Chapters Transcript Video Tackling Challenging Lesions in Peripheral Interventions Back to Symposium Great. Well, first of all, sorry that I'm not there. Uh, great talk so far. We really enjoyed all the talks. Fantastic material. Uh, I guess, I, I wish I was there, but I will be off crutches soon and mobile again. Uh, we're gonna talk a little bit about how do I consider what access and, and what are the different accesses that are available as we start doing peripheral interventions. All right, try to move my slides. These are disclaimer. All right, so what are the different access options? I think we all know about retrograde and antigrade. We've gone through popliteal, tibial, pedal, radial, uh, gone away from brachial, uh, you could do ulnar, but I think you also have to think about alternative access. And whenever you think of access, always think of closure. How are you gonna get out with that particular closure, uh, axis that you're gonna use? I think this is an interesting image. Basically shows all the different kind of pedal and tibial accesses that are available, makes you get an idea of where the, where these vessels could be and how to access them. I think my go to axis is usually going to be retrograde common femoral axis or up and over, and I prefer this, particularly if I'm treating the left leg. So I can treat the right leg, come up and over and treat the left leg. Uh, I think this could be somewhat limited if I'm dealing with tibial pedal disease because I kind of lose some pushability in those cases, I try to do an antegrade access. I think antegrade access is a great option, and I would say we probably use this even though retrograde is my favorite when it comes to. Peripheral vascular disease, it's probably our number one access. It allows us to really concentrate on the extremity that we're dealing with, but you have to do your homework. You need to make sure that common femoral is patent. Usually I like to see a triphasic wave form in my ultrasound, and I also want to make sure that proximal SFA is patent. And then the patient body habit is important, is important. So we use this term, is the patient antegradable, right? And, and that's really what you want to be. You want to be integradable so that we can go with an antigrade puncture. And I talked a little bit about the importance of pushability, torque ability, so we can treat these patients. And again, chemostasis can be more difficult from an antigrade approach, but I think we've really come a long way with our closure devices using ultrasound guidance for the closure devices that I think our complication rates are now much lower for antigrade access. How about a direct SFA puncture? When do I do this? So I reserved this for a patient that I can't really go up and over, and the patient may not be antigradable, but there is a healthy proximal SFA. I need to get down and treat distally. This is an option that a treatment option that is helpful. There's data that shows that a very low complication rate, and again, usually the higher you go, the easier it is to compress and treat. This is something, again, a closure device, usually something a balloon mediated, is helpful. How about popliteal access? Again, we did a lot of popliteal access, and I think there's two ways to approach it. You can do a retrograde popat from a direct prone approach, which is really what we have always done. And every now and then now we'll do a frog leg, particularly if you don't want to flip that particular patient. It could change uh anesthesia in the room, could change the risk factors. So, a lot of times we may now go for frog leg. But again, this is to minimize any, any, uh. Risks to the tibial vessels by staying popliteal. Also, a vessel may be larger. It allows us to use more larger axes. So if we're using things that are 6 or 7 French, access from a popeal approach seems to seems to be an option and a good option for us. And again, closure is important and what kind of closure devices you use. Here I'll give you a setup of a complicated patient that we have a 4 French. A sheath in the popliteal and the contralateral common femoral, we have an up and over sheath. So we're going to be treating, we're going to be treating from the popliteal, but we have a contralateral sheath really for injections and this may be helpful in a patient that has, let's say, iliac stents that you can't get through. You can still inject from above and treat from below, and this is just a good setup of how we can do that. How about pedal access? Again, uh, I think we've come a long way in the last decade with pedal access. I typically still prefer a pedal kit and ultrasound guidance, fluoroscopic guidance if I have to, depends on which vessel I'm looking at. The use of radial dash pedal cocktail to try to reduce spasm, and a lot of times I try to stay as small as possible. So a lot of these, I may do just with the pedal kit and and a wire if necessary, I use a pedal kit and an 018 crossing catheter and try to stay as small as possible through my through my pedal access. There are cases that we're going to have to treat through a pedal access, and again that then I'll reserve and using a larger sheath, go with the 4 French leads, a slender sheath still allows us to do a lot of different interventions from a direct pedal approach. And again, this is something that's in our in our bag, but it's not something that we're going to go to routinely. Uh, tibial access is very similar. Again, understanding where those, uh, vessels are, understanding which ones uh may require a balloon in terms of reducing risk of, of bleeding. But for the most part, I, I think all these, all these tibial vessels are accessible and things that we use for treatment. In terms of axillary access, I think I've abandoned pretty much axillary access. We'll go ahead and do a cutdown and even for a brachial, a lot of times now we'll do a cutdown. I think when we looked at our data, we still had a lot of pseudoaneurysms and a lot of complications from brachial punctures. We do a lot of these, not only for peripheral procedures, peripheral for aortic procedures, and usually a cutdown is so simple that We've gone ahead and really kind of reverted in this particular access to leave that for a cutdown approach. Radial, I think this is something obviously that we do, we could do a lot of low rate of complications. A lot of work has been done on this and from the coronary arena, and we're going to go through some cases to see what other, what options and how we use this. So, case one is a bypass puncture. I think a lot of times people forget that we can puncture a bypass. Um, in this particular case, uh, being able to go and puncture, uh, the cross femoral bypass is very common to puncture a, a fempop bypass. Again, you have to be very careful not to lose that bypass and protect it, but a lot of times this is something you can get access to the puncture, into the bypass, and then closure, you're going to be able to gently close it, uh, usually with manual compression without any difficulty. Case two is a 69-year-old female with severe left leg claudication of 50 ft. She had worsening symptoms over the last five months. She was a smoker and she had an outside the hospital, they had these iliac stents that basically