Why Transpedal Approach is
Important and the Angiosome
Concept
Mehdi H. Shishehbor, DO, MPH, PhD
Director, Endovascular Services
Staff, Interventional cardiology and Vascular Medicine
Cleveland Clinic
Disclosure
Education and Consulting for Abbott
Vascular, Medtronic, Cook, and
Spectranetics but do not take any
Compensation
Will be discussing Off-label products
Lancet. 2005 Dec 3;366(9501):1925-34.
1
Percent with Antegrade Failure
Lancet. 2005 Dec 3;366(9501):1925-34.
J Endovasc Ther. 2008;15:594–604.
Shishehbor, AVS 2014
Ti bi al di sease
CLI
52 yo male, severe DM (HgbA1c: 13),
HTN, HL
2
ABI and TBI
0.36
1.19
ABI/TBI
0.91 - 1.30
Normal
0.70 - 0.90
Mild disease
0.40 - 0.69
Moderate disease
0.00 - 0.39
Severe disease
•ABI >1.3 is abnormal and consistent with calcified vessels - unreliable
•ABI alone is inadequate to assess distal perfusion
•TBI ≥0.7 is normal
TBI = toe-brachial index
Newman AB, et al. Circulation. 1993;88:837-845.
Bunte & Shishehbor submitted 2014
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Bunte & Shishehbor submitted 2014
Method of
Revascularization
Appropriate
Angiosome
Boundary
Angiosome
Endovascular
83%
59%
Bypass
91%
62%
4
1%
8%
14%
36%
11%
27%
1%
52 yo male, severe DM (HgbA1c: 13),
HTN, HL
Transcutaneous Oximetry/TcPO2
• Measures oxygen tension 12 mm deep in the skin from
the local capillary (nutritive)
perfusion
• Useful for wound healing
prediction in extremities
• Can be used to assess
response to HBOT
HBOT = hyperbaric oxygen therapy
Fife CE, et al. Journal Of Undersea and Hyperbaric Medicine. 2009;36:43-53.
5
Transcutaneous Oximetry/TcPO2
• TcPO2 > 70 mm Hg = Normal Value
• TcPO2 < 40 mm Hg = Impaired Wound Healing
• TcPO2 < 30 mm Hg = Critical Limb Ischemia
• Low values of TcPO2 (< 40 mmHg)
–
–
–
–
–
–
–
Peripheral arterial disease
High altitude
Pulmonary disease
Heart failure
Edema
Inflammation
Callous, skin diseases (scleroderma)
Fife CE, et al. Journal Of Undersea and Hyperbaric Medicine. 2009;36:43-53.
52 yo male, severe DM (HgbA1c: 13),
HTN, HL
TcPO2
6
Angiogram
3 Weeks Post-intervention
6 Weeks Post-intervention
Skin Perfusion Pressure (SPP)
• Measurement (mmHg) of the capillary opening
pressure after occlusion
• Uses blood pressure cuffs to occlude blood flow,
followed by controlled pressure release allowing
gradual return of blood flow
• During cuff deflation, laser Doppler is used to
determine return of blood flow (reactive hyperemia)
• The pressure at which movement is detected is the
skin perfusion pressure
Lo T, et al. Wounds 2009; 21(11);310-316.
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Laser Doppler and SPP
SPP Interpretation Guideline (mmHg)
- 50 or > = Normal skin perfusion
- 40 – 50 = Mild ischemia
- 40 +
= Wound healing probable/mild to
moderate ischemia
- 30 – 40 = Gray zone for healing/moderate
ischemia
- 30 or < = Wound healing unlikely/Critical Limb
Ischemia
Lo T, et al. Wounds 2009; 21(11);310-316.
SPP vs. TcPO2
• SPP measures pressure (mmHg)
• TcPO2 measures oxygen molecules (mmHg)
• SPP Advantages
– Not affected by vessel calcification, callous or thickened
skin, or edema and can be used on plantar foot and digits
– Generally more sensitive in its ability to predict wound
healing relative to TcPO2
• SPP Disadvantages
– Not useful for predicting response to HBOT
– Blood flow occlusion of the cuff may be painful
– Patients must lie supine with legs extended
Lo T, et al. Wounds 2009; 21(11);310-316.
New Technologies
Intra-operative Fluorescence Angiography
• Provides real time capillary perfusion assessment
• Determines surface tissue viability
• Imaging head
•
– Charged coupler device camera (CCD)
– Laser light source
– Distance sensor
IV administration of indocyanine green (ICG)
– Binds to plasma proteins
– Hepatic clearance - safe for patients with renal dysfunction
– Not used for patients with Iodine, contrast, penicillin or sulfa
allergies
Perry D, et al. J Diabetes Sci and Technol. 2012;6:204-208.
