BackTable / VI / Podcast / Transcript #69

Podcast Transcript: Retrograde Pedal Access

with Dr. Jim Melton and Dr. Blake Parsons

Dr. Jim Melton and Dr. Blake Parsons discuss the benefits of retrograde pedal access in the treatment of PAD, as well as the team approach of their outpatient CardioVascular Health Clinic , which includes Vascular Surgery, Interventional Radiology, and Interventional Cardiology working together as partners for better patient care. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Endovascular Collaboration Across Specialties

(2) Why Try Pedal Access?

(3) How to Approach a Pedal Access Case

(4) Pedal Access Walkthrough

(5) Pedal Access Challenges and Risks

(6) Pedal Access Devices

(7) Pedal Access Recovery

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[Aaron Fritts]
Hello everyone and welcome to the BackTable podcast, your source for all things IR and endovascular. You can find all previous episodes of our podcast on iTunes, Spotify, Stitcher and listening platform of preference. This is Aaron Fritts, as your host this week and I'm very excited to introduce our guest today, vascular surgeon, Dr. Jim Melton, and interventional radiologist, Blake Parsons, coming to us from Cardiovascular Health Clinic in Oklahoma City.

My goal with this episode is to cover pedal access and hopefully inspire others to learn how to do it, but also to talk a little bit about how IR and vascular surgery can successfully work together for better patient care. And possibly even a better business or practice model for a lot of the IRs coming out of training, especially for the more clinically-oriented trainees coming out of the new IR residency. So, first off, I'm going to ask you guys to tell us a little bit about yourself, and how an IR and a vascular surgeon linked up to tackle vascular disease. I'm going to start with you, Jim.

(1) Endovascular Collaboration Across Specialties

[Jim Melton]
Yes. So, my partner and I started Cardiovascular Health Clinic. We were the initial 12 guys in Oklahoma City that built two gigantic heart hospital systems that were physician owned and partnered with Mercy Systems out of St. Louis, and they were a decent partner. We did that in 2002 and pretty much dominated the market with about 1,500 to 1,600 pump cases a year and about 1,100 open vascular cases a year, and a lot of percutaneous work.

We brought three different groups together from three different hospitals, and did that deal in 2002. And then we built another one, pretty much identical to that one, on the southside of town and that was that. In 2012-13 it became the place that we left because it just became too administrative heavy and you couldn't get your stuff done efficiently like we started. Initially, that's why we left and built the place.

So, in 2015 we left and built Cardiovascular Health Clinic and what's been amazing is just the ability to make this hybrid facility a surgery center, a JCAHO approved surgery center, accredited surgery center, and OBL has worked really well for our practice.

I'll let Blake talk, but Blake contacted us in probably late '15 or early '16, and was a total surprise to me. I knew of his father, because his father practiced in Oklahoma for a long time as an internist, and I knew of his upbringings and reputation, and all that. So, I knew he came from good stock. But it was really strange to think an IR had the entrepreneurial vision that he had at such an early age, because he didn't want to work for a hospital. It's been a great marriage, if you will, together for our practice, because he just adds so many different skill sets and different procedures that work perfectly in the OBL space, or the surgery center, depending on contract negotiations.

So, I first met Blake himself in late 2015. I was a little worried about the clinical skills of IR. When I was working, they were proceduralists only. And when he got out of his fellowship, I was extremely impressed with his ability to run a clinic and clinically be sound, as far as deciding what patients need. And also politically correct, with referrals and everything like that. So, it's been a great experience for us and obviously looking to grow that side of the business with another IR or two, for sure. It's been great.

[Blake Parsons]
It was early 2016. I did my diagnostic residency at OU, University of Oklahoma. I guess I was right in the fellowship match and so, ultimately, I was extremely fortunate to match at the Medical College in Wisconsin there. But I always, I guess, for some reason, through my residency, I always knew I wanted to have kind of an outpatient-based practice, kind of the entrepreneurial spirit of the whole deal.

During my residency, one of our techs actually got hired on here, at Cardiovascular Health Clinic, and she said, "Oh, you'd probably be interested. There's this vascular surgeon and an interventional cardiologist that built a place and it's kind of what you've been talking about." I said, "Oh yeah, sure. This is going to go over well. So yeah, give me their email."

