the importance of popliteal access in vascular surgery

1. Popliteal access ,How important is it ? Mr. Mohamed Omar El-FarokM.Sc, FRCS

2. Topics to be covered How important is popliteal access ? Indication of Popliteal access How to do it ? Steps of CTO recanalization Different scenarios of passing SFA CTO from below up One Case

3. (1) How important is Popliteal access : It can convert a failed procedure to a successful one It is easier to cross SFA lesion from below (clinical experience) Used infrequently (< 5%) Complex proximal anatomy Failed ante-grade recanalization

4. (2) Indications of Popliteal access Failure of SFA recanalization from above Difficult contralateral access Flush occlusion of SFA Tandem lesion in SFA ad iliac both sides

5. (3)How to do popliteal access Percutaneous difficult Ultrasound guided ( safest) Open surgery (least preferred )

6. Percutaneous Pop Access : Direct Fluoroscopy looking for calcifications Do a Roadmap from the upper end Push the wire sub-intimal from the upper end and use it as a marker for popliteal access . Use micro-puncture needle Do not use more the 6 F sheath Continuous heparin infusion

7. Steps of Ultrasound guided pop. Access Patient Conscent Prone or lateral Duplex grey scale Light pressure Advance needle in LS. Or TS Avoid SM Avoid collapsed vein

8. (4) Steps of CTO recanalization All in relation to popliteal artery : Penetrating proximal occlusion Negotiating length of occlusion Distal re-entry

9. (5) Different scenarios of Popliteal CTOs A B C D E

10. Type A “flush” – blunt occlusion No angiographic clue regarding optimal point of entry Usually easier than upper end . Options: Probe proximal occlusion with wire tip supported by catheter Prolapse through (.035 wire) Try different catheters (glide catheter, IMA, ARI, MP, SOS, AL1) Break cap with stiff wire You can use 0.014 plateform

11. SFA-Popliteal CTOs Attempt to prolapse wire through occlusion May penetrate cap If successful, track low profile catheter through occlusion over wire Catheter provides support and direction Redirect wire tip as approximate distal point of reconstitution

12. Trick to be used in type A “centering” balloon for “back-up” support .035” wire (curved or straight) Useful alternative technique to break fibrous cap Exchange for hydrophilic guide wire and support catheter for “conventional” subintimal recanalization

13. Calcification in type A Flush occlusion with associated calcium Use stiff end of the wire for 1-2 mm Catheter directed wire through non-calcified portion Inject saline as your go Incremental advancement of wire and catheter

14. Type B Favorable morphology Tapered, centered beak Advance wire gently into tip of occlusion Slowly advance catheter over wire to support wire Confirm position of wire and tip with angio ( small amount and aspirate)

15. Type B Prolapse wire through occluded segment Incremental advancement of wire followed by catheter Confirm position of system Visual – course of vessel, calcium, “road map” tactile – if excessive binding - redirect

16. Type B Reorient catheter tip towards point of reconstitution Attempt to cross distal segment with straight tip of wire Track catheter across distal segment Assess pressure, waveform and perform end-hole injection

17. Type C Eccentric, narrow proximal occlusion Identify point of recanalization Select catheter with corresponding conformation Glide catheter IMA JR4 Vertebral , or MPA

18. Type C Consider .014” wire/catheter system Track catheter over wire into remnant of vessel lumen Attempt to cross occlusion with wire tip Advance to .035” wire (hydrophilic) as needed

19. Type D Challenging morphology Adjacent side branch Bare wire will tend to prolapse into side branch Solution: orient and support wire with catheter directed away from side branch

20. Type E Most challenging anatomy Bridging collaterals No clearly defined lumen or hint at true lumen If perforation happen go back and try again

21. Technical Aspects of Recanalizing If wire fails to track or if tracks into false channel, redirect wire by changing orientation of catheter Re-advance wire repeat sequence as needed Consider re-entry device Avoid extending dissection into mid-distal popliteal a. or infra-popliteal

23. ostial SFA, excessive calcium

25. proximal – mid popliteal

26. moderate calcium

27. 5-10 cms

28. Non ostial

29. ISRPredicted Success High Low

30. Reanalyzing SFA-Popliteal CTOsPredicted Procedural Time Focal occlusion Long, complex 15-20 mins 20-30 mins 10-15 mins .014-.035 wire 4 Fr catheter Re-entry device FrontRunner Excimer laser Different catheters Wire redirection

31. Case 1

32. Case

41. Lesson I have learned in life Good experience comes from bad judgment And Good judgment comes from bad experience

42. Thank you