1. Retrograde Distal Pedal Artery Access
A Primer to Percutaneous Endovascular intervention
Retrograde Distal Pedal Artery Access
Nelson Lim Bernardo, MD Director, Peripheral Vascular Laboratory
Medstar Heart Institute at Washington Hospital Center
Washington, D.C.

2. Terumo Cardiovascular Systems Group
Nelson L. Bernardo, MD
Honoraria:
Abbott Vascular
Cook Group Incorporated
Cordis Corporation
Covidien
Medtronic, Inc.
Terumo Cardiovascular Systems Group

3. Faculty Disclosure
Abbott Vascular – Training Site
Cook Medical – Training Site
Cordis Endovascular – Training Site
Covidien/eV3 – Training Site
Medtronic – Training Site
No conflict of interest related to this presentation
Non-IFU use of devices will be discussed

4. PEI of Infra-inguinal Occlusions:
Approximately 15-20% of patients with complex infra-inguinal arterial occlusive disease cannot be ‘crossed’ with an antegrade approach using vascular access from the common femoral artery
Retrograde pedal artery access is an alternative to allow successful ‘crossing’ of the lesion and eventual recanalization

5. Retrograde Pedal Artery Access:
Retrograde pedal access in percutaneous endovascular intervention:
Failure of antegrade access – dissection/subintimal course of guidewire
Unfavorable anatomy – ‘flushed’ occlusion
Treatment of femoro-popliteal artery disease not amenable to ‘usual’ antegrade approach

6. Retrograde Pedal Artery Access:
Retrograde pedal access in percutaneous endovascular intervention:
Failure of antegrade access – dissection/subintimal course of guidewire
Unfavorable anatomy – ‘flushed’ occlusion
Treatment of femoro-popliteal artery disease not amenable to ‘usual’ antegrade approach

7. Retrograde Pedal Artery Access:
Retrograde pedal access in percutaneous endovascular intervention:
Failure of antegrade access – dissection/subintimal course of guidewire
Unfavorable anatomy – ‘flushed’ occlusion
Treatment of femoro-popliteal artery disease not amenable to ‘usual’ antegrade approach
Popliteal A.
?? AT artery PT
Peroneal

8. Retrograde Pedal Artery Access:
Retrograde pedal access in percutaneous endovascular intervention:
Failure of antegrade access – dissection/subintimal course of guidewire
Unfavorable anatomy – ‘flushed’ occlusion
Treatment of femoro-popliteal artery disease not amenable to ‘usual’ antegrade approach

9. Retrograde BTK - Pedal Artery Access:
Anterior tibial artery
Dorsalis pedis artery (distal anterior tibial A)
Proximal anterior tibial artery
Posterior tibial artery
Distal (proximal segment of plantar vessels)
Mid segment of the vessel
Distal peroneal artery (+/- through interosseous ligament)

10. Vasculature of the L.E.:
Arterial System
Arterial System
Venous System

11. Retrograde BTK - Pedal Artery Access:
Techniques - ‘Imaging’ guidance for Pedal Artery Access:
Surgical - ‘Open’ cutdown
X-ray Fluoroscopy - Angiography, Roadmapping
Duplex Ultrasound guidance

12. Retrograde Pedal Access: Surgical
‘Open’ surgical cutdown
Cutdown - direct visualization of the artery
Direct puncture of the artery, i.e. dorsalis pedis artery
Cons:
Surgical incision site to manage
??hemostasis
Right Foot

13. Retrograde Pedal Access: Fluoro guidance
X-ray Fluoroscopy guidance
Angiography +/- ‘road-map’
Vessel wall calcification
Peroneal DP
Cons:
The artery is entered ‘blindly’
Radiation, + Contrast agent
Needle

14. Retrograde Pedal Access: Ultrasound guidance
Real time ultrasound (US)-guided vascular access
Allows real time visualization of vessel anatomy and the advancement of needle into the lumen of the vessel