So she gave me Jim's email. I emailed him, basically saying that they should hire me and sent them a bunch of CPT codes, I think, about how much money I could make them. I don't know. I figured this was going to not go well. But to my surprise, I think by the end of that first day that I sent it, they'd already emailed me back and like, "Hey, we're super interested".

We set up a meeting and they definitely took a chance on me, because like you said, they had no idea, really, how this was going to play out. I still hadn't even gone to fellowship yet. Obviously, I graduated from fellowship at MCW in 2017 and now we're going on three years here and it's been great.

Like I said, I was very fortunate to go to MCW, which I believe is one of the top programs in the country. Not only just because we did a lot of peripheral arterial work but we did get a lot of exposure to clinic, like you said. We did a lot of clinic work. We just got a very broad view and training. We got to pretty much do everything there.

When I got back and joined the practice, obviously being able to join a guy that's been doing it a long time and has a great national reputation and is one of the best surgeons in the nation, that's been awesome as a mentor as well and, well, I'm sure we'll get into it too. And kind of as a partner from a different specialty to be able to bounce things off of.

[Aaron Fritts]
So, that's interesting that you had that foresight, Blake, to think that this would be a nice partnership. The way I met you guys was I was very fortunate to be invited to drive up from Dallas and watch you guys because I was interested in learning more about pedal access, and watch you guys perform a number of pedal access cases. I was just really impressed by the facility and the number of cases, the volume of cases, the variety of cases that you guys were doing.

Just real quick, before we jump into the pedal access topic, can you tell us a little bit about how things are? How have things been since the COVID-19 pandemic?

[Jim Melton]
It's obviously been interesting. Our number goals as a business were to protect our employees and our patients as everyone. And so we took policy changes immediately and did all the things that everyone is doing with temperature checks and background checks as far as where you've been and if you've been sick and all that stuff for every patient in. We also keep the families out in their cars and limit the patient volume in the waiting room and all those kinds of normal things.

We were instructed, through a separate call from administration in Oklahoma. They didn't understand our surgery center and what we offered and were very happy to hear that they could offload some of the hospital volume in a COVID setting to our place and get it done in an efficient manner, the way we do it everyday. So we haven't been down like most surgery centers and that's the reason, is because of the pipeline of business that we have.

Those people continue, as you know Aaron, they continue to get sick and they ignore their health because they're afraid to go to the hospital. We have numerous cases of people staying home too long and having big MI's or losing limbs because of their fear of the hospital.

The governor and the State Health people have really been supportive. Because of that we're able to do PCI's. We're able to do devices if they need them. Only emergent devices only until the last week or so. And also, obviously, our critical limb ischemia practice really hasn't slowed down at all. Most of our practice is gangrene and ulcers anyway. That's what we've been doing and, hopefully, making a difference in people's lives, even in this terrible, terrible situation that we're in.

[Aaron Fritts]
That's great that, like you said, there's a lot of anxiety about patients going to the hospital. I was trying to get a patient to get an IVC filter out and he refused because he didn't want to go to the hospital. And so, there is a lot of anxiety about that. It's great that you're able to offer that.

Blake, how about stuff like fibroids--some of the more like this stuff? Has that been curtailed?

[Blake Parsons]
Sure. Yeah, exactly. We stopped all true elective cases kind of on par with some of the regulations. Just like you said, we've only been doing urgent, emergent type cases. Emergent as you can be in an outpatient setting. Mainly everything we've been doing, on Jim and my part, has been peripheral vascular work. Like you said, we do have a lot of patients with ulcerations and wounds. So, obviously, we still have been performing procedures for those patients and trying to heal their wounds now. Claudicants and all those know that it's a good time for them to continue doing their exercise programs and conservative therapy.

On the vascular side it's all been primarily wounds and stuff. Now, for the other, like you're saying, we have three interventional cardiologists that are partners at our clinic as well. That's kind of what he meant by still being able to do coronary stuff and screenings and procedures for those people.

[Aaron Fritts]
And I forgot to mention, the other unique thing about your center is, as Jim talked about in the beginning, is having cardiology, vascular surgery, and IR all under the same roof.