jailed us from going up and over the bifurcation. She also had left SFA stent. So, my initial approach with her was, hey, maybe we go from a radial approach. We went for a radial approach. You see radio access and ultrasound for a radio access is now standard practice and coming down from the into the left iliac system. You can see here doing angiography demonstrating a lesion in the common femoral artery, lesion in that popliteal artery, and some instant restenosis in that distal SFA stent. You can see here the runoff pretty well preserved. So this is the moment of truth, right? When you're doing a radio procedure, what's your bailout? What are you willing to sacrifice? And a lot of times we use radio as a necessity. We'll use radio when I need to go radio as opposed to Some operators will have radial as choice. They prefer to do radial, and I think now we have a lot better tools and we continue to add tools to our toolbox so that we're not needing to sacrifice too much by going from a radial approach. And I think this is going to be helpful and continue to drive growth in peripheral R2P procedures. So this particular patient, we went ahead and placed a sheath and able to perform an angioplasty of the common femoral artery cross this very uh really a rock of a lesion, and then angioplasty that lesion, uh. And, and we're pretty happy with that result. And you can see the changes in her, in her post procedure study. Again, we're here. This is a time where we didn't have any drug-coated balloons or a drug therapy that could reach this far, and this is how we treated the patient. We'll, we'll talk about her a little bit later. How about this patient, a patient with an occluded SFA we tried an integrated approach, really could not get into the SFA, kept getting. Subinal. One of the approaches is to puncture the stent or puncture the SFA. You can see here, a lot of times I'll go ahead straight with an 035 needle. I feel that 035 needle gives me a little bit more pushability. You could go with a microaxis needle, and then a lot of times you go ahead and upsize and then. Get that 035 wire into your stent, and the stent really helps you as you push that wire and then able to push through into the common femoral artery, snare the wire and work. Here's another case of alternative access. He was a 70 year old. He was a pool cleaner, very famous pool cleaner, because everyone was concerned about his claudication was getting so bad that he couldn't really clean people's pools, and he refused to bypass. He says, I can't stop working. And uh you can see he has a really chronic SFA occlusion. Really calcified a lot of collaterals. You can see here, I'm sorry, it's cut off in the bottom, on the third panel, you can see how there's a little proximal AT. We went ahead, integra, and basically got into this subventable disaster here and did not feel comfortable really kind of re-entrying this particular patient with such a long SFA occlusion and the fact that it involved pretty much in that P1 segment. So we went ahead and we punctured the high AT. I love this kind of access. Uh, again, this is an access where you want to stay small. Uh, you can access this vessel. A lot of times patients will have another AT. I, I'd like to puncture it in that straight portion, get the wire to go up, and then work from. There is an alternative access, a little bit easier to manage than a popliteal puncture, and a guy that gives me a good rail. And in this particular patient, I was able to go ahead and perform an outback reentry from that access and then be able to treat the patient. How about this patient, 72 year old with a non-healing ulcer in the left heel and first toe. Uh, You can see that lesion. You can see this patient also had a really tough access uh that we couldn't go up and over on. And you get an idea of really significant. Uh, uh, we had previously treated that right groin, which was uh kind of ugly, ugly groin. We're trying to figure out, stay away from that groin, so we went, uh, from a radial approach. And again, a lot of times we'll go from the radial approach and stay small, go with the 4 French, put a catheter to help assist. Us from treating something in a retrograde fashion as opposed to treating everything from a retrograde fashion. If we have a catheter antigrade, this catheter will allow us to inject, see what's going on, and gives us some control. So here we can see if radio access, place a catheter, allowed us to really perform a left lower extremity runoff, get an idea of what we're dealing with, really a long segment flush SFA occlusion. And then with this, with the patient, and we actually did the procedure with the patient prone, you can see I still have the radio access here. I can inject through here and then I can go ahead and puncture popliteal and work from popliteal access to pretty much. Recatalyze the SFA and treat from below, and you can see here, here's a re-entry with um with a pioneer device, an IVIS guided reentry, and then be able to treat this patient and, and place a drug coated stents from below to help again establish and revascularize this patient with a good result. You can see here post-procedure and after debridement, and patient healed and did well. Let's go back to that first patient I showed you that 70, uh, this patient now comes back to see her. She's 73 years old. And this is the woman that had those stents in the distal, uh, in the both iliac stents that extended into the aorta that made it really difficult to get to. And when I first saw her again, she had uh good tibial vessels, but her issue was recurrent disease in that left SFA stent and right SFA disease over the last 5 years. And we had, uh, you can hear some of the previous treatments like I showed you going radial, and, uh, we also at one point had to go and uh retrograde from the pedal approach, and we're able to treat her retrograde uh that way from a pedal approach, uh, with IVL and then DCB angioplasty. So, she came back and said, you know, I really don't want to have a cutdown. I don't want to have general anesthesia. I feel like, uh, it's really affecting me cognitively. Uh, what can you do? I need help with my right leg. So in this particular approach, we actually use a steerable sheath. So those stents again go pretty far up, but in those here with the steerable sheath, and we've been able to use this with a lot of different aortic work, be able to really get pretty secure access to the bifurcation through that steerable sheath, able to secure both the profunda and the SFA, help really revascularize the common femoral and the origin of both the profunda and the superficial femoral artery. And really get her uh and the uh SFA and get really good results in her recantalization. So, I'm kind of giving you a whirlwind tour of how I evaluate access, why I think access is obviously it's critical, why it's important before you walk in that you have a plan, Plan A, Plan B, Plan C, and always consider what your tools are, or what tools you may want to use so you have an idea of what size sheath you need, and then also consider what your closure is going to be. So, hopefully, I was able to stay on time. Thank you very much. I'm sorry I'm not there. Published Created by
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