staged for intervention given his renal insufficiency. Given the tortuosity of the bifurcation, it was felt an antegrade access would allow for more catheter support in crossing the occlusion as well as being less challenging than trying to deliver a sheath from the contralateral approach. The patient’s body habitus (Figure 3) and location of common femoral artery bifurcation were not ideal for antegrade access, particularly in the outpatient setting. Therefore, after review of the diagnostic angiogram, it was decided to attempt posterior tibial access first (with contralateral as a default). This would allow straight-line flow to the angiosome (anterior tibial) and restore 3-vessel run-off.  

Procedure 

The right posterior tibial artery was prepped and draped in a sterile fashion. The right posterior tibial artery was accessed under Doppler guidance with a micropuncture needle and sheath (Figure 4) and exchanged for a Slender sheath (Terumo). A radial cocktail was administered and contrast was injected through the sheath (Figure 5). A workhorse wire was then advanced in a retrograde fashion to the occlusion and a .035 CXI support catheter (Cook) was then advanced. Retrograde angiography demonstrated the occlusion (previous angiography had demonstrated an occluded popliteal with reconstitution and collateral filling of the infrapopliteal vessels). Additional heparin was administered to an activated clotting time (ACT) greater than 200. Using a Victory 30-gram wire (Boston Scientific) and the .035 CXI support catheter, we crossed the occluded segments in a retrograde fashion. The Victory wire seemed to cross retrograde into the true superficial femoral artery (SFA), but there was some difficulty wiring (free movement). Therefore, we pulled the CXI catheter back and rewired with a Glidewire (Terumo), which went straight up the SFA (Figure 6). We advanced the CXI catheter across the lesion and confirmed that we were in the lumen. In addition, angiography was performed through the CXI catheter above the lesion to “roadmap” areas of required treatment (Figure 7). We exchanged out for the .018 wire and removed the CXI catheter. A 2.0 laser fiber was then used to perform atherectomy of the TP trunk and popliteal (Figure 8). Initial settings were 45/25, 60/40, 60/60, and 60/80. Total atherectomy time was about 1 1/2 minutes. There was extensive calcification across the knee joint with a visible calcific lesion, noted on tactile movement of the laser catheter with decreasing resistance with each pass. Following laser atherectomy, we had a channel (no residual stenosis in TP trunk, but residual present in the popliteal). A 5.0 x 100mm Charger balloon (Boston Scientific) was used to pre-dilate the lesion, with initial inflation at 6 atmospheres for 5 minutes and a second inflation at 10 atmospheres for 5 minutes. There was still some slight recoil in that region. However, in an effort to avoid stenting across the knee joint, we placed a buddy wire and did a 6.0 x 100mm balloon at 6 atmospheres for 5 minutes (Figure 9 shows a makeshift focal force balloon). After this inflation, we removed the buddy wire, advanced the CXI catheter above the lesion, and did an injection demonstrating brisk flow in the vessel with about a residual 30% stenosis in the popliteal, but no visible dissection and good run-off (Figures 10-11). There was no evidence of embolization. The patient tolerated the procedure well with an excellent angiographic result. The equipment was removed and a TR Band (Terumo) was placed over the posterior tibial (Figure 12). The patient was able to sit immediately and ambulate shortly thereafter. Follow-up in the office two weeks later demonstrated good pulse distally that was palpable.