It's pretty amazing. I imagine the level of patient care you're providing is unparalleled in other parts of the country where there are a lot of turf wars. I just think collaboration is the way to go in terms of better care and so hats off to you guys for making that happen.

Anyway, let's delve into the topic for today. Like I said, I learned a great deal from you guys when I came up there. I want to take a step back before we get into the details of technique of pedal access and ask Jim, what inspired you to first start trying pedal access, since it is a relatively newer technique? How did you learn it and how long did it take you before you felt comfortable?

(2) Why Try Pedal Access?

[Jim Melton]
Over at the heart hospital, in 2013, I was trying to get through a TO with an ulcer of an SFA or something and I got tired of not getting all the way through it or even being able to get past the proximal cap at all. I started sticking pedals with ultrasound guidance which, as you know, an interventional radiologist is the best, by far, at that--no questions asked, period. And then, I mean, it was a skill I had to learn.

I learned that and just stuck small needles and put a wire in, just so I could know I could do it. And then I said, "You know what? Let me try to get through this distal cap." And it just became very obvious, very quickly, that distal caps were so much softer than the proximal caps. A lot of times you just fly up with not a lot of product cost involved and you're able to save a bypass for another rainy day.

So, I think that, at the end of the day, it was that that really got me started. Then we just started sticking more in 2014 and then I left in 2015. Blake does some crazy IR stuff that I don't do sometimes, but my practice is probably 98% pedal. I hardly ever stick a femoral or anything. That's from 2015 to present. I think Blake's practice is starting to reach that too, whether it's BK disease, SFA disease, or three level disease including the iliacs. We just feel a lot better with just multiple things.

We're trying to get a paper out for the radiation dose decrease is gigantic going pedal. Contrast usage is markedly decreased going pedal. And the put through is, as Aaron said earlier, a put through of actual patients goes up about 2.6 per day, if you do all pedal as opposed to femoral.

[Aaron Fritts]
It was impressive how many cases you guys were knocking out that day I was there. And so, Blake, was pedal access something that you learned in fellowship? And, maybe, along those lines, tell us a little bit about how the transition was from fellowship to working with Dr. Belton and some stuff you picked up.

[Blake Parsons]
Sure. Definitely. So, we did a lot of peripheral arterial work. We were fortunate, and this kind of goes back to me working with a vascular surgeon. At MCW you kind of worked hand-in-hand with the vascular surgery program there. So I had already had previous relations at work during fellowship between vascular surgery and interventional radiology, and it was great. So I kind of knew all this was awesome because I'm going to be able to take this same approach, this same ability to work at patients, and bounce things off of each other back at my practice.

I would say we only did a handful of true retro-pedal or, what people call, TAMI cases. When we stuck tibial arteries it was because you're doing a safari or something of that nature. I talked to Jim on the phone and he'd be bragging about how many retro-pedal cases he's doing and giving me a hard time. I was like, "Yeah, yeah, yeah."

And then sure enough I got back and my practice was obviously slow at the beginning because trying to get the general public to understand what the heck an interventional radiologist is--that’s just part of the battle. So, I'd scrub in on cases with him and watch him do cases and, sure enough, he had a lot of retro-pedal access, and I just saw the ease and the decrease in time. We're talking complex, multi-level leg maybe an hour and a half, typically. Total time. I'm not talking about the fluoro time, obviously. I'm talking about the total time of getting in there and doing the case. Significant reduction, like you said, in your contrast dose, patient dose, because you're not having to go up and over. You're not radiating the pelvis as much.

I became a believer. And then, obviously, as my peripheral work increased over the past three year. Like you said, I probably do 95%. Now, there's still times I'll go integrate femoral, SFA, or up and over femoral if I know it's all below the ankle or pedal loop or something like that, that I want to get a better vantage point to. But, for the most part, I also go retro-pedal from the foot.

[Aaron Fritts]
I guess to clarify for some of our audience, like you said, you talk about the safari technique where you're still getting the access in the groin and in the foot. Would you mind clarifying that? Like, what you guys are doing? You're just solely getting access in the foot in the majority of the cases rather than getting dual access, right?

