Vascular Access Strategies to
Increase Success During
Lower Extremity Endovascular
Interventions
D. Chris Metzger, MD, FACC
Director, Cardiac & Peripheral Cath Labs
Medical Director, Clinical Research
Holston Valley Medical Center
Cardiovascular Associates
Kingsport, TN, USA

OVERVIEW
• Access Strategies for LE PVI
• Contralateral
• Antegrade
• Popliteal
• “Assisted Retrograde”
• Combined approaches
• Special Circumstances
• Closure of Various Unique Access
• CASES to illustrate

Access for LE PVI
• Proper access route is essential for
successful PVI in tough cases
• Carefully consider access b4 case!!
• For complex access cases, often best
for ≥ access sites; ROADMAP
2
• May need to modify access during case
• Educate patient and staff for difficult
access

CONTRALATERAL
(“around the horn”) Access
• Used for majority of standard SFA cases
• Standard retrograde access, aortogram,
unsubtract, 5F IM catheter, Glidewire and
exchange to stiffer wire, XC for contalateral
sheath
• OmniFlush for steep bifurcations
• Wire deeper for tough bifurcations; R.map
• May not provide enough length for BTK
cases, esp. in tall patients & pedal disease

ME- Contralateral Access w EIA CTO

GT-STEEP Aorta Bifurcation

SP- Contalateral thru Kissing Stents

POPLITEAL ACCESS
• Good for ostial or prox SFA CTO’s which
can’t be crossed from above
• Gain retrograde access on contralateral
side- use for roadmap and “angios from
above”
• Dual angios; access pop on roadmap
• I use Perclose to close popliteal artery
• Need motivated patient AND staff
• Use sterile extension tubing for injections

RSu- Popliteal Access for 1995 CTO

ANTEGRADE ACCESS
• Good for distal SFA & infrapopliteal
disease; also for ABiFem patients
• Can’t use for ostial/prox SFA CTO/dz
• Roadmap if access there, not needed
• Start stick high
• Difficult in obese patients
• Closure devices effective for me

ANTEGRADE ACCESS

CeA- AxFem & Pop Access

DB-Difficult CIA CTO Access
& Assisted retrograde access

LS- Contralateral & Retrograde

PEDAL ACCESS

CONCLUSIONS
• There are multiple routes for arterial
access for lower extremity
intervention
• Knowledge and use of these
techniques, coupled with persistence
and resourcefulness, allows
successful treatment of increasingly
complex lower extremity PV cases

Thank You for Your
Attention!

RSu- Popliteal Access for 1995 CTO

BM Pop access from prior CTO Talk