Transradial and transpedal access forisolated below-the-knee lesions

in critical limb ischemia

Ruzsa Z., Nyerges A., Bellavics R., Nemes B., Hüttl K., Merkely B.

AimRadial 2017

Disclosure Statement of Financial Interest

I, Zoltán Ruzsa Dr. DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

Recanalisation strategy- BTK CTO (2012 TCT)

Anterograde BTK recanalisation-

wound releated artery

1. Drilling technique

2. Penetration technique

3. Subintimal technique

1. Inflow disease

2. Outflow disease

unsuccessful

Retrograde recanalisation

Transpedal access

(ATA, PTA, peroneal)

unsuccessful

Collateral dilatation

(malleolar)

Femoropopliteal

lesion-occlusion

present

Yes

No

Retrograde recanalisation

Plantar loop technique

Paralell patent artery and plantar

arch present

Yes

No

Peroneal artery and malleolar

collaterals present

Yes

Multilevel PTA

-Balloon

angioplasty

- Stent in flow

limiting dissections

or recoil

Success

Retrograde technique

Distal ATA or PTA puncture

Sheathless technique with Pilot 150 GW

Balloon support with low-profile balloon

1. Drilling technique

2. Subintimal technique with Pilot 150 GW

3. GW change for penetration technique

ower-the-wire balloon (Miracle, Progress)

unsuccessful

unsuccessful

unsuccessful

4. Sheath insertion

5. „Randezvous technique”: Dual ballon inflation

from anterograde and retrograde way

Retrograde balloon dilatation

During balloon deflation attempt to

advance the anterograde wire

unsuccessful

Success

Externalisation of the wire

1. Advancement in the sheath

2. Anterograde lassoo

unsuccessful

Retrograde balloon dilatation and

retrograde stenting in flow limiting

cases

Pull back the retrograde balloon

Advance the anterograde balloon until the punture site

Pull back the retrograde GW

Compress the puncture site

Anterograde POBA

Stent in flow limiting dissection and significant reoil

Ballooning the puncture site if necessary

Success

Transpedal punction- dist. ATA

Background• Transradial access for BTK lesions

• Technically possible, but only in limited cases due to short delivery systems

• Transpedal access for BTK lesions• Potential advantage

• It needs a short delivery system

• Less access site complications at the femoral access site

• Excellent pushability

• Immediate mobilisation

• Potential disadvantage• Target or donor artery occlusion

• Less techniques are available than during anterograde access for example plantar archreconstruction

• Retro only strategy has many limitations and anterograde GW advancement is necessaryin many cases

Aim of the study

• To assess the feasibility of the TR and TP approach in isolated BTK disease in CLI

• To investigate the clinical success rate angioplasty

• To investigate the complication rate of the TP access in BTK disease

Methods• 19 consecutive patiens with CLI

• Study design• Prospective pilot study

• Inclusion criteria• Critical limb ischemia on the lower limb (Rutherford IV-VI)

• Isolated below-the-knee stenosis or occlusion (more than 70%) and viable limb

• Exclusion ctiteria• Non viable lower limb

• At least one BTK artery with good distal run-off

• Infected puncture site

• End-points• Technical success

• Clinical success

• Complications (Procedural and MAEs)

• Procedural releated factors

Below-the-knee and CLI

ANTEROGRADE FEMORAL

ACCESS

1. Inflow disease

2. Outflow disease

unsuccessful

Secodary TRANSPEDAL

Retrograde recanalisation

(ATA, PTA, proneal)

unsuccessful

Collateral dilatation

(malleolar)

Femoropopliteal lesion-occlusion

present

Retrograde recanalisation

Plantar loop technique

Paralell patent artery and

plantar arch present

Peroneal artery and malleolar

collaterals present

- Balloon angioplasty

- Stent in flow

limiting dissections

or recoil

Success

TCT 2011

Good distal run-offPatent ATA or PTA

BTK and primary transpedal(radial angio and TP PTA)

60/40 Hgmm 160/80 Hgmm

Demographic and clinical datan, %

Age 66.2

Male 15 (83.3)

Hypertension 17 (94.4)

Hyperlipidaemia 18 (100)

Diabetes mellitus 8 (44.4)

Smoking 17 (94.4)

Renal insufficiency 2 (11.1)

CAD 5 (27.8)

COPD 1 (5.5)

Previous bypass operation 2 (11.1)

Previous PTA 3 (16.6)

Rutherford

- IV

- V

- VI

9 (50)

1 (5.5)

8 (44.5)

Angiographic dataDilated arteries n, (%)

SFA 0 (0)

POA III 0 (0)

ATA 15 (83.3)

TFT 1 (5.5)

PEA 2 (11.1)

PTA 1 (5.5)

Angiographic data n (%)

Chronic total occlusion 8 (44.4)

Lesion length (mm) 98.6 (58.8-138.1)

Reference vessel diameter 2.8 (2.5-3)

Diameter stenosis (%) 90.5 (86.7-96.4)

Severe calcification 6 (33.3)

Intraluminary thrombus 0 (0)

Angiographic and procedural results

Angiographic result

PTA result n (%)

Unsuccessful 0 (0)

Sucessful 0 (100)

Puncture site

Puncture site n (%)

ATA and pedal artery 15 (83.3)

Peroneal artery 2 (11.1)

PTA 1 (5.5)

Procedural parameters

X Ray dose (Gy/cm2) 10.8 (2.3-12.1)

Fluroscopy time (sec) 558 (275.1-842.3)

Contrast consumption (ml) 94.4 (55.3-133.5)

Procedure time (min) 35.5 (25.8-45.2)

Clinical success Patientsn, (%)

MAE (1 month)

Patientsn, (%)

Releaved rest pain 19 (100) Death 3 (16)

Healing of ulcer

and gangrene

9 (100) Major unplanned amputation

1 (5.2)

Avoidance of

unplanned

amputation and

surgical procedure

18 (94.7) Urgent bypassoperation

0 (0)

Clinical success(summary)

18 (94.7) Summary 4 (21%)

Clinical success and MAE (6 month)

Device consumptionEquipments n, (%)

Sheath 18 +10 (155)

Diagnostic catheter 18 (100)

Guiding catheter 0 (0)

Guidewire 0.035 18 (100)

PTA/ PTCA Guidewire(0.14”) 44 (244)

Balloon 23 (127)

Self expandable stent 0 (0)

Drug eluting stent 9 (50)

Thrombus aspiration 0 (0)

IVUS 0 (0)

Rotational atherectomy 0 (0)

Vascular complications

Radial artery site: N (%)

-Pseudoaneurysm:

-Major haematoma

-Major bleeding:

-AV fistula:

0 (0)

0 (0)

0 (0)

0 (0)

Distal puncture site: N (%)

-Occlusion:

-Severe Spasm:

-Pseudoaneurysm:

-AV fistula:

-Compartment syndrome

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

TCT 2011

Can we perform BTK stenting from TR and TP access ???

Final angio from TP and TR access

Conclusion

• Below-the-knee artery angioplasty can be safely and effectively performed using radial and transpedal access in selective patient population