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New Technologies
Pre-intervention
Post Intervention
(Anterior Tibial Artery Angioplasy)
Wound Perfusion + Clinical Variables
Physiologic/Anatomic
• ABI/PVR
• TBI
• TcPO2
• Laser/skin perfusion
• Ultrasound
• Collateral flow in the
foot
62 year old male
• Severe DM
• Prior right LE BKA
• HTN
• HL
• CRI ~ 1.4
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Wound Treated:
01/12/12
02/07/12
03/12/12
TcPO2
10
TcPO2
3 weeks
2 Weeks Post-intervention
7 weeks
10 Weeks Post-intervention
10 weeks
30 Weeks Post-intervention
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Thank You!!
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7/2/2014
Pedal Access: When and How
Carlos I. Mena, M.D., FACC, FSCAI
Assistant Professor of Medicine
Medical Director Vascular Medicine
Yale School of Medicine, Yale New Haven Hospital
New Haven, CT
CTO Crossing Technology Landscape
• CTOs are present in ~40% of patients
treated for symptomatic peripheral
artery disease1
• Nearly 40% of CTOs require
adjunctive technology for crossing2
• Endovascular CTO treatment
increasing with new technology
options3
• No “gold standard” CTO solution4
Ima ge provi ded by John La ird, MD. Results from ca se studies are not predictive of results in other ca ses. Results i n other ca ses may va ry.
1
A. Boguszewski, et al, Endovascular Today, May 2010, 33-8 . 2 2010-2011 Global PI Tracking Study; US
physicians; N= 70. 3 True lumen re-entry devices facilitate subintimal angioplasty and stenting of CTOs – Jacobs,
D, et al, Journal of Vasc Surgery, Jun 2006. 4 PI MAB 2011 Feedback.
Factors That Influence Treatment Success
Multiple lesion characteristics influence the success
rate of endovascular treatment of CTOs:
–
–
–
–
–
Duration of occlusion
Lesion length and morphology
Calcification
Presence of collaterals (esp near proximal cap)
Distal flow
Melzi G., et al., Catheter Cardiovasc Interv 2006; 68:29-35.
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7/2/2014
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7/2/2014
Hybrid Approach
CTO:
• Acute/Sub acute
•Minimum Calcium
•Lack of collaterals
•No prior Attempts
Antegrade Approach:
Ipsilateral vs. Contralateral:
• Inflow Disease
•Above or Below the knee
Unsuccessful:
•Subintimal
• >10 min fluoro time
Successful:
• Intraluminal
• <10 min flouro
RETROGRADE ACCESS
The Foot By Angiosome
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6/30/2014
Ultrasound-Guided Tibial-pedal
Access
J.A. Mustapha, MD, FACC, FSCAI
Larry J. Diaz-Sandoval, MD, FACC, FSCAI
Metro Health Hospital
Wyoming, MI
Anterior Tibial Artery Access
The anterior tibial and
dorsalis pedis arteries
are accessed with the
foot in a neutral position:
• Foot is prepped and
draped separately.
• Orientation of the foot
is adjusted depending
on the target tibial
vessel.
Posterior/Peroneal Tibial Artery Access
• To access the posterior tibial
artery (PT) the foot is
rotated laterally and the leg
will be bent slightly at the
knee level for patient
comfort.
• To access the peroneal
artery the foot needs to be
rotated laterally further to
separate the fibula and
tibia. This maneuver will
facilitate direct cannulation
of the artery.
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6/30/2014
Step by Step Tibial-pedal Access
1
2
3
4
5
6
7
8
9
Pre Access EVUS mapping
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6/30/2014
Access Site Located
EVUS Guided Access
EVUS Wire Advancement
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6/30/2014
Retrograde Tibial Access
and CTO Crossing Attempt
EVUS Guide AT Access
EVUS Wire Advancement
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6/30/2014
Sheath anchor placement
Retrograde Angiogram
Retrograde Angiogram
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6/30/2014
Initial arterial tibial access failed and venous
puncture reoccurred; re-attempt under EVUS
Post retrograde tibial access,
retrograde tibial angiogram is performed
•
•
Needles are reflective of US waves
It is essential to visual the needle during the
puncture of the artery
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6/30/2014
WIRES
Reverberation artifacts appear as
multiple, equally spaced parallel lines
Why is this better than fluoroscopy?
