Tips for Pedal Access: Technical Evolution and Review

Abstract

Review article (beginning and end dates not provided). The authors point out that retrograde access via the pedal arteries may be the only feasible technique to cross chronic total occlusions (CTOs) of infrageniculate arteries and suggest that this approach may yield successful rates of recanalization >90% of cases. They emphasize that preparation for pedal access should be planned preprocedure in the event an antegrade approach is unsuccessful so as not to bring the patient back a second time. Using ultrasound-guided access, a 0.014- or 0.018-inch guidewire should be advanced under fluoroscopic guidance through a pedal or tibial artery. The authors even advocate using plantar arteries if the more proximal tibial or pedal vessels are occluded. A 4 French micropuncture sheath should be used for pedal access (various Pedal Access Kits are available). Straight or angled 0.014- or 0.018-inch support catheters are useful, such as the Quick-cross support catheter (Spectranetics, Colorado Springs, Colo). Once the retrograde guidewire crosses the lesion, it can be snared from a proximal antegrade sheath and externalized from the antegrade access site. Full through-and-through guidewire access is then obtained and the intervention can be performed from the antegrade approach. The advent of pedal access revolutionized endovascular treatment of critical limb ischemia, making any CTO amenable to percutaneous recanalization. Patients that were once facing certain amputation are now experiencing higher rates of limb salvage.