Updated: Oct 21
Choosing the appropriate procedural equipment can be daunting due to the breadth of options available. Dr. Dhand and Dr. Madassery discuss guidewire choices, balloon sizing for angioplasty, and more when treating peripheral arterial disease.
The BackTable Brief
Using a 0.014” guidewire may be helpful in the smaller vessels of the lower leg, whereas an 0.018” system has improved torque-ability; Dr. Dhand and Dr. Madassery both recommend familiarization with a single guidewire to maximize your efficiency when using them.
For balloon angioplasty, a suggested guideline is to use a 1.5 mm balloon in the pedal arch, 2 mm balloon in the ankle, a 2.5 mm balloon in the tibials, and a 3 mm balloon in the TP trunk proximally.
A smaller vascular access site leads to less time for hemostasis; Dr. Madassery prefers using a Micropuncture access sheath (inner 3 french size) during cases requiring pedal access.
Disclaimer: The opinions expressed by the participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Which Guidewire Do I Start With?
[Kumar Madassery] … We use a SEEKER or a Quick-Cross, and an 0.014” wire. Normally we start with a soft wire, something like Hydro ST or a Command or something and try to navigate our way. And then in the attempts, which are sometimes pedal, to go antegrade we'll switch to a heavier set wire or a weighted tip wire, Astato or something like that. And once you're in the tibials, if that's not going, that's when we get the foot going. I think if you're in the 0.018” - 0.014” platform, that's pretty much standard for everybody with the tibials.
[Sabeen Dhand] Actually it's funny. A lot of people I talk to start off with an 0.014” system, but I like the 0.018” just because there's just more torque-ability and push-ability. I don't think it's worth going into all the different wires. It was overwhelming for me when I started because I didn't really know. Everyone that says, "This wire's good, this wire's,"...Whatever you pick, you stick with it, you learn that wire, and you get really good. Mine is the V-18, but I think everyone else can use anything just as long as you remain consistent.
[Kumar Madassery] Agreed.
Choosing the Correct Balloon Size for a Particular Vessel
[Kumar Madassery] Luckily, we're fortunate now to have much smaller balloons too. And tapered balloons, and yeah, sometimes you have to go down to a 1.5 mm when you're going around the pedal arch or down by the dorsal, and work your way up. Everybody may have a slightly different approach but for us, below the ankle, we try to get at least up to a 2 mm balloon. And then go up to about 2.5 mm along the tibials, and sometimes up to 3 mm by the TP trunk proximally. That's kind of our expected end points on the balloon side. If we can get that caliber, that's what we want.
[Sabeen Dhand] Yeah, I agree. It's exactly the numbers we use. I’m slowly trying to push it these days now, and I'm trying to go half a milliliter larger. I'm like, "Okay, maybe this whole vessel can take a 3 mm, and maybe a 3.5 mm on top." And the angio looks great after.
But it's still a question. What's the top number to use for me, and I'm still kind of experimenting. I think staying with 3 mm at the tibials, I don't see that many dissections or occlusions right after. So I think whether we're under treating a little bit on the sides, you're saving the vessel versus over treating and oversizing and then damaging the vessel. It's a balance.
[Kumar Madassery] I think if you take into consideration what the vessels look like, like you're saying, and kind of ... I think everybody develops their own guidelines, but everybody's kind of in that range, within a few millimeters. You work with the premise of the enemy of good is your motto, and you go from there.
Using a Micropuncture Sheath During Pedal Approaches
[Kumar Madassery] ... And for us, typically what most of us do is through the Micropuncture we'll put a V-18, or Nitrex wire first, make sure it goes up, and then put the inner 3 french of the microcatheter in there, and inject a little contrast just to prove that you're actually in the artery. Sometimes you might get fooled with the vein. And then through the inner 3, we'll put a V-18 as our primary wire to go all the way retrograde. But like Sabeen said, the majority of the time, we just keep that inner 3 french in there. That's about as big of a profile system we put in there. Once we're doing our flossing and stuff, we'll keep the inner 3 with a little flow switch. Then when we're ready to switch our direction, we put the wire across and then hemostasis takes just like a finger touch hold because it's such a small hole.
In our entire experience of pedal access we've almost never used a particular sheath. Even though they do have a couple of companies, Cook and there's a slender sheath. They're small profile sheaths, but we just prefer not to make big holes down there because those are lifelines for what we're trying to keep open. ----------
Dr. Sabeen Dhand is a practicing interventional radiologist at PIH Health in Whittier, CA. Dr. Kumar Madassery is a practicing interventional radiologist with Rush University in Chicago. Dr. Michael Barraza Jr is a practicing interventional radiologist at Radiology Alliance in Nashville.
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