[Blake Parsons]
Sure. So we call it retro-pedal. I know the other name out there, everyone calls it TAMI.. But, yes, we're talking single access within a distal tibial artery, PT or AT, sheath placed, and then all treatment is done from that sole tibial artery access. We're able to, like we said, accomplish that probably 95% of the time.

[Jim Melton]
I can tell you, my in practice since we opened in '15, I haven't done one safari. I think Blake's done a few just because of the extent of the disease or whatever.

[Blake Parsons]
Pretty rare, pretty rare.

[Jim Melton]
Pretty rare, yeah.

(3) How to Approach a Pedal Access Case

[Aaron Fritts]
Along these lines, so let's go into how you guys approach a case. The majority of your cases are done by pedal access because you guys have the experience and the confidence. But, for somebody maybe newer... you guys get a lot of visitors that come through and watch you guys and probably a common question is, what are the big contraindications to pedal access for you?

[Jim Melton]
When docs come to the center and we have the opportunity to, hopefully, help them and give them a good time while they're here, we try to go through some of that stuff. But, I mean, it all starts with a really good clinical exam. That's what, again, I was a little worried about, not with Blake, but IR in general. But Blake, like I said, he came from a program that had that and it was really a pleasant surprise.

A good clinical exam with a hand-held Doppler in the room, trying to figure out where these lesions are, is really the coolest thing that I do in the clinic. I walk out and I know exactly where this lesion is. So, a good clinical exam and then I also tell the docs that come and haven't done much pedal to go ahead and do a duplex below the knee and visualize that the AT and PT is open. It makes them feel a little more comfortable sticking it. Or the interosseous, any of those three vessels.

I think that that's probably the best thing. You know, your first 100 cases or so I would probably stay from one vessel runoff. Blake and I both, still to this day, still do that a little bit. If we think it's a one vessel runoff case, we'll probably do a diagnostic first with either a little antegrade dilator or something like that or an up and over small sheath and then decide whether we want to go primary pedal or not. Pretty rare on that but I think, at the end of the day, once you get some under your belt you feel more comfortable doing one vessel runoff also. But, I think that just comes with a comfort level and experience as you go, going down the road.

I think it's a really good way to recanalize a lot of vessels below the knee that are totally occluded with the selection of wires, that we try to show docs if they come to the course. But, I think at the end of the day, it's good for all three levels, below knee, obviously SFA's that have never dreamed of getting through and then inflow disease also.

[Aaron Fritts]
And so, a lot of your patients are obviously CLI patients, guys with wounds. Anything in terms of like where the wounds located or do you worry about the access itself causing a wound?

[Jim Melton]
We like to try to identify the wound in these certain angiosomes for sure. And try to figure out which vessel is important to healing that angiosome. That's part of that clinical exam deal on the front end. We try to cover up all the wounds on the prep, on the patient, and prep them out, if you will. And try to obviously stick away. We have over 2500 cases, CLI cases now for sure. I've never seen a wound caused by the perc stick that didn't heal or anything, to date.

(4) Pedal Access Walkthrough

[Aaron Fritts]
Let's walk through a typical pedal access case. Assuming decent vessels, whether it would be AT or PT, where do you like to stick for your pedal access?

[Blake Parsons]
First off, obviously, we're using ultrasound. From an ergonomic standpoint, the PT's a little easier to work with. But, that is all just based solely on what changes we're going after, what's their preclinical evaluation of what we think is open prior to getting in there. You can always be fooled but distal collaterals that reconstitute the distal AT, PT, DP, and you get a monophasic signal and you think it's open and then you get another case and it's not. So, it just kind of depends.

AT obviously, distal AT, PT usually around the ankle. It just kind of depends whether we'll stick a DP more distal. Obviously, you're a little limited on your sheath size if you think there's more proximal disease. But, now even, like you're saying, if I know and am pretty sure they've only got say a single vessel AT to the foot and I can't hear signal in their peritoneal or their posterior then I'll sometimes even just try sticking their occluded vessel and see how hard the plaque is. I'm not going to hurt it. Obviously, it's already down. So, I'll stick it and then it's kind of like a freebie. As long as I can get up through that then I can get up and fix everything from there.

