Homemade Device to Facilitate Percutaneous Venous Arterialization in Patients With No-Option Critical Limb Ischemia

Purpose: To describe a maneuver to facilitate percutaneous arteriovenous fistula creation during venous arterialization procedures in patients with no-option critical limb ischemia. Technique: Following a failed arterial recanalization attempt, a balloon catheter is passed up to the tip of the guidewire. Venous access is gained distally, a 4-F sheath is antegradely passed, and a 4-mm GooseNeck snare is advanced through it. A fluoroscopic view that overlaps the snare and the inflated balloon is obtained. If the vein remains anterior with respect to the artery, a needle is inserted across the vein, passing through the snare loop and puncturing the intra-arterial balloon. A wire is inserted and placed inside the punctured balloon. The balloon is retrieved and the wire externalized through the femoral access. A catheter is advanced antegradely over this wire from the artery into the vein. If the vein remains posterior to the artery, a needle is inserted, puncturing the balloon and thereafter the vein (crossing through the snare). A wire is inserted, captured by the snare, and externalized through the vein sheath. A catheter is finally advanced over this wire from the vein into the artery. Conclusion: This maneuver is a simple alternative to create an arteriovenous fistula during venous arterialization procedures in patients with no-option critical limb ischemia.

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Endovascular Distal Plantar Vein Arterialization in Dialysis Patients With No-Option Critical Limb Ischemia and Posterior Tibial Artery Occlusion: A Technique for Limb Salvage in a Challenging Patient Subset

Journal of Endovascular Therapy ◽

10.1177/1526602817750211 ◽

2017 ◽

Vol 25 (1) ◽

pp. 127-132 ◽

Cited By ~ 16

Author(s):

Roberto Gandini ◽

Stefano Merolla ◽

Jacopo Scaggiante ◽

Marco Meloni ◽

Laura Giurato ◽

...

Keyword(s):

Limb Salvage ◽

Critical Limb Ischemia ◽

Balloon Catheter ◽

Limb Ischemia ◽

Venous Access ◽

Posterior Tibial Artery ◽

Percutaneous Technique ◽

Posterior Tibial ◽

Tibial Artery ◽

Esrd Patients

Purpose: To detail a percutaneous technique for distal plantar venous arterialization in diabetic, end-stage renal disease (ESRD) patients with no-option critical limb ischemia (CLI). Technique: After failure of standard intraluminal recanalization attempts, a subintimal approach through the posterior tibial artery (PTA) is begun using a 0.014-inch, 190- or 300-cm-long guidewire supported by a 2-×20-mm, low-profile balloon catheter positioned a short distance behind the narrow “U-shaped” loop in the guidewire. Typically, heavy calcification in the distal tortuous segment of the PTA prevents reentry to the arterial true lumen; however, an entry in the distal lateral or medial plantar vein from a subintimal channel in the plantar artery can be intentionally pursued as a bailout technique, pointing the tip of the guidewire opposite to the arterial wall calcifications. Venous access is confirmed by contrast injection through the balloon catheter. Once the guidewire is advanced in the distal lateral or medial plantar vein and a plantar arteriovenous fistula (AVF) has been created, the AV anastomosis and the occluded PTA segment are dilated with 0.014-inch balloon catheters. The technique has been attempted in 9 consecutive diabetic, ESRD patients (mean age 69 years; 5 men) with no-option CLI; an AVF was created between the PTA and plantar vein in 7 patients. The mean TcPO2 at 1 month was 30±17 mm Hg (vs 7.3±2.2 at baseline). Six ulcers healed over an average of 21±4 weeks. Three of the 9 patients had below-knee amputations. Conclusion: Although further investigations are required, distal plantar venous arterialization may represent a promising technique to improve recanalization rates and limb salvage in diabetic ESRD patients with extremely calcified PTA occlusions.

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Antegrade vs Crossover Femoral Artery Access in the Endovascular Treatment of Isolated Below-the-Knee Lesions in Patients With Critical Limb Ischemia

Journal of Endovascular Therapy ◽

10.1177/1526602817701251 ◽

2017 ◽

Vol 24 (3) ◽

pp. 331-336 ◽

Cited By ~ 3

Author(s):

Yukun Li ◽

Ali Esmail ◽

Konstantinos P. Donas ◽

Georgios Pitoulias ◽

Giovanni Torsello ◽

...