15. Retrograde Pedal Access: Ultrasound guidance
Real time ultrasound (US)-guided vascular access
Allows real time visualization of vessel anatomy and the advancement of needle into the lumen of the vessel
Major Advantage over the Fluoroscopy-guided technique
The vessel is NOT entered BLINDLY

16. Retrograde Pedal Access: Ultrasound guidance
In the lower extremity, each artery is accompanied by corresponding two (2) veins
These structures (artery + 2 veins) are easily dileneated by vascular duplex imaging study
Ultrasound - shows the structure of the vessel
Doppler - shows the movement of red blood cells (flow through the structure)
Allows real time visualization of vessel anatomy and flow during vascular access

17. Retrograde Pedal Access: Ultrasound guidance
BTK - Pedal Artery Access:
Front wall stick
Access with the first puncture
to prevent spasm
to avoid vascular injury
Avoid cannulating the vein
Imaging views for needle ‘entry’:
Transverse
Longitudinal

18. Retrograde Pedal Access: Ultrasound guidance
BTK - Pedal Artery Access:
Front wall stick
Access with the first puncture
to prevent spasm
to avoid vascular injury
Avoid cannulating the vein
Imaging views for needle ‘entry’:
Transverse
Longitudinal

19. US-guided Pedal Access: Equipment
Vascular probe + US machine

20. US-guided Pedal Access: Equipment
Vascular probe + US machine
Linear Array
MHz
“Hockey Stick”
~18 MHz

21. US-guided Pedal Access: Equipment
Vascular probe + US machine
4F micropuncture kit + Tuohy-Borst/Copilot control valve

22. Retrograde Pedal Access: Access Needle
Cook 4F micropuncture kit + Tuohy-Borst/Copilot control valve
An echogenic tip needle is not essential
can also ‘score’ needle tip
21G Echogenic Tip Needle
21G Micropuncture Needle

23. Retrograde Pedal Access: Step-by-Step
Have a dedicated RVT hold the probe and guide you (2-person operation):
Size of the vessel
‘Short’ landing zone
Ultrasound-guided access of
Right Dorsalis Pedis artery

24. Retrograde Pedal Access: Dorsalis Pedis
Imaging – Longitudinal Axis
Peroneal DP
Ultrasound-guided access of
Right Dorsalis Pedis artery

25. Retrograde Pedal Access: US guidance
Imaging – Longitudinal Axis
Peroneal DP
Ultrasound-guided access of
Right Dorsalis Pedis artery
Doppler – Arterial flow

26. Retrograde Pedal Access: US guidance
Confirm arterial doppler-flow signal to
avoid cannulating the accompanying vein
Imaging – Longitudinal Axis
Peroneal DP
Ultrasound-guided access of
Right Dorsalis Pedis artery
Doppler – Arterial flow

27. US-guidance: Delineating the artery/vein
Things to look for on duplex ultrasound:
Vessel wall - calcification of the arterial wall (if present)
Doppler flow (including color flow doppler)
Arterial flow vs Venous flow signal
Manuever to alter ‘flow state’
Venous augmentation

28. Augmentation of Venous color flow doppler signal
US-guidance: Delineating the artery/vein
Augmentation of Venous color flow doppler signal

29. Retrograde Pedal Access: Dorsalis Pedis
Advancement of micropuncture needle into right DPA
Needle entering right Dorsalis Pedis Artery

30. Retrograde Pedal Access: Dorsalis Pedis
Successful vascular access of right Dorsalis Pedis Artery

31. Retrograde Pedal Access of Dorsalis Pedis A.
Peroneal DP
Right DPA

32. Retrograde Pedal Access: Foot Positioning
‘Frog-leg’ position + Dorsiflexion
Plantar Flexion
PT artery
Dorsalis pedis, distal AT artery
‘Frog-leg’ position
PT artery, Peroneal artery