It just depends. A little bit of it is we do have a pretty good idea before we ever step into the room. But, obviously, you've got to adjust on the fly some too.

[Aaron Fritts]
So, once you get access, walk us through a little bit of your step-by-step in terms of micropuncture set, sheath size, and PO cocktail.
[Jim Melton]
The Terumo glide sheath is what we used when we first started, pretty much exclusively. We found that those are really good sheaths, obviously. They're high-end sheaths, a high-end company, a very good company. But, I think, at the end of the day they're not braided as much as you really need for pedal because they kink a lot. This doesn't keep you from getting the case done, but you just have to use a dilator a lot and back in and out and in and out. I think, at the end of the day, we found a Merit sheath and now there's a Bard sheath that is braided. The Bard sheath is marked really nicely on the tip. Merit sheath is a really good sheath too. It comes in 7 and 10 sonometer links. The Bard goes all the way up to 90, I think. But we don't use long sheaths. We just use short sheaths in the foot.

As soon as we get in, a micropuncture set with a short needle--we use short needles instead of the long ones. It's just a little bit easier to not come out of the vessel when you hit it and you're trying to get the wire in. A hydrophilic type wire is usually better with a little bit of support on the back. All the micropuncture sets are a little different, so you've kind of got to find the one that's a sweet spot for you.

Depending on our clinical exam, what we think is going on, we either put a 4.5 or 5.6 Merit, Turemo or Bard sheath in. And then we put a cocktail in that's about 400 units of nitro and 3,000 units of heparin. We just haven't seen an advantage in using any other drugs in there like they do for radial cocktails.

[Blake Parsons]
We don't put verapamil in.

[Jim Melton]
So, I think that's our cocktail. And then we usually take a shot with either very little, literally 3cc of dye, below the knee and then we go after as far as what the clinical findings are and what we think we're going into which is, most of the time, very ugly vessels.

[Aaron Fritts]
Welcome to the South.

[Blake Parsons]
From there, there's definitely certain wires. Everyone's got their kind of particulars. Based on that initial shot, is it all below the knee? Is it involving more proximal and the below the knee is not too bad? That will kind of depend on what size system we go with, like with the .035 right off the bat or an .018. So, we're going to start with an .035 glide. Am I going to start with an .018 Command wire and then, obviously, take it up from there. We'll get wire access all the way into the aorta.

And then, depending on the patient's creatinine and those things, we'll either do an angiogram through the catheter back down the leg, as well as, obviously, we have very strong beliefs in using intravascular ultrasound. So that's kind of our next step: an intravascular ultrasound. Not only can we see the extent of the lesion but also so we can see and get appropriate size measurement of vessels for both angioplasty, as well as potential stenting, and plaque morphology so we can decide, if we need to, what type of atherectomy system to use. We're fortunate enough here, since we're not in a hospital system, we get to pretty much have all the bells and whistles that we want. So, we have a lot of options that we can tailor to each patient's condition.

(5) Pedal Access Challenges and Risks

[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. So 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, it sometimes stabilizes that calcified vessel so it doesn't roll on you as badly. That's a little bit of a trick sometimes.

[Aaron Fritts]
I remember, during one of my first ones I did, I was worried about because the DP was so diseased I kept going higher and higher into the AT and I was starting to worry that I could cause compartment syndrome or something if my access site was bleeding. Is there anything, any words 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 concerning. 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]
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 careful about, but any suggestions to help prevent spasm or dissection?

[Blake Parsons]
Sure. So kind of like you're saying, we use nitro pretty liberally around here. Both on your initial stick and our cocktail, but also on the way out. Because you will get a spasm in an artery that you accessed. And then there's times you'll pull the sheath and they're holding pressure and you come back and they're foot’s 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. 15 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. They're pretty rough.

From a dissection point, 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.

(6) Pedal Access Devices

[Aaron Fritts]
So getting into what the capabilities are, obviously angioplasty is being done below the knee. Tell me a little bit about what kind of atherectomy devices you're doing from pedal access, and also even stenting. I saw Jim stent a common iliac from the pedal which was pretty impressive. But, I want to get into the capabilities in what you guys are doing.

