Page 10 - Carotid and peripheral vascular interventions textbook
P. 10


                        After f nishing DSA, the catheter is torqued towards   familiar with less subsequent vascular complications.
                    the ostial contralateral iliac artery, the Glidewire  is then   This approach also permits to treat contralateral common
                    forwarded distally to the CFA level enabling suitable length to     femoral and ostial SFA disease. The disadvantages of this
                    forward a selective catheter within the distal external iliac     approach are less catheter and wire support and trackability
                    artery. In diff cult anatomy, roadmap function with f uoroscopy    as it is working from a distance, technical diff culty with
                    may be used to facilitate during the Glidewire  navigation.   calcif ed and/or angulated aortoiliac bifurcations, and not
                        As compared to antegrade common femoral approach,   feasible with previous aorto-bifemoral bypass or aortoiliac
                    this retrograde access is much easier to achieve, more   kissing stents.

                       Table  12-1.  Summary of potential access sites for femoropopliteal and lower extremity endovascular

                        Access site  Target vessels    Advantages                  Disadvantages

                        Contralateral   - Contralateral distal    - Lower bleeding risk than antegrade   - May not be technically feasible with
                        femoral      common iliac, external   femoral approach      angulated and/or calcif ed aortoiliac
                        (crossover)  and internal iliac  - Permits approach to contralateral    bifurcations, or with prior aorto-
                                    - Contralateral femoral,   common femoral and ostial SFA   bifemoral bypass, kissing stents
                                     popliteal and      disease                    - Less catheter and wire trackability and
                                     below-knee vessels                             support than antegrade femoral access
                        Antegrade   - Ipsilateral non-ostial   - More catheter and wire support    - Higher vascular complication rate
                        common       SFA, popliteal,    and better manipulation for distal   - Not technically feasible for very obese
                        femoral      and below-knee     disease, total occlusions   patients
                        (ipsilateral)                  - No need to crossover in angulated    - Needs learning curve
                                                        and/or calcif ed aortoiliac    - Early thrombotic occlusion of the target
                                                        bifurcations                lesion caused by f ow reduction during
                                                                                    manual compression for hemostasis
                        Retrograde   - All ipsilateral vessels   - Good support    - Higher vascular complication rate
                        popliteal    proximal to distal SFA  - Potentially useful if unable to cross    - Nerve injury
                                    - Ostial SFA occlusion   or re-entry SFA occlusion from above  - Not convenient for a patient in prone
                                     with no stump                                  position
                        Retrograde   - Tibial vessels, popliteal,   - Potential useful if unable to cross    - Obtaining access often technically
                        dorsalis     SFA                femoropopliteal and infrapopliteal   challenging, needs skill and ultrasound
                        pedis, tibial                   tibial stenosis from above  guidance
                                                                                   - Limited experience
                                                                                   - Injury or occlusion of target vessel
                                                                                    for bypass graft
                        Radial      - Aorta            - Lowest vascular complication rate    - Distance from target vessels limits
                                    - Proximal iliac vessels  of all access sites   ability to reach infra-iliac lesions
                                    - CFA and proximal SFA                         - Limited to 6-Fr sheath size
                                                                                   - Subclavian and aortic tortuosity may
                                                                                    limit catheter manipulation

                        Brachial    - Aorta            - Permits larger diameter sheaths than   - Substantially increased vascular
                                    - Iliac vessels, CFA,    radial artery          complication rate compared to the
                                     proximal-to-mid SFA                            radial approach
                        Axillary    - Aorta            - Ability to reach more distal lesions   - Vascular complications
                                    - Iliac vessels     than with radial or brachial access  - Brachial plexus injury
                                    - Proximal-to-mid SFA

                       CFA, common femoral artery; SFA, superf cial femoral artery.
   5   6   7   8   9   10   11