Peripheral arterial disease (PAD) is an epidemic, affecting more than 8 million people in the United States.1 Percutaneous endovascular intervention has become the first-line approach to treat symptomatic PAD compared to a surgical approach. Infrainguinal artery chronic total occlusions (CTOs) are present in up to 50% of PAD patients presenting with claudication or critical limb ischemia.2 Traditionally, for CTO intervention, femoral artery access with a crossover or antegrade approach has been favored. However, given the higher risk of vascular complication associated with transfemoral access, there has been an increasing trend in use of alternative access sites, including pedal/tibial (transpedal) and radial artery access, which have proven to be feasible and with fewer complications compared to transfemoral access.3-5
We present a unique case of a patient with iliac artery stenosis, chronic total occlusion of the left superficial femoral artery, and tibial artery stenosis, who underwent successful percutaneous endovascular intervention with dual access using a combined transpedal and transradial approach.
This is a 62-year-old male with a prior history of coronary artery disease status post coronary stent implantation, moderate left carotid artery stenosis, active smoker, mild distal abdominal aortic aneurysm, and hypertension. He presents with lifestyle-limiting, left-sided claudication with rest pain (Rutherford Class 4). Left-sided ankle-brachial index (ABI) was 0.56 and 0.59 on the right side. He continued to have symptoms despite maximal medical therapy (aspirin, clopidogrel, atorvastatin, metoprolol succinate, isosorbide mononitrate, and cilostazol). Based on his limiting symptoms and the abnormal lower extremity ABI, a plan was made to proceed with a diagnostic peripheral angiogram and percutaneous endovascular intervention, if needed.
The left dorsalis pedis artery was cannulated under ultrasound guidance using a 21-gauge echogenic needle (Terumo) and a 4 French Precision Glidesheath (Terumo) was introduced into the anterior tibial artery. After confirming flow, nitroglycerin 200 mcg, verapamil 1 mg, and heparin 5000 IU were given intra-arterially. To achieve an activated clotting time (ACT) > 300 seconds, additional heparin was given if needed. An .018-inch, 300 cm V-18 ControlWire (Boston Scientific) loaded inside a 125 cm, 4 French Tempo Aqua Vertebral catheter (Cordis) was used to perform a diagnostic angiogram, which showed a high-grade stenosis in the mid anterior tibial artery (Figure 1A), mild atherosclerosis of the popliteal artery, and chronic total occlusion of the distal superficial femoral artery (SFA) (Figure 1B). The 4 French Glidesheath was upsized to a 6 French Slender Glidesheath (Terumo). This Slender Glidesheath has an outside diameter equivalent to a 5 French sheath, but can accommodate 6 French equipment. An .035-inch Aquatrack Regular Angled 260 cm Glidewire (Cordis) loaded inside a vertebral catheter was advanced to the distal SFA. Attempts were made to puncture the extensive calcified distal cap of the occlusion and the wire remained in the subintimal plane in the proximal SFA. Subsequently, the left radial artery was cannulated using a 4 French Glidesheath. A 4 French, 110 cm Flexor Shuttle Sheath (Cook Medical) was exchanged and positioned into the lower abdominal aorta. This was exchanged for a 4 French Multicurve 150 cm catheter (Terumo) for selective angiogram which showed high-grade stenosis of the left common iliac artery, left external iliac artery, left proximal SFA (ostial), and complete occlusion of the left mid SFA (Figure 1C). An .035-inch Aquatrack (Stiff Angled) 260 cm Glidewire was advanced in an antegrade fashion into the ostial left SFA CTO. Using the controlled antegrade and retrograde tracking (CART) technique6, a 6.0 x 100 mm Saber balloon (Cordis) was inflated in the subintimal space via the retrograde wire (Figure 2A). The antegrade wire was advanced into the subintimal place and subsequently into the true lumen of the popliteal artery. A 3 French, 175 cm Amplatz Goose Neck Microsnare (Medtronic) was inserted through the pedal access. The antegrade Aquatrack wire was captured and externalized through the pedal access (Figure 2B). The 4 French, 125 cm Tempo Aqua Vertebral catheter was advanced over the externalized wire and positioned into the left common iliac artery. It was exchanged for an .035-inch, 260 cm Advantage Glidewire (Terumo), and then the vertebral catheter was removed. A 6.0 x 100 mm Saber balloon was inflated at the lesion in the proximal left common iliac artery and left external iliac artery, followed by deployment of a 9.0 x 100 mm Smart stent (Cordis) (Figure 3A). The same balloon was inflated at the lesion in the left proximal, mid, and distal SFA, followed by deployment of two 7.0 x 150 mm Smart Flex stents (Cordis) in the SFA (Figure 3B). Another 3.5 x 100 mm Saber balloon was inflated at the lesion in the mid anterior tibial artery (Figure 3C). Final results showed excellent re-establishment of normal flow to the infrainguinal vessel (Figure 4A-C).
The left radial artery and left dorsalis pedis artery introducer sheaths were removed without complications. A TR Band (Terumo) was placed on the left radial artery puncture site and a VasoStat (Forge Medical, Inc.) was placed on the left dorsalis pedis artery puncture site for one hour to achieve patent hemostasis. The patient was discharged home 2 hours after the procedure without any complications. At 1-month follow-up, the patient reported no claudication and a Doppler study showed patent iliac artery, SFA, and pedal arteries.
Traditionally, transpedal access was used as an adjunct to/or alternative to tranfemoral access for endovascular treatment of SFA CTOs when an antegrade approach failed.5 However, Kwan et al reported a large series of patients showing the safety and feasibility of transpedal access as an initial approach for the evaluation and treatment of PAD, with fewer vascular complications when compared to transfemoral access.3 Patients with an SFA CTO can be treated via transpedal access alone; however, with some disadvantages. It would be difficult to assess the proximal vessel anatomy. In complex cases, a dual approach with radial and pedal access similar to the case described is necessary.5,7
In this case report, we demonstrate that by using a dual transradial and transpedal approach, multi-level, multi-lesion stenting with the CART technique, including stenting of a CTO in the superficial femoral artery, is feasible and safe without femoral access.
- Allison MA, Ho E, Denenberg JO, et al. Ethnic-specific prevalence of peripheral arterial disease in the United States. Am J Prev Med. 2007 Apr; 32(4): 328-333.
- Banerjee S, Sarode K, Patel A, et al. Comparative assessment of guidewire and microcatheter vs a crossing device-based strategy to traverse infrainguinal peripheral artery chronic total occlusions. J Endovasc Ther. 2015 Aug; 22(4): 525-534. doi: 10.1177/1526602815587707.
- Kwan TW, Shah S, Amoroso N et al. Feasibility and safety of routine transpedal arterial access for treatment of peripheral artery disease. J Invasive Cardiol. 2015 Jul; 27(7): 327-330.
- Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol. 1997; 29: 1269-1275.
- Amoroso NS, Shah S, Liou M et al. Superficial femoral artery intervention by single transpedal arterial access. J Invasive Cardiol. 2015 Nov; 27(11): E236-241.
- Surmely JF, Tsuchikane E, Katoh O et al. New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: the CART technique. J Invasive Cardiol. 2006 Jul; 18(7): 334-338.
- Auguste U, Rosero H, Bertrand OF, Kwan TW. Combined transpedal and transradial approach for treatment of iliac artery chronic total occlusion. Cardiovasc Revasc Med. 2015 Sep; 16(6): 370-372. doi: 10.1016/j.carrev.2015.04.006.