Successful Revascularization of Infrapopliteal Chronic Total Occlusions Using the Plantar Arch as a Conduit and Retrograde Pedal Access.

Zola N’dandu ,Tamunoinemi Bob‐Manuel ,Koyenum Obi

doi:10.31486/toj.20.0085

Zola N’dandu , Tamunoinemi Bob‐Manuel + Show 1 more

Open Access

https://doi.org/10.31486/toj.20.0085

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Abstract

Background: With the rising prevalence of critical limb ischemia (CLI), the pedal-plantar loop technique and retrograde access may be needed to increase interventional success.Case Report: A 63-year-old female with severe peripheral artery disease presented with a 2-month nonhealing wound on the dorsum of her left foot despite wound care. We inserted a 65-cm Destination Guiding Sheath and crossed the right superficial femoral artery (SFA) chronic total occlusion (CTO) that we initially treated with a 4.0-mm Ultraverse balloon. We attempted unsuccessfully to cross the distal anterior tibial artery into the dorsalis pedis artery. We obtained antegrade access of the posterior tibial artery at the level of the ankle with a 2.9-French Cook pedal access kit. We inserted a 90-cm CXI catheter with a 0.014 Fielder XT wire and used the lateral plantar artery as a conduit to cross the dorsalis pedis artery and distal anterior tibial artery CTO with retrograde wire manipulation via lateral plantar artery. Finally, we performed distal anterior tibial and dorsalis pedis CTO balloon angioplasty with a 2.5 × 220-mm Ultraverse balloon and performed SFA percutaneous transluminal angioplasty and stenting with a 7.0 × 120-mm Zilver PTX stent, postdilated with a 6.0-mm Ultraverse balloon. We successfully established in-line flow to the foot with 3-vessel runoff. The patient's wound healed in a month.Conclusion: Retrograde pedal access can improve the success rate of recanalization of below-the-knee disease in patients with CLI.

Highlights

The prevalence of critical limb ischemia (CLI)—characterized by multilevel peripheral artery disease (PAD)—is increasing, and below-the-knee disease is especially difficult to treat.[1,2] To avoid the major economic cost, disability, and mortality associated with CLI and amputation, an endovascular first approach is recommended.[3,4]The pedal-plantar loop technique and retrograde access, together with an antegrade ipsilateral common femoral artery (CFA) approach, can increase the success rate of revascularization and the clinical outcome of belowthe-knee disease, improving the wound-healing process.[5]
We present the case of a patient with a 2-month history of a nonhealing foot wound that responded to revascularization of the pedal arch
Because of lack of awareness of PAD among patients and physicians and increasing comorbidities such as diabetes, the prevalence of CLI characterized by multilevel PAD is rising

Summary

Background

With the rising prevalence of critical limb ischemia (CLI), the pedal-plantar loop technique and retrograde access may be needed to increase interventional success. Case Report: A 63-year-old female with severe peripheral artery disease presented with a 2-month nonhealing wound on the dorsum of her left foot despite wound care. We attempted unsuccessfully to cross the distal anterior tibial artery into the dorsalis pedis artery. We inserted a 90-cm CXI catheter with a 0.014 Fielder XT wire and used the lateral plantar artery as a conduit to cross the dorsalis pedis artery and distal anterior tibial artery CTO with retrograde wire manipulation via lateral plantar artery. We performed distal anterior tibial and dorsalis pedis CTO balloon angioplasty with a 2.5 × 220-mm Ultraverse balloon and performed SFA percutaneous transluminal angioplasty and stenting with a 7.0 × 120-mm Zilver PTX stent, postdilated with a 6.0-mm Ultraverse balloon.

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DISCUSSION