Page 11 - Carotid and peripheral vascular interventions textbook

CHAPTER 12 • FEMOROPOPLITEAL ARTERIAL DISEASE

ANTEGRADE COMMON FEMORAL approach include vascular complication at the puncture
site (e.g., retroperitoneal hemorrhage) especially in an
In select cases, such as a calcif ed and/or angulated obese patient, and early thrombotic occlusion of the target
aortoiliac bifurcation, antegrade common femoral access is lesion caused by post-interventional f ow reduction during
preferred. This method requires positioning a sheath within manual compression for hemostasis.
the CFA which is pointed distally (toward the ipsilateral
foot), and depicts an alternative technique for managing POPLITEAL RETROGRADE
lesions distal to the CFA (such as mid to distal SFA,
popliteal, and below knee) and in patients who have aortoiliac The ipsilateral popliteal retrograde access is rarely
bifurcation anatomy that precludes the crossover technique. used and reserved for CTOs of the SFA which cannot
The antegrade approach may also permit easier guide be crossed from above, because the distal “cap” for
wire torquability and pushability and improved catheter the occluded arterial segment can be punctured easier
support, particularly when dealing with a more complex using a guide wire compared with the proximal cap of
disease, such as heavily calcif ed disease or total occlusion the occlusion. Using ultrasound to identify the accurate
of tibial vessels or the distal SFA. In patients with ostial or position of the popliteal artery prior to obtaining access is
early proximal SFA lesion, this approach is contraindicated recommended and can minimize the occurrence of nerve
owing to insuff cient room for a sheath placement. injury and vascular complications.
This technique involves accessing the CFA cranial to After failure from contralateral femoral or antegrade
the bifurcation of SFA and PFA, in an antegrade approach. femoral approach, the sheath is secured and draped under
Right and left-handed operators need to stand by the right a sterile towel. The patient is placed in a prone position
and left side of the catheterization table, respectively. A 4-Fr and then the popliteal fossa is prepped and draped. The
or 5-Fr micropuncture set should be routinely used. Using level of the femorotibial joint space is f uoroscopically
the head of femur as a landmark, the CFA is punctured identif ed. The skin is anesthetized at approximately
above the bifurcation under f uoroscopic guidance. This 3 cm superior to the joint space, because at this point the
will result in a skin puncture site that is signif cantly higher degree of overlapping of the popliteal artery, popliteal vein
than that used for the retrograde approach. The angle of (lateral) and popliteal nerve is minimal. Using ultrasound
needle should be fairly vertical (75° approximately) and guidance or contrast injection from above, the popliteal
sometimes in obese patients, the artery has to be accessed artery is punctured using a 4-Fr to 5-Fr micropuncture
from the lateral aspect. Once the needle is in the CFA, needle. Then, a 0.018” wire is advanced, and a sheath is
the 0.018” wire is forwarded using f uoroscopy within inserted. Most popliteal arteries are suff ciently large to
the SFA and a standard 6-Fr short sheath is placed. If the accommodate a 6-Fr sheath. The disadvantages of this
wire is advanced into the PFA, it should be redirected into access are vascular complication or nerve injury that might
the SFA before inserting a short sheath. If the attempts occur more frequently because of small vessel size and 339
at redirecting the guide wire into SFA are unsuccessful, the lack of familiarity with this access.
the needle should be withdrawn, pressure held and a
reassessment of puncture site made. Usually, the initial BRACHIAL OR RADIAL APPROACH

puncture was “too-low” or caudal, so the second attempt
should be higher. Once the guide wire is advanced into Obtaining an access by the radial or brachial may
the SFA, a skin nick with adequate track should be made. serve as an alternative technique to image or to perform
The sheath is advanced under f uoroscopy. Since there intervention when severe aortoiliac or bilateral CFA disease
can be stenosis in the proximal femoral artery, an 11 cm is present and mitigates the usual femoral approach. As
sheath usually is optimal. The guide wire should never be a result of the high risks for local vascular complications
completely removed, since the sheath may kink, making associated with brachial access, using the radial artery has
re-access diff cult and dangerous. grown more popular and familiar among interventional
Antegrade femoral access is more technically demanding cardiologists. Since there are long guiding catheters (120
compared with the retrograde femoral approach and needs or 150 cm) and long shaft (200 cm) of balloon and stent
a considerable learning curve. The complications of this delivery systems [Radial to peripheral (R2P™) products,