Keyword(s):

Endovascular Treatment ◽

Success Rate ◽

Femoral Artery ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Technical Success ◽

Femoral Access ◽

Technical Success Rate ◽

Below The Knee ◽

Antegrade Approach

Purpose: To evaluate the safety and effectiveness of antegrade vs crossover femoral artery access in the endovascular treatment of isolated below-the-knee (BTK) lesions in patients with critical limb ischemia (CLI). Methods: Between January 2014 and December 2015, 224 high-risk patients (mean age 75.8±9.8 years; 151 men) with CLI underwent infragenicular interventions on 292 crural vessels in 3 European vascular centers. All patients had isolated TransAtlantic Inter-Society Consensus (TASC) C (n=26) or D (n=198) BTK lesions. Primary endpoints were freedom from access-related complications and technical success comparing the antegrade vs crossover access groups. Results: Balloon angioplasty was the most used treatment modality (169 vessels, 75.4%). The technical success rate was 88.4% in the entire cohort and 88.0% in the antegrade group vs 90.4% in the crossover group (p>0.99). In all patients, the technical success rate was higher for stenotic lesions (100%) vs occlusions (85.5%, p=0.002) and in patients with TASC C BTK lesions (100%) vs TASC D (86.9%, p=0.033). The overall freedom from access-related complications was 97.8%: 99% in the antegrade group and 90.6% in the crossover group (p=0.022). Larger sheath size (5/6-F vs 4-F) was associated with a significantly higher risk for access-related complications (7.1% vs 1.1%, respectively; p=0.047). Conclusion: The present multicenter study showed high technical success and a low incidence of access-related complications in the treatment of isolated BTK lesions using either antegrade or crossover femoral access. The antegrade approach with the use of a 4-F system seems to have a significantly lower rate of access-related complications.

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Upper extremity distal dual bypass enables arteriovenous fistula construction in a critical limb ischemia

Journal of Surgical Case Reports ◽

10.1093/jscr/rjz022 ◽

2019 ◽

Vol 2019 (2) ◽

Author(s):

Tsukasa Nakamura ◽

Kiyokazu Akioka ◽

Shuji Nobori ◽

Shumpei Harada ◽

Norio Yoshimura ◽

...

Keyword(s):

Arteriovenous Fistula ◽

Upper Extremity ◽

Critical Limb Ischemia ◽

Limb Ischemia

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Evaluation of a Dedicated Balloon Catheter for Infrapopliteal Difficult Calcified Lesions in Diabetic Patients With Critical Limb Ischemia

CardioVascular and Interventional Radiology ◽

10.1007/s00270-010-9941-8 ◽

2010 ◽

Vol 34 (1) ◽

pp. 170-173 ◽

Cited By ~ 1

Author(s):

Tommaso Lupattelli

Keyword(s):

Critical Limb Ischemia ◽

Balloon Catheter ◽

Limb Ischemia ◽

Diabetic Patients

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P4705Transpedal access for below-the-knee lesions in critical limb ischemia

European Heart Journal ◽

10.1093/eurheartj/ehz745.1086 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

Z Ruzsa ◽

A Csavajda ◽

M Deak ◽

E Vegh ◽

V Orias ◽

...

Keyword(s):