33. Retrograde Pedal Access: Posterior Tibial A.
Artery
Vein

34. Retrograde PT Artery Access: Technique
Confirmed arterial doppler-flow signal

35. Retrograde PT Artery Access: Technique
Application of local anesthesia
Confirmed arterial doppler-flow signal
Insertion of micropuncture needle

36. Look for “Tenting” of the vessel wall
Retrograde PT Artery Access: Technique
Look for “Tenting” of the vessel wall
Needle approaching Posterior Tibial Artery

37. Retrograde PT Artery Access: Technique
Needle entering Posterior Tibial Artery
Blood return - micropuncture needle

38. Retrograde PT Artery Access: Technique
Needle entering Posterior Tibial Artery
Advancement of guidewire into vessel lumen

39. Retrograde Pedal Artery Access:
Access with the first puncture
to prevent spasm
to avoid vascular injury
Adequate anti-coagulation (i.e. Heparin)
“Anti-spasm” cocktail
Nitroglycerin
Ca++ channel blocker – Verapamil, Nicardipine

40. Retrograde DP Access: Sheath Mgt
21G Micropuncture needle
in right DP artery
4F Micropuncture sheath + Tuohy-Borst/Co-pilot
in right DP artery

41. Retrograde Pedal Access: Access Site Mgt
Management of Access Site-Sheath Options:
‘Bare-back’ over guidewire with balloon catheter or support catheter
Vessel wall trauma with repeated entry

42. Retrograde Pedal Access: Access Site Mgt
Management of Access Site-Sheath Options:
‘Bare-back’ over guidewire with balloon catheter or support catheter
Vessel wall trauma with repeated entry
Use of the Micropuncture introducer sheath
No need to exchange out; attach Tuohy- Borst/Copilot control valve
Inner diameter = 2.9F (can accommodate the entire length of Cook CXI 0.018” support catheter)

43. Retrograde Pedal Access: Access Site Mgt
Management of Access Site-Sheath Options:
‘Bare-back’ over guidewire with balloon catheter or support catheter
Vessel wall trauma with repeated entry
Use of the Micropuncture introducer sheath
No need to exchange out; attach Tuohy- Borst/Copilot control valve
Inner diameter = 2.9F (can accommodate the entire length of Cook CXI 0.018” support catheter)

44. Retrograde Pedal Access: Access Site Mgt
Management of Access Site-Sheath Options:
‘Bare-back’ over guidewire with balloon catheter or support catheter
Vessel wall trauma with repeated entry
Use of the Micropuncture introducer sheath
No need to exchange out; attach Tuohy- Borst/Copilot control valve
Inner diameter = 2.9F (can accommodate the entire length of Cook CXI 0.018” support catheter)
‘Dedicated’ 3F pedal access sheath

45. Retrograde Pedal Artery Access: Hemostasis
Manual compression (external)
??compromise distal outflow

46. Retrograde Pedal Artery Access: Hemostasis
Manual compression (external)
??compromise distal outflow
Mechanical compression
(external)
Use of blood pressure cuff
Use of TR-band
TR-band – Over left distal PT artery access site

47. Balloon inflation x 5 minutes
Retrograde Pedal Access: Hemostasis
Balloon occlusion (internal)
2.0-mm diameter
Balloon catheter
Balloon inflation x 5 minutes

48. Balloon inflation x 5 minutes
Retrograde Pedal Access: Hemostasis
Balloon occlusion (internal)
2.0-mm diameter
Balloon catheter
Balloon inflation x 5 minutes

49. KL: Successful CLI revascularization
Good hemostasis
Post: 2-vessel run-off

50. Retrograde Pedal Access
Retrograde pedal access is a valuable technique to have in an interventionalist’s armamentarium needed for the percutaneous treatment of lower extremity arterial occlusive disease/critical limb ischemia.
Real time ultrasound-guided pedal access requires training and experience to ensure good outcome & avoid complication(s).

51. A Primer to Percutaneous Endovascular intervention
Thank You