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1. Dr. M. Manzi
Interventional Radiology Unit
Foot & Ankle Clinic
Policlinico Abano Terme
Regional Center of Reference for Diabetic Foot
Treatment
Pedal Access: When and
How to do it

2. DISCLOSURE:
Marco Manzi, MD
•Abbott Vascular: Consultant/Advisory Boarder
•BARD: Consultant
•COOK: Consultant
•Covidien/EV3: Proctor
•Boston Scientific: Proctor
•Medtronic-Invatec: Consultant/Proctor

4. Our Technical Strategies for Revascularization
Combine all these strategies (antegrade –
retrograde for successful endovascular
therapy in diabetics with CLI

5. RESCUE SOLUTION
Pedal Puncture after Failed Subintimal Dissection

6. Pedal Puncture after Failed Subintimal Dissection
RESCUE SOLUTION

7. 1. Pedal/Metatarsal puncture
2. Wiring the artery
3. Retrograde foot or/and
tibial arteries recanalization
4. PTA + haemostasis
Retrograde Digital Artery Access
• After antegrade recanalization failure
• Absence of pedal / plantar sites for
puncture
• Retrograde pedal / plantar access failure
Indications and Purposes of Pedal and Arch/Metatarsal Access

8. Correct projection
criteria
Correct RX Projections for Pedal and Arch/Metatarsal Access

9. 1. Digital artery
puncture
Verapamil [5 mg/ 2 ml] diluted to 10 ml, inject 9
ml of this solution intra-arterially, close to the
foot. Local anaesthesia is administered in the
subcutaneous tissue along with 1 ml diluted
Verapamil to avoid spasms.
First/Second Dorsal digital branch are the best
option
• Chose the best digital branch for access
• Correct Radiological Projections
• Prepare for the stick
• STICK the artery
Use calcifications or CM injection
Techniques for Pedal and Arch/Metatarsal Access

10. 21 gage, 4 cm echogenic needle
Short Tip
• 21G Needle Micropuncture Set
Needle and Artery
Must be Allined!
Techniques for Pedal and Arch/Metatarsal Access

11. 2. Wiring the Digital
branch
Deploy the sheath and the support catheter
after retrograde wiring of the target foot
artery
Intraluminal wiring and recanalization of
digital branch and pedal arch
• 0.018”-in guide wire provide good
support
• Through the first dorsal branch reach
the pedal arch
• Micro-sheath and support catheter
Techniques for Pedal and Arch/Metatarsal Access

12. • 0,018 Dedicated Wire (Cook)/ V18 cw Ready to be Introduced
• Dedicated Micro-Sheath (CooK) permits
wires exchange, support catheters and
balloons introduction;
Check-Flo®
hemostasis valve
Micropuncture®
introducer

13. Wiring the Digital Branch

14. 3. Retrograde
recanalization
Intraluminal wiring and recanalization of
digital 0.018”-in and 0.014”-in guide wires
• Combined intraluminal and
subintimal technique
• Rendez-vous with the antegrade
catheter
• Antegrade wiring
Techniques for Pedal and Arch/Metatarsal Access

15. 4. PTA and Haemostasis
1.5 mm in diameter at nominal pressure
• Low-profile-OTW catheter balloon
PTA for 3-5 min.
• Long-balloon for definitive PTA in
the foot and tibial vessels
Technical aspects: Haemostasis and Angioplasty

16. C.S. 75 yo
Diabetes, Hypertension
CLI, TcPO2 =11 mmHg
Previous apex amputation I toe
Gangrene IV toeTUC 3C
Previous AT antegrade failure

17. Baseline Angio

18. Intervention Movie

19. PRE
POST
Acute Angio Result

20. Follow up @ 1 month/3months
“well demarcated gangrene
with surrounding granulation ,
no infection,
TcPO2 = 40 mmHg”
After amputation very good
wound TcPO2= 45mmHg

21. (Admission)
• M.G. 66 year old
• Diabetes
• Hypertension
• CLI, TcPO2 =3 mmHg
• Prev apex 1° and 2° amp
• TUC 2C

22. Baseline Angio

23. Retrgrade Loop Puncture

24. Angio & Clinical Result

25. CONCLUSIONS 1
Consider Retrograde Pedal/distal
approach as a “RESCUE Procedure”
Consider the retrograde techniques
when there are the right anatomical
conditions
Antegrade Plantar and
Pedal accesses

26. CONCLUSIONS 2
The retrograde distal approach
combined with all the other
advanced techniques could improve
our success rate in CLI

27. THANKS FOR YOUR ATTENTION