Page 9 - Carotid and peripheral vascular interventions textbook

CHAPTER 12 • FEMOROPOPLITEAL ARTERIAL DISEASE

STEP-BY-STEP TECHNIQUE CONTRALATERAL FEMORAL (CROSSOVER)

VASCULAR ACCESS Arterial access may be obtained contralateral or

ipsilateral to the target lesion. Commonly, contralateral
The selection of access location is left to the vascular access is preferable. This approach allows a
operator’s discretion. The most common vascular suitable working length for imaging and treating sequential
access for femoropopliteal intervention is the CFA. lesions located within the distal external iliac, femoral
Most interventionists are usually familiar with the and popliteal arteries, and also it is frequently used for
CFA puncture. However, it may be challenging in below-knee interventions. This approach is associated
patients with diminished or absent palpable pulse, with less access-related complications while allowing
calcif ed CFA disease, obese patients, and high the easier application of closure devices when indicated.
bifurcation. In these diff cult cases, f uoroscopy- When contralateral access is gained, a guide wire is
guided puncture or using ultrasound-guidance should forwarded retrograde along the iliac arteries and aorta using
be used to reduce multiple punctures and the f uoroscopic guidance. For SFA angioplasty, the sheath sizes
complication rates. The suitable point for puncture may vary between 4- and 7-French (Fr). When in placed,
is the inner lower third of the femoral head, because the vascular sheath needs f ushing with heparinized saline.
the femoral head contributes a solid surface to support Through the vascular sheath, a diagnostic catheter (e.g., Judkins
CFA compression which is required for hemostasis. right (JR), internal mammary (IM), Sos Omni, Simmons,
Besides CFA access, in selected cases, radial or or Cobra) is advanced over a 0.035”, angle-tip angled
brachial artery (antegrade approach) or popliteal or Glidewire (Terumo) into the distal abdominal aorta. Then
®
pedal artery (retrograde approach), can be used for DSA of the aorta with the iliac arteries is then performed,
an additional access (Fig. 12-6). Table 12-1 summaries except when this area has been already surveyed by MRA or
the vascular access sites commonly used for CTA. This angiography helps to assess the inf ow and to
femoropopliteal intervention and its features. facilitate crossing the aortic bifurcation into contralateral limb.

A B C

337

D

Figure 12-6. Vascular access for femoropopliteal intervention. A: Common femoral artery (retrograde and antegrade access); B: Brachial
and radial artery (retrograde access); C: Popliteal artery (retrograde access); D: Dorsalis pedis or tibial artery (retrograde access).