Presentazione di PowerPoint

Dr. M. Manzi

Interventional Radiology UnitFoot & Ankle ClinicPoliclinico Abano TermeRegional Center of Reference for Diabetic Foot TreatmentPedal Access: When and How to do it

DISCLOSURE:Marco Manzi, MDAbbott Vascular: Consultant/Advisory Boarder

BARD: Consultant

COOK: Consultant

Covidien/EV3: Proctor

Boston Scientific: Proctor

Medtronic-Invatec: Consultant/Proctor

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Our Technical Strategies for Revascularization

Combine all these strategies (antegrade retrograde for successful endovascular therapy in diabetics with CLI

RESCUE SOLUTION Pedal Puncture after Failed Subintimal Dissection

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Pedal Puncture after Failed Subintimal DissectionRESCUE SOLUTION

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Pedal/Metatarsal punctureWiring the arteryRetrograde foot or/and tibial arteries recanalizationPTA + haemostasis

Retrograde Digital Artery Access

After antegrade recanalization failure Absence of pedal / plantar sites for puncture Retrograde pedal / plantar access failureIndications and Purposes of Pedal and Arch/Metatarsal Access

Correct projection criteriaCorrect RX Projections for Pedal and Arch/Metatarsal Access

Digital artery punctureVerapamil [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 arteryUse calcifications or CM injectionTechniques for Pedal and Arch/Metatarsal Access

Short Tip

21G Needle Micropuncture Set

Needle and ArteryMust be Allined!Techniques for Pedal and Arch/Metatarsal Access

2. Wiring the Digital branchDeploy 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

0,018 Dedicated Wire (Cook)/ V18 cw Ready to be Introduced

Dedicated Micro-Sheath (CooK) permits wires exchange, support catheters and balloons introduction;

Wiring the Digital Branch

3. Retrograde recanalization

Intraluminal wiring and recanalization of digital 0.018-in and 0.014-in guide wiresCombined intraluminal and subintimal technique

Rendez-vous with the antegrade catheter

Antegrade wiring

Techniques for Pedal and Arch/Metatarsal Access

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

C.S. 75 yoDiabetes, HypertensionCLI, TcPO2 =11 mmHgPrevious apex amputation I toeGangrene IV toeTUC 3CPrevious AT antegrade failure

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Baseline Angio

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Intervention Movie

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PREPOSTAcute Angio Result

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Follow up @ 1 month/3monthswell demarcated gangrene with surrounding granulation , no infection, TcPO2 = 40 mmHgAfter amputation very goodwound TcPO2= 45mmHg

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(Admission)

M.G. 66 year oldDiabetesHypertensionCLI, TcPO2 =3 mmHgPrev apex 1 and 2 ampTUC 2C

Baseline Angio

Retrgrade Loop Puncture

Angio & Clinical Result

CONCLUSIONS 1Consider Retrograde Pedal/distal approach as a RESCUE Procedure Consider the retrograde techniques when there are the right anatomical conditions

Antegrade Plantar and Pedal accesses

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

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THANKS FOR YOUR ATTENTION