Discussion

Antegrade recanalization of infrapopliteal and infrainguinal occlusion is still the default approach for most lesions; however, failure to cross (to either penetrate the proximal cap or re-enter the true lumen distally) remains a factor in about one-fifth of cases. Some difficult crossings have been overcome with use of dedicated crossing devices and re-entry catheters, and transcollateral techniques. An alternative approach is retrograde access using the pedal arteries. The presence of less fibrotic and calcified tissue distal to the occlusion has been thought to be the reason for a high success rate with retrograde revascularization, similar to what has been documented for coronary arteries.^1,2 Ultrasound (US) guidance has been proven to be effective in radial artery catheterization as well as in the guidance of access in tibial arteries of patients with critical limb ischemia (CLI). It has demonstrated an increase in successful canalization, and is safe and feasible.^3,4 Unfortunately, in our lab, we currently do not have US guidance equipment. Therefore, we use a combination of Doppler guidance (to locate the access site) and fluoroscopic guidance to visualize wire advancement. Either a 21-gauge Jelco angiocath (Smiths Medical), using a double-wall puncture technique, or micropuncture needle (both from the radial access kit) are used for arterial access. The 6 Fr Glidesheath Slender, which employs a smaller outer diameter that is equivalent to a standard 5 Fr sheath, is then inserted (Figure 13). The thinner-wall sheath has a slightly bigger outer diameter = 2.46mm as opposed to 2.29mm), permitting use of laser atherectomy, orbital atherectomy, atherotomy balloons, and stenting, if indicated. After the procedure, a large TR Band was placed at the access site. The TR Band was inflated at the site of pedal puncture and the sheath removed. The TR Band was deflated slowly until the appearance of blood flow and an extra 1cc of air was then added, which confirmed occlusion at the puncture site. Five (5) ccs were withdrawn every 30 minutes (with reinflation to 1cc above blood flow, if needed). With some minor modifications, this TR Band approach is similar to what we use for brachial and popliteal access. 

In addition to minimizing potential complications with femoral access, transpedal access can overcome some of the issues with a challenging aortic bifurcation (tortuosity, aorto-fem bypass, ostial iliac stents, etc.), antegrade access, or popliteal access. In addition, transpedal access allows for quicker ambulation and recovery, which in turn may increase workflow. Obvious potential limitations include, but are not limited to, decreased visualization of the extent of disease, inability to utilize certain devices that may require a larger sheath size, and potential inability to treat multiple tibial vessels if needed. Kwan et al recently published a series demonstrating the safety and feasibility of pedal access for peripheral arterial disease (PAD) using variations of radial techniques, whereas previous studies had been done in critical limb ischemia (CLI) patients.^5,6

Alternative arterial access, such as US-guided tibial pedal arterial access for the diagnosis and treatment of complex and severe PAD and CLI, as with any technique, has a learning curve. Doppler access is not as accurate, but may provide an alternative to fluoroscopic guidance (to minimize radiation exposure to the operator). Proficiency in radial access is not necessary, but can facilitate successful pedal access. There is considerable overlap in the two approaches, including small vessel access, minimizing attempts in order to prevent spasm, use of a cocktail, ability to work through smaller sheaths, use of US or Doppler, and hemostasis techniques. Knowledge of the arterial anatomy of the leg and foot is necessary for operators to become well acquainted with proper technique. Selection of the adequate puncture site in the adequate vessel, as well as the adequate indication, should be considered when choosing alternative access.

References

1. Saito S. Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion. Catheter Cardiovasc Interv. 2008; 71: 8-19.

2. Montero-Baker M, Schmidt A, Bräunlich S, Ulrich M, Thieme M, Biamino G, Botsios S, Bausback Y, Scheinert D. Retrograde approach for complex popliteal and tibioperoneal occlusions. J Endovasc Ther. 2008; 15: 594-604.

3. Shiloh AL, Savel RH, Paulin LM, Eisen LA. Ultrasound-guided catheterization of the radial artery: a systematic review and meta-analysis of randomized controlled trials. Chest. 2011; 139: 524-529.

4. Mustapha JA, Saab F, Diaz L, et al. Utility and feasibility of ultrasound-guided access in patients with critical limb ischemia. Catheter Cardiovasc Interv. 2013; 81: 1204-1211.

5. Kwan TW, Amoroso N, Shah S, et al. Feasibility and safety of routine transpedal arterial access for treatment of peripheral artery disease. J Invasive Cardiol. 2015; 27: 327-330.

6. Mustapha J, Saab F, McGoff T, et al. Tibio-pedal arterial minimally invasive retrograde revascularization in patients with advanced peripheral vascular disease. The TAMI technique. Original case series. Catheter Cardiovasc Interv. 2014; 83: 987-994.