retrograde approach using plantar arch pathway
TRANSCRIPT
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Cardiovascular Center – Tokeidai Memorial Hospital – Sapporo, Japan
Breakfast Meeting – BTK Intervention
My Best Brilliant Techniques for Saving Foot
Retrograde Approach
Using Plantar Arch Pathway
Kazushi Urasawa, MD, PhD, FJCC
Katsuhiko Sato, MD, PhD, Ryoji Koshida, MD, PhD
Michinao Tan, MD, Yuya Nakagawa, MD
Cardiovascular Center, Tokeidai Memorial Hospital
Sapporo, Japan
TCTAP 2013, Apr. 23-26, 2013, Seoul, Korea
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1. Antegrade wiring
2. Bi-directional wiring with distal puncture
Dorsalis Pedis
distal ATA
distal PTA
distal PA
Plantar artery
Digital arteries
3. Bi-directional wiring using collateral channel
Trans-collateral angioplasty (TCA)
Wiring techniques for BTK-CTO
Pre-existing collateral channel = pedal arch
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Case 1
Case: 80’s Male
Diagnosis: CLI (Rutherford 5)
Risk factors: Hypertension
Diabetes Mellitus
Dyslipidemia
Ischemic Heart Disease (PCI)
Foot lesion: Ulcer at 1st toe
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Control angiography
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Angiography of BTK level
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Selective angiography from distal peroneal A.
There is a fine
collateral channel
connecting PA and
Dorsalis.
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Advance wire into a collateral channel to DP
Cruise 0.014”
Prominent
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Retrograde wiring into the ATA-CTO
Ruby hard
0.014” 9g
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Antegrade wiring for the ATA-CTO
Astato XS9-12
0.014” tapered
Prominent
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Wire Rendez-vous
Antegrade
Astato XS9-12
Prominent
RetrogradeCruise
Corsair
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Advance antegrade guidewire into the DP, ATA
Cruise (NEOS)
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POBA for ATA-CTO
Amphilion-deep
3.0x120mm
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Angiography after POBA for ATA-CTO
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Tip injection at DP
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Advance guidewire to lateral plantar A.
Cruise (NEOS)
Corsair (Asahi Intec)
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Retrograde wiring for PTA-CTO
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Wire Rendez-vous in the PTA-CTO
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Advance antegrade microcatheter beyond CTO
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Balloon angioplasty for PTA-CTO
Amphilion-deep
3.0x120mm
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Balloon angioplasty for PTA-CTO (prox)
Amphilion-deep
3.0x120mm
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Final angiography
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Case 2
Case: 80’s Male
Diagnosis: CLI (Rutherford 5)
Risk factors: Hypertension
Old cerebral infarction
Parkinson’s disease
Aortic stenosis
Foot lesion: Ulcer at 1st and 2nd toe
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Control angiography
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Advance microcatheter beyond pedal arch
Prominent-BTA
(Tokai Medical
Products)
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Advance antegrade guidewire
Tip injection from
Prominent-BTA
provided an excellent
guidance for the
antegrade wiring.
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Tip injection from antegrade microcatheter
Corsair-PV (Asahi
Intec)
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Balloon angioplasty of DP and distal ATA
Shiden 2,0x200mm
(Kaneka)
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Balloon angioplasty of proximal ATA
Shiden 2.0x200mm
(Kaneka)
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Balloon angioplasty of PTA
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Final angiography
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Case 3
Case: 80’s Female
Diagnosis: CLI (Rutherford 5)
Risk factors: Hypertension
Diabetes Mellitus
Dyslipidemia
Ischemic Heart Disease
Foot lesion: Ulcer at 1st toe
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Control angiography
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Balloon dilatation of PA stenosis
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Angiography after PA dilatation
Increased collateral flow
provides better view of
BTA area.
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Antegrade wiring for ATA-CTO
Under the guidance of
contrast injection from the
microcatheter at distal PA.
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Advance antegrade guidewire into pedal arch
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Advance antegrade guidewire into plantar A.
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Balloon dilatation of pedal arch
Rapid stream 1.5x20mm
(Nipro)
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Balloon dilatation of ATA / DP – CTO
Amphirion-deep
2.0x120mm (Invatec)
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Final angiography
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Cardiovascular Center – Tokeidai Memorial Hospital – Sapporo, Japan
Pedal arch is a pre-exiting communication
vessel which connects anterior tibial and
posterior tibial artery.
If one tibial artery remains open, it should
be used for sending retrograde guidewire to
the opposite occluded tibial artery.
Summary
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Fighting for Limb salvage