The Novel Use of Retrograde Proximal Anterior Tibial Artery Access for treatment of TASC D Femoropopliteal Occlusion
Presenter
Ahmad Z Arham, M.D., Yale New Haven Health, New Haven, CT
Ahmad Z Arham, M.D.1, Aaron E. Brice, M.D.2, Yulanka Castro, MD, FSCAI3, Zain Ahmed, MD, MPH4, Carlos I. Mena-Hurtado, M.D., FSCAI5 and Sameer Nagpal, M.D.4, (1)Yale New Haven Health, New Haven, CT, (2)University of Arkansas for Medical Sciences, New Haven, --, (3)University Hospitals Harrington Heart & Vascular Institute, Cleveland, OH, (4)Yale New Haven Hospital, New Haven, CT, (5)Yale University, New Haven, CT
Title
The Novel Use of Retrograde Proximal Anterior Tibial Artery Access for treatment of TASC D Femoropopliteal Occlusion
Introduction
Successful revascularization of long femoropoliteal lesions is challenging depending on calcification, lesion length, and stenosis vs occlusion. The ability to approach such lesions via antegrade and retrograde access has led to more successful revascularization procedures. This report describes the retrograde proximal anterior tibial artery as another access option for a skilled operator.
Clinical Case
A 77-year-old male is evaluated for worsening claudication symptoms in the Left leg, which have now progressed to rest pain over the past 1 month, Rutherford stage 4. His risk factors include Hypertension (HTN), Diabetes (DM), Dyslipidemia, and Coronary Artery Disease. His peripheral angiography (after getting Right common femoral artery access) showed no significant inflow disease. There is a flush occlusion at the ostium of the Left SFA with reconstitution of the popliteal artery. Infrapopliteal 2 vessel runoff is via the Anterior Tibial (AT) Artery and Posterior Tibial (PT) Artery. The Anterior Tibial artery gives off a diminutive Dorsalis Pedis artery and the Posterior Tibial artery gives off the medial and lateral plantar arteries, forming an incomplete arch. For intervention, a second retrograde access is planned in the Left Proximal Anterior Tibial Artery because of its larger caliber, instead of the diminutive dorsalis pedis artery. The Left Proximal Anterior Tibial Artery is identified on angiographic study under fluoroscopic guidance. A micropuncture needle and kit allows successful access and placement of a 4-French sheath. A combination of 0.014 Fielder XT and 0.018 Astato wire with microcatheter support allows successful retrograde crossing of the long totally occluded SFA segment. This wire is externalized through the right CFA sheath. The system is then rearranged into a proper antegrade position. A 0.014 V14 wire is advanced into the distal Anterior Tibial Artery beyond the retrograde access site. Hemostasis is achieved at the Proximal AT arteriotomy site after sheath pull with simultaneous intravascular balloon tamponade via a 4 x 80-mm Armada balloon and extravascular manual pressure for 5 minutes. PTA is then performed in the occluded SFA with a 6 x 150-mm Armada balloon and a 6 x 250-mm Medtronic INPACT drug-coated balloon to re-establish flow.
Discussion
Retrograde access affords certain advantages in treating femoropopliteal lesions. Firstly, the distal lesion site is less likely to be fibrotic and calcified, allowing passage of guidewire. Secondly, an access point close to the lesion allows more control and penetrability of the guidewire. The chance of local infection at this access site is low and it also saves the distal artery from any manipulation, allowing for future surgical treatment, if needed. An operator should only use low profile sheath at this access site to reduce risk of thrombosis and distal vessel occlusion. Adequate hemostasis should be ensured to avoid complications of local bleeding and compartment syndrome.