Critical Limb Ischemia ◽

Clinical Success ◽

Limb Ischemia ◽

Fluoroscopy Time ◽

Peroneal Artery ◽

Anterior Tibial Artery ◽

Access Site ◽

Femoral Access ◽

Tibial Artery ◽

Below The Knee

Abstract Background Traditional access for the treatment of below-the-knee (BTK) lesions is the femoral approach, but in failed anterograde cases transpedal access can be utilized. The aim of the study was to evaluate the safety and technical and clinical success of endovascular BTK artery revascularization by a primarly retrograde transpedal access. Methods The clinical and angiographic data of 115 consecutive patients treated via transpedal access with symptomatic BTK stenosis were evaluated two cardiovascular centers (Europe and USA). We have selected patients with good distal run-off and non-infected distal puncture zone. The distal pedal artery was punctured by ultrasound guidance, and the procedural guidance was done by transpedal (TPA) or transradial angiography (TRA). Distal pressure at the end of the pedal sheath was also measured before and after the intervention. The primary endpoint was a composite of procedural success, major adverse events, and rate of access site complications. Secondary endpoints were: angiographic result of BTK intervention, fluoroscopy time, X-ray dose, procedure length, cross over rate to another puncture site and duration of hospitalization. Results The indication of the intervention was critical limb ischemia in all patients. Overall technical success was achieved in 99.1% of the patients at least in one BTK artery. The distal puncture was successful in 114/115 patients 99.1% of the patients and the access site was anterior tibial artery in 96 patients (83.55), posterior tibial artery in 15 patients (13%) and peroneal artery in 4 patients (3.5%). Pedal to femoral access site cross over was 0.5%. Control angiography was done in 73 patients (63.5%) from radial and in 42 patients (36.5%) from transpedal access. The average contrast, procedure and fluoroscopy time was 109.9 [97–123]vs 31.4 [27–35]ml (p<0.001), 43.2±22.3 vs 47.8±25.5 min and 581±448.7 vs 788±605 sec in the TR and TP group.The average systolic transpedal pressure has been increased from 100.1 mmHg ±44 to 131±36.4 mmHg after the procedure. Major adverse event at one month was detected in six patients (5.2%).Radial and pedal artery access site complications were encountered by ultrasound in 3/73 (4.1%) and 3/115 patients (2.6%) during follow up. Conclusion Below-the-knee artery angioplasty can be safely and effectively performed using radial and transpedal access in selective patient population.

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Retrograde Revascularization of Tibial Arteries in Patients with Critical Limb Ischemia: Plantar-Arch Versus Transpedal Approach

Journal of Endovascular Therapy ◽

10.1177/15266028211036480 ◽

2021 ◽

pp. 152660282110364

Author(s):

Erik Stahlberg ◽

Andreas Stroth ◽

Alexander Haenel ◽

Ulrike Grzyska ◽

Franz Wegner ◽

...

Keyword(s):

Limb Salvage ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Target Lesion ◽

Technical Success ◽

Access Site ◽

Femoral Access ◽

Tibial Arteries ◽

Significant Difference ◽

Procedural Success

Purpose: To compare retrograde plantar-arch and transpedal-access approach for revascularization of below-the-knee (BTK) arteries in patients with critical limb ischemia (CLI) after a failed antegrade approach. Materials and Methods: Retrospectively we identified 811 patients who underwent BTK revascularization between 1/2014 and 1/2020. In 115/811 patients (14.2%), antegrade revascularization of at least 1 tibial artery had failed. In 67/115 (58.3%), patients retrograde access to the target vessel was achieved via the femoral access and the plantar-arch (PLANTAR-group); and in 48/115 patients (41.7%) retrograde revascularization was performed by an additional retrograde puncture (TRANSPEDAL-group). Comorbidities, presence of calcification at pedal-plantar-loop/transpedal-access-site, and tibial-target-lesion was recorded. Endpoints were technical success (PLANTAR-group: crossing the plantar-arch; TRANSPEDAL-group: intravascular placement of the pedal access sheath), procedural success [residual stenosis <30% after plain old balloon angioplasty (POBA)], and procedural complications limb salvage and survival. Correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were tested. Results: Technical success was achieved in 50/67 (75%) patients of the PLANTAR-group and in 39/48 (81%) patients of the TRANSPEDAL-group (p=0.1). Procedural success was obtained in 23/67 (34%) patients of the PLANTAR-group and in 25/48 (52%) patients of the TRANSPEDAL-group (p=0.04). In 14/49 (29%) cases with calcification at the pedal–plantar loop, technical success was not achieved (p=0.04), and in 33/44 (75%) patients with calcification at the tibial-target-lesion, procedural success was not attained (PLANTAR-group) (p=0.026). In the TRANSPEDAL-group, correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were not observed (p=0.2/p=0.4). In the PLANTAR-group, minor complications occurred in 13/67 (19%) and in the TRANSPEDAL-group in 4/48 patients (8%) (p=0.08). Limb salvage at 12 (18) months was 90% (82%) (PLANTAR-group; 95%CI 15.771–18.061) and 84% (76%) (TRANSPEDAL-group; 95%CI 14.475–17.823) (Log-rank p=0.46). Survival at 12 (18) months was 94% (86%) (PLANTAR-group; 95%CI 16.642–18.337) and 85% (77%) (TRANSPEDAL; 95%CI 14.296–17.621) (Log-rank p=0.098). Conclusion: Procedural success was significantly higher using the transpedal-access approach. Calcifications at pedal–plantar loop and target-lesion significantly influenced technical/procedural failure using the plantar-arch approach. No significant difference between both retrograde techniques in terms of feasibility, safety, and limb salvage/survival was found.

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