Ultrasound-Guided Tibial Pedal Arterial Access: Growing Alternative Strategy in the Treatment Of Complex Peripheral Artery Disease

“Whenever you find yourself in the side of the majority, it is time to reform (or pause and reflect).” - Mark Twain (Notebook, 1904)

The ability to safely gain arterial access is undoubtedly one of the most important steps in the performance of routine and complex endovascular procedures. Utilization of ultrasound (US) guidance has been proven to be effective in radial artery catheterization, being associated with a 71% improvement in the likelihood of successful cannulation.¹ Multiple arterial access sites have been utilized for a variety of endovascular procedures, including radial,² brachial and axillary arteries,³ antegrade or retrograde access of the common femoral artery (CFA), superficial femoral artery (SFA) and popliteal artery,^4-7 as well as tibial access into the posterior tibial (PT), dorsalis pedis (DP), anterior tibial (AT), peroneal,^8-10 and even the transmetatarsal arteries.¹¹ The use of US-guided access of the CFA for cardiac catheterizations has been shown to reduce the risk of complications by 60%,¹² and the use of this technology to guide access even when performed in tibial arteries of patients with critical limb ischemia (CLI) has also been deemed safe and feasible.¹³

In this issue of the Journal of Invasive Cardiology, Kwan et al¹⁴ report on a single-center retrospective case series of 80 patients who were referred for the treatment of symptomatic peripheral arterial disease (PAD). Fifty-four patients (67%) had claudication (Rutherford II-III), while 26 patients (33%) had CLI. Sixty-four patients (80%) underwent puncture of the AT or DP arteries (which represent the easiest of the tibial-pedal vessels to be accessed given their superficial location), while fifty-one patients (64%) underwent successful peripheral arterial intervention through this approach. Seventy-two of 75 patients (96%) who underwent transpedal or transtibial arterial puncture returned for a 1-month follow-up, and the authors showed a 100% rate of US-demonstrated patency of the arterial access point. This reported result is of significant importance as it raises the proposal of protocols that establish the need for adequate clinical and US follow-up for all patients undergoing these procedures.

While the concept of alternative arterial access to treat severe and complex PAD is gaining momentum, is attractive, represents a step away from the majority and invites to reform our approach (specifically in the setting of CLI and procedures performed for limb salvage purposes, where benefits always outweigh risks), it is important to explain to the readers at large that a strategy of puncturing one or two tibial-pedal arteries may not be necessarily recommended as a “routine” approach in patients with end-stage renal disease and diabetes (who typically have diffusely calcified tibial arteries) with Rutherford class-II symptoms at baseline, as these patients may end up with severe complications if two out of three vessels have access-related complications (hence, pause and reflect). We wholeheartedly agree with the fact that US-guided tibial pedal arterial access should become a skill that belongs in the armamentarium of the different vascular specialists who treat complex PAD and CLI, as well as selected claudicants who are considered to have no option for traditional contralateral retrograde CFA access (previous aorto-bifemoral bypass graft, previous endovascular repair of abdominal aortic aneurysms, extreme angulations of the aorto-iliac bifurcation, iliac artery occlusion) or for ipsilateral antegrade CFA access (morbid obesity, infected groin, extensive groin scars, patients with hip contractures).

Tibial pedal arterial access may eventually become “the radial of the leg,” with the intent to minimize the complications well known to be related to CFA access; however, once again we voice caution with the recommendation to implement this strategy as routine at this point in time. It has been clear that the rate of implementation of radial arterial access has been slow (at best), despite the ever-growing amount of evidence to support its use in the treatment of coronary artery disease. As opposed to the radial artery, the tibial and pedal vessels are characterized (especially in patients with PAD) as having diffuse disease and calcification, which makes them more difficult to cannulate than their wrist counterparts. Specifically, the PT artery (when calcified) tends to have a significant range of motion, and tends to dive rather deep when pushed by the access needle. In inexperienced hands (and without proper US guidance), this may result in repeated attempts to cannulate the vessel, which may then translate into severe spasm and sometimes even occlusions causing an unforeseen complication. 

