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Radial, Pedal and Direct SFA Puncture for SFA Revascularization
Beau Hawkins, MD, FSCAI May 22, 2019
Disclosures
- None
Radial, Pedal and Direct SFA Puncture for SFA Revascularization - - PowerPoint PPT Presentation
Radial, Pedal and Direct SFA Puncture for SFA Revascularization - - PowerPoint PPT Presentation
Radial, Pedal and Direct SFA Puncture for SFA Revascularization Beau Hawkins, MD, FSCAI May 22, 2019 Disclosures None Rationale for Alternative Access Anatomical Needs Lack of antegrade stump Iliofemoral tortuosity
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Rationale for Alternative Access
- Anatomical Needs
- Lack of antegrade stump
- Iliofemoral tortuosity
- Procedural efficiency
- Failure to cross or re-enter
antegrade
- Reduce complications
Mustapha et al Interv Cardiol 2015;7:1-17
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Transradial Approach- Important Distances
Nakamura et al. Ind Heart J 2018;70:99-104
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Transradial Approach
- Familiar to coronary operators
- Low bleeding risk
- Pushability/torque limited
- Limited equipment for
complications (eg perforation)
Korabathina et al. Vasc Heath Risk 2010;6:503-9
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Retrograde Popliteal
- Advantages
- Support/pushability
- Full armamentarium of tools
(stents, atherectomy)
- Disadvantages
- Prone positioning
- Hemostasis issues
- Single access
- Manual pressure versus balloon
tamponade
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Retrograde Popliteal- Complications
Large AV Fistula
- 68 year old male with RLE
claudication
- Prior RSFA Stenting for CLI
(foot ulcer)
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Retrograde Pedal
- 60 yo female with LLE ischemic
rest pain
- Prior distal aorta/iliac stenting
with high neo-carina
- Radials occluded, “no brachial
lab”
- Plan- retrograde AT approach
9 cm SFA/pop CTO RCFA
- cclusion
Diffuse SFA disease
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Retrograde Pedal
- Ultrasound-guidance 5/6 slender
sheath
- Retrograde crossing with
hydrophilic .014’’ wire/.018 catheter
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Retrograde Pedal
- PTA/stent
- Manual pressure x 20 min
- Bedrest x 1hour
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Retrograde Pedal- 38 yo female with rest pain, prior aortofemoral bypass
Courtesy of M. Adu-Fadel
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Retrograde Pedal
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Retrograde Pedal
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Retrograde Pedal
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Retrograde Pedal- Practical Aspects
- Ideal for simple SFA lesions and assists with learning curve
- No antegrade access needed
- Need adequate pre-procedure imaging (eg angiogram, duplex)
- Anticoagulate well
- Spasm is common- frequent vasodilators
- Impact of tibial thrombosis is less clear
- Caution needed in CLI patients with poor outflow
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Where is Complex SFA Intervention Headed?
Ruzsa et al. JACC Interv 2018;11:1062-71
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Alternative Access Selection- Personal Preferences
- Dynamic algorithm with annual modifications
- Primary access: Pedal>radial
- Primary pedal if approaching a simple, stenotic lesion
- Primary femoral if complex, lengthy CTO or multilevel intervention planned
- No brachial
- No retrograde popliteal
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Conclusions
- Alternative access site use can improve procedural success
- Procedural complexity and complication risk may be reduced with
radial and/or pedal approaches
- Increasingly complex lesions can be tackled via alternative access
using proper patient selection and preparation
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