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6/30/2014
THANK YOU
J.A. Mustapha, MD, FACC, FSCAI
Larry J. Diaz-Sandoval, MD, FACC, FSCAI
Metro Health Hospital
Wyoming, MI
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7/2/2014
Equipment Selection for
Transpedal Interventions
Anand Prasad, MD
Avoid ad-hoc intervention…
• Study the
angiogram…consider
approach, equipment,
potential problems
Access Approach
And
Sheaths
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7/2/2014
Factors which access/sheath
selection
 Wire/Catheter Support
 Visualization
 Planned treatment PTA vs Stent vs
Atherectomy
 Patient height and target vessel
Which approach is best for intervention?
Approach
Pros
Cons
Contralateral
Most operators
comfortable with this
access
Ipsilateral antegrade
•
•
•
More support
Can reach plantar arch
Better visualization
•
Can help cross CTOs
•
with poorly defined caps
Crossing CTO distal cap •
is sometimes easier
Retrograde crossing via
transpedal approach
Tibopedal arterial
minimally invasive (TAMI)
•
•
•
Single retrograde sheath
Treat completely from
below
•
•
•
Poor support
Equipment length issues
Wastes contrast
•
May seem challenging at
first
Inexperience can lead to
vascular complications
•
•
•
Requires suitable pedal
vessel
Must prevent spasm and
thrombosis
Requires suitable pedal
vessel
Limits equipment
selection
Contralateral vs Antegrade Visualization
Contralateral
Antegrade
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7/2/2014
Antegrade technique
• Use ultrasound…practice US
• Ok if your wire goes into the profunda,
use a second wire (V18) and redirect to
SFA
• Ok to stick the proximal SFA. Manual
pressure works and get good with the
Mynx
Retrograde transpedal access technique
• Ultrasound guided is the way to go…avoid flouro guided access
• Dorsiflex and rotate out foot for PT
• Plantarflex foot for DP
• Peroneal access much more challenging due to hemostasis issues
• Minimize use of lidocaine and be liberal with nitrates
El Sayed et al Debakey Heart Journal 2013
Sheath Choice
Manufacturer
Description
Sheathless
N/A
Limits support and
retrograde treatment
options
Pinnacle Precision Sheath
Terumo
4.0 Fr ID/6.0 Fr OD
Micropuncture® Pedal
Introducer Access Set
with CheckFlo valve
Cook
2.9 Fr ID/4.0 Fr OD, can
accommodate 1.25 micro
CSI crown
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7/2/2014
TAMI…
 Single access technique
 Treat lesion retrograde
 4 Fr Terumo Precision sheath is key
 Modalities of treatment are orbital atherectomy
and PTA
 TAMI solution prevents
spasm.
Crossing Strategies:
Wires
Catheters
Dedicated devices
Non-CTO lesion:
Workhorse 0.014” wire
Chronic Total Occlusions
 Wire escalation strategy
 Direct use of heavy tipped wire
Selected Equipment
Manufacturer
Characteristics
MiracleBros Wires, 0.14”
Abbott/Ashai
3-12 gram tip weight
Hydrophobic coated
Approach, 0.014”
Cook
6-25 gram tip weight
PTFE coated
Treasure 12, 0.018”
Asahi
12 gram tip weight
Hydrophilic tip coating
PTFE shaft coating
Astato 30, 0.018”
Asahi
30 gram tip weight
Hydrophilic tip coating
PTFE shaft coating
Astato XS 20, 0.014”
Asahi
20 gram tip load
Hydrophilic tip coating
PTFE shaft coating
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7/2/2014
Support Catheters
0.014”
0.018”
0.035”
0.038”
Straight tip
Tapered
Angled tip
Catheter
Manufacturer
Quickcross,
Spectranetics
Mini
Vascular Solutions
Trailblazer
Covidien
CXI
Cook
Navicross
Terumo
Finecross
Terumo
Crossing Device
Manufacturer
Description
Viance
Covidien
Blunt manual
probing/controlled
dissection
Can be used
retrograde
KittyCat
Avinger
Manual or assisted
blunt dissection
Ocelot
Avinger
Manual or assisted
blunt dissection with
OCT guidance
Peripheral Crosser
Bard
High frequency
vibrations to
penetrate tissue
TruePath
Boston Scientific
Diamond coated
rapidly rotating tip
Frontrunner XP
Cordis
Blunt microdissection
Re-entry Device
Manufacturer
Description
Outback
Cordis
Flouroscopic/Angiographic guided needle reentry
Pioneer
Volcano
IVUS guided needle re-entry
6 Fr system
Enteer
Covidien
Flouroscopic/Angiographic guided wire re-entry
using a balloon to help align and direct wire
OffRoad
Boston Scientific
Flouroscopic/Angiographic guided wire re-entry
using an angled balloon to help align and direct
wire
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7/2/2014
Should we use a wire catheter
strategy first or a dedicated
crossing device?
