Pedal artery angioplasty for dorsal pedis artery puncture preceding endovascular treatment for occluded anterior tibial
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IMAGES IN CARDIOVASCULAR INTERVENTION
Pedal artery angioplasty for dorsal pedis artery puncture preceding endovascular treatment for occluded anterior tibial artery Yu Sakaue1 · Tetsuya Nomura1 · Kenshi Ono1 · Masakazu Kikai1 · Natsuya Keira1 · Tetsuya Tatsumi1 Received: 28 December 2018 / Accepted: 21 February 2019 © Japanese Association of Cardiovascular Intervention and Therapeutics 2019
Introduction An 81-year-old man was admitted to our hospital for the treatment of refractory ulcers on the right lower extremity (Fig. 1a, b). Skin perfusion pressure (SPP) was 25 mmHg at the right dorsum of the foot. Angiography showed occlusion of the superficial femoral artery (SFA), anterior tibial artery (ATA), posterior tibial artery (PTA), and dorsalis pedis artery (DPA) (Fig. 1c). After recanalizing the occluded SFA, we electively performed infrapopliteal angioplasty. Antegrade guidewire advancement to the ATA occlusion easily resulted in getting into subintimal space. Therefore, we switched to the procedure of retrograde approach. Because the exit point of the occluded ATA was unclear, we retrogradely approached the occluded DPA via the pedal arch after treating the short occlusion in mid portion of the PTA (Fig. 1d, e). However, the guidewire was too rigid to advance into the occluded ATA. Therefore, we retrogradely dilated the DPA (Fig. 1f) and punctured it, targeting the existing guidewire (Fig. 1g). Thereby, we could establish a bidirectional approach and successfully introduce the antegrade
guidewire into the retrograde microcatheter (Fig. 1h). We dilated the occluded ATA and DPA for a prolonged period (Fig. 1i) and finally achieved favorable recanalization of the occluded below-the-knee arteries (Fig. 1j). SPP at the right dorsum of the foot recovered to 69 mmHg, and the refractory ulcers have gotten better (Fig. 1k, l). Infrapopliteal artery disease is predominant in critical limb ischemia [1]. Bidirectional approaches such as distal site puncture (DP) [2] and a trans-pedal approach (TPA) [3] are critical for successful endovascular treatment (EVT), and they have some strong and weak points, respectively. DP is simple and easy to understand, and maneuverability of the guidewire is favorable. However, we cannot always puncture the appropriate site. On the other hand, we can establish a bidirectional approach without DP by TPA in some cases. However, TPA sometimes involves technical difficulty in channel tracking and the loss of guidewire performance. Taking advantage of the merits of these different bidirectional approaches, we performed successful EVT for the occluded below-the-knee arteries.
* Tetsuya Nomura [email protected] 1
Department of Cardiovascular Medicine, Kyoto Chubu Medical Center, 25, Yagi‑Ueno, Yagi‑cho, Nantan City, Kyoto 629‑0197, Japan
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Fig. 1 Refractory ulcers on the right lower thigh (a) and dorsum of the foot (b). c Control angiography of the right infrapopliteal arteries. d Pedal arch angiography by microcatheter tip injection. e Guide
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