Retrograde transpedal access with transradial guidance for revascularization of below-the-knee arteries in patients with critical limb ischemia - Zoltan Ruzsa

1. Transradial and transpedal access for
isolated below-the-knee lesions
in critical limb ischemia
Ruzsa Z., Nyerges A., Bellavics R., Nemes B., Hüttl K., Merkely B.
AimRadial 2017

2. Disclosure Statement of Financial Interest
I, Zoltán Ruzsa Dr. DO NOT have a financial interest/arrangement or
affiliation with one or more organizations that could be perceived as a
real or apparent conflict of interest in the context of the subject of this
presentation.

3. Recanalisation strategy- BTK CTO (2012 TCT)
Anterograde BTK recanalisation-
wound releated artery
1. Drilling technique
2. Penetration technique
3. Subintimal technique
1. Inflow disease
2. Outflow disease
unsuccessful
Retrograde recanalisation
Transpedal access
(ATA, PTA, peroneal)
unsuccessful
Collateral dilatation
(malleolar)
Femoropopliteal
lesion-occlusion
present
Yes
No
Retrograde recanalisation
Plantar loop technique
Paralell patent artery and plantar
arch present
Yes
No
Peroneal artery and malleolar
collaterals present
Yes
Multilevel PTA
-Balloon
angioplasty
- Stent in flow
limiting dissections
or recoil
Success

4. Retrograde technique
Distal ATA or PTA puncture
Sheathless technique with Pilot 150 GW
Balloon support with low-profile balloon
1. Drilling technique
2. Subintimal technique with Pilot 150 GW
3. GW change for penetration technique
ower-the-wire balloon (Miracle, Progress)
unsuccessful
unsuccessful
unsuccessful
4. Sheath insertion
5. „Randezvous technique”: Dual ballon inflation
from anterograde and retrograde way
Retrograde balloon dilatation
During balloon deflation attempt to
advance the anterograde wire
unsuccessful
Success
Externalisation of the wire
1. Advancement in the sheath
2. Anterograde lassoo
unsuccessful
Retrograde balloon dilatation and
retrograde stenting in flow limiting
cases
Pull back the retrograde balloon
Advance the anterograde balloon until the punture site
Pull back the retrograde GW
Compress the puncture site
Anterograde POBA
Stent in flow limiting dissection and significant reoil
Ballooning the puncture site if necessary
Success

5. Transpedal punction- dist. ATA

6. Background
• Transradial access for BTK lesions
• Technically possible, but only in limited cases due to short delivery systems
• Transpedal access for BTK lesions
• Potential advantage
• It needs a short delivery system
• Less access site complications at the femoral access site
• Excellent pushability
• Immediate mobilisation
• Potential disadvantage
• Target or donor artery occlusion
• Less techniques are available than during anterograde access for example plantar arch
reconstruction
• Retro only strategy has many limitations and anterograde GW advancement is necessary
in many cases

7. Aim of the study
• To assess the feasibility of the TR and TP approach in isolated BTK
disease in CLI
• To investigate the clinical success rate angioplasty
• To investigate the complication rate of the TP access in BTK disease

8. Methods
• 19 consecutive patiens with CLI
• Study design
• Prospective pilot study
• Inclusion criteria
• Critical limb ischemia on the lower limb (Rutherford IV-VI)
• Isolated below-the-knee stenosis or occlusion (more than 70%) and viable limb
• Exclusion ctiteria
• Non viable lower limb
• At least one BTK artery with good distal run-off
• Infected puncture site
• End-points
• Technical success
• Clinical success
• Complications (Procedural and MAEs)
• Procedural releated factors

9. Below-the-knee and CLI
ANTEROGRADE FEMORAL
ACCESS
1. Inflow disease
2. Outflow disease
unsuccessful
Secodary TRANSPEDAL
Retrograde recanalisation
(ATA, PTA, proneal)
unsuccessful
Collateral dilatation
(malleolar)
Femoropopliteal lesion-occlusion
present
Retrograde recanalisation
Plantar loop technique
Paralell patent artery and
plantar arch present
Peroneal artery and malleolar
collaterals present
- Balloon angioplasty
- Stent in flow
limiting dissections
or recoil
Success
TCT 2011
Good distal run-off
Patent ATA or PTA

10. BTK and primary transpedal
(radial angio and TP PTA)
60/40 Hgmm 160/80 Hgmm

11. Demographic and clinical data
n, %
Age 66.2
Male 15 (83.3)
Hypertension 17 (94.4)
Hyperlipidaemia 18 (100)
Diabetes mellitus 8 (44.4)
Smoking 17 (94.4)
Renal insufficiency 2 (11.1)
CAD 5 (27.8)
COPD 1 (5.5)
Previous bypass operation 2 (11.1)
Previous PTA 3 (16.6)
Rutherford
- IV
- V
- VI
9 (50)
1 (5.5)
8 (44.5)

12. Angiographic data
Dilated arteries n, (%)
SFA 0 (0)
POA III 0 (0)
ATA 15 (83.3)
TFT 1 (5.5)
PEA 2 (11.1)
PTA 1 (5.5)
Angiographic data n (%)
Chronic total occlusion 8 (44.4)
Lesion length (mm) 98.6 (58.8-138.1)
Reference vessel diameter 2.8 (2.5-3)
Diameter stenosis (%) 90.5 (86.7-96.4)
Severe calcification 6 (33.3)
Intraluminary thrombus 0 (0)

13. Angiographic and procedural results
Angiographic result
PTA result n (%)
Unsuccessful 0 (0)
Sucessful 0 (100)
Puncture site
Puncture site n (%)
ATA and pedal artery 15 (83.3)
Peroneal artery 2 (11.1)
PTA 1 (5.5)
Procedural parameters
X Ray dose (Gy/cm2) 10.8 (2.3-12.1)
Fluroscopy time (sec) 558 (275.1-842.3)
Contrast consumption (ml) 94.4 (55.3-133.5)
Procedure time (min) 35.5 (25.8-45.2)

14. Clinical success Patients
n, (%)
MAE
(1 month)
Patients
n, (%)
Releaved rest pain 19 (100) Death 3 (16)
Healing of ulcer
and gangrene
9 (100) Major unplanned
amputation
1 (5.2)
Avoidance of
unplanned
amputation and
surgical procedure
18 (94.7) Urgent bypass
operation
0 (0)
Clinical success
(summary)
18 (94.7) Summary 4 (21%)
Clinical success and MAE (6 month)

15. Device consumption
Equipments n, (%)
Sheath 18 +10 (155)
Diagnostic catheter 18 (100)
Guiding catheter 0 (0)
Guidewire 0.035 18 (100)
PTA/ PTCA Guidewire(0.14”) 44 (244)
Balloon 23 (127)
Self expandable stent 0 (0)
Drug eluting stent 9 (50)
Thrombus aspiration 0 (0)
IVUS 0 (0)
Rotational atherectomy 0 (0)

16. Vascular complications
Radial artery site: N (%)
-Pseudoaneurysm:
-Major haematoma
-Major bleeding:
-AV fistula:
0 (0)
0 (0)
0 (0)
0 (0)
Distal puncture site: N (%)
-Occlusion:
-Severe Spasm:
-Pseudoaneurysm:
-AV fistula:
-Compartment syndrome
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
TCT 2011

17. Can we perform BTK stenting from TR and TP access ???

19. Final angio from TP and TR access

20. Conclusion
• Below-the-knee artery angioplasty can be safely and effectively
performed using radial and transpedal access in selective patient
population