The use of alternative arterial access, such as US-guided tibial pedal arterial access for the diagnosis and treatment of complex and severe PAD and CLI, has previously been proven feasible and safe. Deep knowledge of the arterial anatomy of the leg and foot, as well as extensive training with US guidance, is necessary for operators to become well acquainted with proper technique. Selection of the adequate puncture site, in the adequate vessel, for the adequate indication, in the adequate patient is of paramount importance and should be at the forefront when considering this alternative. After properly weighing the risks and benefits of the traditional common femoral approach versus those related to this new technique in each individual patient, the properly trained and experienced operator should then be faced with an easy decision, which will undoubtedly lead to the best possible care being delivered to each one of these patients.

The study by Kwan et al¹⁴ represents the first published study looking at routine US-guided tibial pedal arterial access for the invasive diagnosis and treatment of patients with a wide spectrum of PAD symptoms, and their results echo the previously reported findings of feasibility and safety of this technique when performed exclusively among patients with CLI.¹⁵ It also provides us with evidence that the natural evolution process is finally taking place in the infrapopliteal space. The first-ever guidelines for the use of peripheral interventions in the infrapopliteal segment were published only recently,¹⁶ demonstrating the lack of available high-quality data to guide interventions in this arterial segment. As Kwan et al notice,¹⁴ there is still a large amount of work to be done. Ultimately, prospective and multicenter studies (likely registries) should probably be performed to further validate this strategy and its adequacy as a default approach.

References

1. 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.
2. Rao SV, Turi ZG, Wong SC, et al. Radial versus femoral access. J Am Coll Cardiol. 2013;62(17 Suppl):S11-S20.
3. Sos TA. Upper extremity access for renal artery stenting: radial, brachial and axillary access: how to do them safely and pitfalls to avoid. J Cardiovasc Surg. 2010;51:741-746.
4. Gutzeit A, van Schie B, Schoch E, et al. Feasibility and safety of vascular closure devices in an antegrade approach to either the common femoral artery or the superficial femoral artery. Cardiovasc Intervent Radiol. 2012;35:1036-1040.
5. Ye M, Zhang H, Huang X, et al. Retrograde popliteal approach for challenging occlusions of the femoral-popliteal arteries. J Vasc Surg. 2013;58:84-89. 
6. Feiring AJ, Wesolowski AA. Antegrade popliteal artery approach for the treatment of critical limbs ischemia in patients with occluded superficial femoral arteries. Catheter Cardiovasc Interv. 2007;69:665-670.
7. Gandini R, Del Giudice C, Assako Ondo EP, et al. Stent puncture for recanalization of occluded superficial femoral artery stents. J Endovasc Ther. 2012;19:30-33. 
8. Zhuang KD, Tan SG, Tay KH. The “SAFARI” technique using retrograde access via peroneal artery access. Cardiovasc Intervent Radiol. 2012;35:927-931.
9. Walker C. Pedal access in critical limb ischemia. J Cardiovasc Surg (Torino). 2014;55:225-227.
10. Narins CR. Access strategies for peripheral arterial intervention. Cardiol J. 2009;16:88-97.
11. Palena LM, Brocco E, Manzi M. The clinical utility of below-the-ankle angioplasty using “transmetatarsal artery access” in complex cases of CLI. Catheter Cardiovasc Interv. 2014;83:123-129.
12. Seto AH, Abu-Fadel MS, Sparling JM, et al. Real-time ultrasound guidance facilitates femoral arterial access and reduces vascular complications: FAUST (Femoral Arterial Access With Ultrasound Trial). JACC Cardiovasc Interv. 2010;3:751-758.
13. 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.
14. 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.
15. 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.
16. Gray B, Diaz-Sandoval LJ, Dieter RS, Jaff MR, White CJ. SCAI expert consensus statement for infrapopliteal arterial intervention appropriate use. Catheter Cardiovasc Interv. 2014;84:539-545. 

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From Metro Heart and Vascular, Metro Health Hospital, Wyoming, Michigan. 

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Mustapha reports consultant and/or medical advisory fees from Bard Peripheral Vascular, Cardiovascular Systems, Inc, Terumo Corporation, Spectranetics, Medtronic, Cook Medical, Abbott Vascular, and Boston Scientific. Dr Diaz-Sandoval reports consultant fees from Bard Peripheral Vascular and Cardiovascular Systems, Inc.

Address for correspondence: Jihad A. Mustapha, MD, Metro Heart and Vascular, Metro Health Hospital, Wyoming, MI. Email: Jihad.Mustapha@metrogr.org