Pedal Access Tools, Techniques & Tips

[Aaron Fritts]
Any pitfalls to getting access? Anything that you've experienced a lot early on that you kind of were able to work out that you could suggest for a young guy trying this?

[Blake Parsons]
I think for IR guys it's not really much different than sticking a radial artery. Obviously, there's a huge radial first movement so most IR guys are doing a lot of stuff from the wrist. It's not much different, both from a depth standpoint. Now, from the posterior tibial, kind of the more proximal up the leg you get and depending on the amount of calcification in the artery, it can get a little more challenging because that thing's going to roll around on you quite a bit. So, in that, it just takes some practice. AT's are a little easier because you've got the tibia right underneath it so you can kind of pin it to it. But, definitely, the more calcified the vessel is, it's going to give you a little more challenge. A lot of it's just practicing and developing good ultrasound skills, actually seeing the needle tip enter the artery and not just watching tissue move and hoping that you're over the top of it.

[Jim Melton]
If you can get a lot of tumescence in there with the local anesthesia it sometimes stabilizes that calcified vessel so it doesn't roll on you as bad. That's a little bit of a trick sometimes.

[Aaron Fritts]
For one of my first pedal access cases I did, the thing I was worried about, because the DP was so diseased, was going higher and higher into the AT and potentially causing compartment syndrome or something if my access site was bleeding. Is there anything, any worries like that, of going too high in the AT or PT?

[Jim Melton]
You can. I've had one compartment syndrome out of all those cases that I just fixed here at the OBL with local anesthetic and stuff. I did a fasciotomy and they did fine. It was AT distribution, so it's always a little concern. You have to just clinically watch. If you go halfway up the leg on the AT, the other halfway up is about the same depth so we just try to stay at halfway down on AT.

[Aaron Fritts]
When you're putting those larger sheath sizes in, are you keeping an eye on the clock and kind of making sure that you don't have that pedal artery occluded for very long before you decide to change access sites for whatever you're doing?

[Blake Parsons]
Well, I think you're going to find arteries occluded regardless. You'll do a shot through the sheath and you'll get collateral flow, distal to the sheath, that you can see that's still open. That's what we're obviously monitoring and how much heparin we're giving during the case as well as the nitro and all that, trying to minimize any kind of thrombin. You're going to be occlusive, especially when the average size is probably a three in a tibial. They're a hell of a lot smaller than that whenever you first start and highly calcified. And we know there's going to be inflow disease. I have them prep the groin as well just in case of an emergency. We have a whole team that knows everything that's going on... if we have a concern for a rupture, we've got everything already waiting, ready to rock and roll. Luckily, we haven't really had any issue with that. I know the iliac thing freaks a lot of people out, especially trying to do it from the foot. If it's a case that's really high risk, heavy calcium, super stenosed, there's a very high likelihood you're going to crack something and have an issue. That might not be a case that I'm going to do here. I'm going to take it to the hospital and I'm going to make sure that we have the support that we need and get femoral access still and do that. We're not complete gun slingers. The patient's health is still always at the forefront of what we're doing and making sure that what we're doing is safe.

[Aaron Fritts]
Okay. So, in terms of other potential complications, dissection, spasm, and we just mentioned basically rupture or bleeding, are you finding those less common, very rare? It's something to be, obviously, careful about but any suggestions to help prevent spasm or dissection?

[Blake Parsons]
We use nitro pretty liberally around here, both on initial stick and in our cocktail, but also on the way out. You'll get spasm in an artery that you accessed. And then there's times you'll, say, pull the sheath and they're holding pressure and you come back and their foot is not looking super great. You try to put a Doppler on it and you're not hearing much. That's because you get spasm right at the access site. Most of the time you give it 15 minutes, come back, and their foot's perfect flow and you've got a bounding signal. I've had maybe three times where I put a little nitro paste over the top of it, where the access site was and same thing. Fifteen to 30 minutes later, the patient's doing great. Pulses are great all the way down into the toes. Other than that, I haven't really had too much of an issue. Obviously, we have a ton of ESRD and diabetes patients here, so a lot of calcified disease, tibial arteries, to begin with. From a dissection point, not really unless we're purposely... we try not to go subintimal if we can, especially in the tibials. I just don't feel like they stay open as long. But sometimes it's inevitable. Most of the time you're able to cross intraluminal and stay intraluminal.

[Aaron Fritts]
And so what do you guys do about pedal loop revascularization? Are you going up and over from AT to PT? How are you guys handling those kinds of cases?

[Blake Parsons]
A lot of times, just like you said, either you stick the AT or PT and then go up and over and down the opposite, all the way down into the foot and into the pedal loop. If I can't for some reason, if their anatomy is too steep or I can't get a good mechanical advantage on it, then that's when I'll probably stick the patient antegrade femoral or SFA and then come that way. But, most of the time, we're able to do it from that PT access and come up and over and treat everything from that. And we found some certain catheters will make it easier to get... because a lot of people will say, "Well, how the heck am I going to get up and over?" We have a 90 degree Berenstein that will clip and make it shorter...It hasn't really been much of an issue, honestly, getting up and going back down the opposite artery and then getting treated what you need to.