Transpedal Approach for Acute Limb Ischemia When Traditional Femoral Access Sites Are Unavailable

Purpose: Acute limb ischemia (ALI) is described as the rapid onset decrease of limb perfusion that threatens limb viability with almost all cases being related to arterial occlusion. Despite therapeutic advances, the management of this disease remains a challenge with prevailing high rates of morbidity, mortality, and limb loss. Endovascular revascularization, via a femoral approach, remains the cornerstone of ALI management. This case aims to illustrate the feasibility of a retrograde ipsilateral transpedal approach when commonly used contralateral femoral and ipsilateral anterograde femoral approaches are not available.

Materials and Methods: We present a 53-year-old man with a history of extensive peripheral vascular disease, including a repaired type B aortic dissection complicated by occlusion of the left subclavian artery requiring carotid to subclavian bypass. The patient then had a subsequent repair of a graft endoleak complicated by left iliac artery occlusion requiring a femorofemoral bypass. He presented to the emergency department with progressively worsening left foot pain associated with pallor and weakness. Physical examination was notable for non-Dopplerable dorsalis pedis and posterior tibial pulses. The vascular team was urgently consulted, and there was an immediate concern for ALI and a need for prompt revascularization. However, given the extensive prior vascular surgeries, traditional femoral approaches were unable to be used. Therefore, a retrograde ipsilateral transpedal approach was chosen as the only remaining possible access site for angiography and intervention.

Results: The left anterior tibial artery was cannulated via a 4-Fr access. The angiogram revealed a total occlusion in the left posterior tibial artery with a poor pedal arch flow. Via the 4-Fr system, treatment with mechanical thrombectomy, percutaneous transluminal angioplasty, and thrombolysis with tissue plasminogen activator was performed, and successful restoration of flow to the limb was achieved.

Conclusions: This case highlights the feasibility of the retrograde ipsilateral transpedal approach for endovascular revascularization in patients with ALI, especially when traditional contralateral and ipsilateral anterograde femoral accesses are not available.