Hadidi O,…Prasad A, Banerjee S, et al. J Am Coll Cardiol Intv. 2014;7(2_S):S35-S35
Wire capture
Treatment options
Atherectomy:
 Orbital (CSI)
 Directional (Turbohawk, Covidien)
 Rotational w aspiration (Jetstream,
Boston Scientific)
 Rotational (Rotablator, Boston Scientific)
 Laser (Spectranetics)
Balloon Angioplasty:
“standard PTA”
Specialty Balloons:
Chocolate (Trieme)
Angiosculpt (Angioscore)
Cutting Balloon (Boston Sci)
Stenting:
Small diameter nitinol
(Xpert, Abbott)
Drug eluting coronary
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7/2/2014
Case#1: transpedal posterior tibial access
72 y/o obese male, poorly controlled diabetes, HTN, atrial fibrillation on warfarin,
chronic kidney disease.
 The patient developed left great toe blister 6 weeks ago that “popped” and
since then has had progressive discoloration of the toe. Reports a throbbing pain
in the toe.
3/2014 UTHSCSA, Anand Prasad and Hinan Ahmed
Approach… Indirect revascularization
 Too short of “healthy” PT vessel for 4 Fr Precision and TAMI
 Antegrade left access for visualization
and treatment (55 cm 6 Fr sheath)
 Cook 4 Fr Pedal Access sheath placed
in PT under US Guidance
 TAMI solution running through
sidearm of hemostatic valve
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7/2/2014
 Terumo FineCross 0.014” catheter
 MiracleBros 12 gram wire
Spectranetics QuickCross Capture Catheter
• Exchanged CTO wire for Viperwire
• CSI Orbital atherectomy 1.25 Micro –multiple
passes on low to ankle
• PTA with RapidCross 2.0 x 200 mm (Covidien)
• and then AngioSculpt 2.5
and 3.0 balloons
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7/2/2014
• Restored inline flow into PT
and into foot
Case #2:
68 year old male with DM, CAD, CHF EF 40%, CKD 3, p-afib on warfarin.
Pt with R heel, R great toe ulcer with gangrene and severe rest pain of foot despite narcotics.
2/2014 UTHSCSA, Anand Prasad and Hinan Ahmed
Lesions:
Ostial AT
AT CTO
Moderate ostial PT and Peroneal
Severe PT lesions
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7/2/2014
Posterior tibial is occluded distally, small in caliber with diffuse distal disease
Procedural Approach….
 Elected to address pain and open larger vessel in AT
 Elected TAMI approach
 US guided Pedal access with 4 Fr Terumo Precision sheath
The best laid plans….
• Navicross catheter with 6 gram MiracleBros wire
• Wire enters subintimal space mid way….
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7/2/2014
Stingray balloon from pedal
sheath.
Navicross from antegrade sheath placed above
Snared wire
PTA with 2.0,
2.5 balloons
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7/2/2014
3 Xience DES stents later….
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7/2/2014
US-GUIDED
ACCESS &
INTERVENTIONS IN
CLI
Larry J. Diaz-Sandoval, MD, FACC ,FSCAI, FAHA, FSVM
J.A. Mustapha, MD, FACC, FSCAI
Metro Health Hospital
Grand Rapids, MI
CASE PRESENTATION
 47 y/o male with long hx of Type 1 DM.
 NH Ulcer in lateral aspect right foot (Rutherford
V).
 ESRD (Cr 5.0 mg/dL, GFR: 13.29 ml/min/1.73 m ).
 Pt has canceled procedure several times due to
2
fear of nephrotoxicity.
 Finally accepted when told he would not go on
transplant list until wounds healed.
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7/2/2014
A
B
C
D
PCA
PT
*
*
PT
PCA
CTO CAPS DYNAMICS:
Proximal Cap:
ANTEGRADE CONVEX
Best
Strategy:
Follow
Concavity
RETROGRA
DE APPROACH
Distal Cap: RETROGRADE CONCAVE
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7/2/2014
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7/2/2014
Wiring PT under US (right to left)
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7/2/2014
1 Month Post Follow-up
7
7/2/2014
THANK YOU
Larry J. Diaz-Sandoval, MD, FACC ,FSCAI, FAHA, FSVM
J.A. Mustapha, MD, FACC, FSCAI
Metro Health Hospital
Grand Rapids, MI
PT DUS Pre-intervention:
PT DUS Post-intervention:
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7/2/2014
AT DUS Pre-intervention:
AT DUS Post-intervention:
Doppler:
ABI: 1.27
9