Procedure Guide

Arterial Revascularization

Arterial revascularization is one of the cornerstones to treatment for peripheral arterial disease. These patients and their procedures can range in scope, complexity and level of difficulty. Understanding key concepts will help an interventionist begin to dive into this complex topic.

Step-by-step guidance on how to perform Arterial Revascularization. Review tools, techniques, pearls, and pitfalls on the BackTable Web App.

Pre-Procedure Prep

Indications

• Peripheral vascular disease - including focal or long segment stenoses and/or chronic total occlusions.

Contraindications

• Uncorrectable bleeding diathesis
• Stenotic/occlusive disease with high thromboembolic risk
• Renal failure
• Extreme vessel tortuosity

Things To Check

• History and Physical
• Patient anticoagulation status
• Creatinine, coagulation profile
• Any prior imaging - Vascular ultrasound, CTA, MRA
• Lower extremity pulses

Arterial Revascularization Podcasts

Ep. 113

Below-Ankle Interventions

Dr. Sabeen Dhand and Dr. Kumar Madassery discuss the importance of below-ankle interventions in limb salvage, including patient selection, technique, and a patient-centered longitudinal care plan.

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Ep. 60

Building A Limb Salvage Program

CLI fighters Dr. Jihad Mustapha and Dr. Sabeen Dhand building a Limb Salvage program, including broadening skill sets such as pedal access, and meticulous patient follow up.

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Ep. 37

Treating PAD in the OBL

Dr. Mike Watts and Dr. Omar Saleh discussing the ins and outs of treating PAD in the Outpatient Based Lab (OBL) setting.

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Ep. 9

Hashtag StopTheChop

Dr. Kumar Madassery and Dr. Sabeen Dhand discuss their PAD practices and the story behind the #stopthechop hashtag.

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Procedure Steps

Procedural Steps

• Access common femoral artery of contralateral leg using micropuncture needle under US
• Advance wire centrally
• Place a 5, 6 or 7 Fr sheath (depending on the potential atherectomy device).

Angiography

• Advance flush catheter over the wire into the aorta.
• Perform AP aortogram - 15 mL/sec for 30 mL.
• Pull flush catheter back into the distal aorta
• Perform iliac artery arteriogram - 10 mL/sec for 20 sec.
• Keep catheter in distal aorta and perform lower extremity runoff arteriography - 8 mL/sec for 80 mL

Evaluate Lesion(s)

• Exchange for a selective catheter and catheterize target artery.
• Position catheter proximal to lesion.
• Administer heparin bolus prior to crossing lesion (2500-5000 U)
• Gently advance guidewire across stenosis.
• If resistance is met - avoid dissection and retract wire. Redirect catheter and readvance wire until successful passage.
• Direct guidewire through central canal of lesion. Advance selective catheter over wire across the lesion
• Angiogram following lesion crossing to confirm position
• Exchange crossing guidewire for a 0.014" guidewire.

Treatment

• Many options from balloon angioplasty to atherectomy
• Introduce atherectomy device over guidewire; perform atherectomy across lesion
• Inject contrast through sheath or catheter to evaluate progress. Determine if further intervention is needed. May need balloon angioplasty, or stent placement if dissection occurs.
• Remove access sheath and close arteriotomy site - closure device or manual pressure.

Arterial Revascularization Articles

Pedal Access Tools, Techniques & Tips

Pedal access tools, techniques, and pro tips for beginners treating occluded lower extremity arteries with significant calcification.

Pedal access

Retrograde Pedal Access Collaboration, Case Selection & Benefits

Retrograde pedal access is becoming popular among both patients and interventionalists for the treatment of critical limb ischemia and peripheral vascular disease. Vascular surgeon Dr. Jim Melton and interventional radiologist Dr. Blake Parsons discuss IR and vascular surgery collaboration in their practice.

Posterior tibial artery retrograde pedal access

Challenges and Evolutions in Limb Salvage

Challenges with building a limb salvage program and advances in tibial-pedal access and extravascular ultrasound for optimal CTO crossing

Tibial-pedal access in limb salvage

Building a Limb Salvage Program

Limb salvage programs focus on preventing amputations from Critical Limb Ischemia (CLI). We spoke with Dr. Mustapha to learn what limb salvage is, how to build a successful limb salvage program, & the importance of a multidisciplinary team.

Pedal access for limb salvage

Post-Procedure

Obtain Hemostasis

• Supine bedrest for 3 hours with closure device. 6 hours with manual pressure

Complications

• Arterial injury - dissection, rupture, hematoma, distal embolization, thrombosis.
• Groin complications

Arterial Revascularization Demos

Atherectomy of Common Femoral and Superficial Femoral Arteries

Dr. Chris Metzger performs atherectomy of the common femoral and superficial femoral arteries.

CO2 Angiography

Dr. Craig Walker demonstrates CO2 angiography and discusses the advantages of this imaging technique. He then shows the tools and technique to image an iliac artery.

Complex Below-the-Knee Revascularization by Dr. Scott Brannan

Dr. Scott Brannan demonstrates wire escalation strategies, intravascular ultrasound, and rotational atherectomy to achieve revascularization in complex BTK disease

Complex Revascularization of SFA Occlusion Using Rotational Atherectomy

Dr. Jihad A. Mustpha demonstrates treatment of a CTO in a patient with diabetes, CKD-3, and CAD. He highlights technique and the benefits of vessel prep with atherectomy prior to DCB.

Related Content

No related content.

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Podcast

Treating PAD in the OBL

Treating PAD in the OBL Podcast Guest Dr. Mike Watts
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Podcast

Hashtag StopTheChop

#StopTheChop Podcast Guest Dr. Kumar Madassery
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Demo Video

Infrapopliteal Artery Interventions Part 2

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Demo Video

Retrograde Tibial Approach For Treatment Of Critical Limb Ischemia

Join The Discussion

References

[1] Mittleider D, Russell E. Peripheral Atherectomy: Applications and Techniques. Tech Vasc Interv Radiol. 2016;19(2):123‐135. doi:10.1053/j.tvir.2016.04.005
[2] Wilkins LR, Sabri SS. Strategies to Approaching Lower Limb Occlusions. Tech Vasc Interv Radiol. 2016;19(2):136‐144. doi:10.1053/j.tvir.2016.04.006
[3] BackTable, LLC (Producer). (2017, August 16). Ep 9 - #StopTheChop [Audio podcast]. Retrieved from https://www.backtable.com/podcasts

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.