[Jim Melton]
There's really not a lot of devices that we can't put through a 5.6 in either one of those three brands of sheaths. Below the knee, we can look at plaque morphology with IVUS and, depending on what that is, if it's more thrombosed and less calcified we'll use a laser. Either a .19, 1.4, or 1.7. all of those go through a 4.5 Fr and a 2.0 goes through a 5.6. The appropriate sized vessels are listed for those.

And that same thing applies for the SFA. As far as atherectomy goes, we have CSI devices. We have Phoenix or Spectranetics Phillips devices--those are the rotational atherectomy devices we have. And then we have the Laser 2.0 and then the laser that has the tip that moves around a little bit better for ISR. So we have all those tools in the box, which you never find at a hospital. I think it's always good to have whatever you need. For iliacs, we are obviously extremely careful. I think we have a very low complication rate in our space because of IVUS. We measure those specifically. We don't overdilate and we are always ready, when we're doing an iliac, to put a 6.7 Terumo glide in and be able to take a seven VBX in at any time and dial it up to at least 12 if needed, in iliac.

Those are things that we have done. We are ready to do with just a quick, little sheath change and fluid support until we get there to fix it. I think those are all things that you have to be ready for in this space. It's important that, if this space is going to survive, you have to be ready for those kinds of things in order to take the best care of patients.

[Aaron Fritts]
And so, 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, because 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 how much heparin we're giving during the case as well as the nitro and all that, trying to minimize any kind of thrombin. Because you're going to be occlusive, especially when some of these vessels. Average size is probably a three in a tibial, and so they're a hell of a lot smaller than that whenever you first start and highly calcified. You're going to be occlusive.

And like you said, we know there's going to be inflow disease. At least for me, at the time, I have them prep the groin as well, just in case of an emergency. We have a whole PAC 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. We can get that taken care of.

Luckily, we haven't really had any issue with that. Just like you said, 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, at least for me, 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 gunslingers. 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.

[Jim Melton]
The plaques are really important. At the end of the day we have a really large series of TO's, iliac TO's, that are easily fixed in the foot. I'd like to get that published some time soon. I think that it's a great way to keep somebody from having a fem/fem that gets infected. That's a nightmare in my world. I think, at the end of the day, it's a great way to fix people if you can get it done. We don't hesitate to pull out re-entry devices, and our re-entry device of choice is a Pioneer device. We have a low threshold for opening that device also.

(7) Pedal Access Recovery

[Aaron Fritts]
So once you fix the lesion and, everybody knows how to close groin access. How do you close pedal access and talk us through recovery for the patients, how long they're sitting in recovery? Because I do think this is one of the best benefits of pedal access.

[Blake Parsons]
Sure. I think both of us, we typically give a little nitro at the very end of the sheath. At the very end we'll do, obviously, a retrograde run to the end of the sheath to make sure the tibials still look good and everything's nice and open. And then, we typically give some nitro just for dilatation purposes. Then, I would say ,the majority of the time, they just hold pressure. We'll take the patient back to the room. The nurse will then pull the sheath there and then we're continuously monitoring with valve pressures being held with Doppler, distal, and making sure that we've got flow. Just like if you're holding up pressure on a fistula or something. We obviously don't want to be occluding it.

And then, after that, the pressure's probably held for 15-20 minutes, at the most. Those patients really start dangling their leg off the bed at an hour and a half or so, and then most of them are out the door within an hour and a half to two hours.

[Jim Melton]
It's usually a 90 minute protocol we have. Most of them are ready to go in 60 minutes. The beauty of it too is when they come back they've ordered their box lunch from the deli down the street and they're up eating. They're not laying flat on their back and a nurse is not holding pressure on their groin. they're sitting up eating while either there's a radial band on the pedal site or there's two finger pressure with documented distal flow. I keep talking about these papers but we're getting there. We're private practice so it's kind of hard to compete with the ivory tower. I have a really nice paper of a look at almost 500 cases that we did Duplex on post-pedal and proved that the wave forms distal to stick site were all really good.

So, at the end of the day, that's what people really want to know: if this procedure is safe, and we intend on proving that.

[Aaron Fritts]
Like many others I was scared to do more harm than good with the whole pedal access thing, especially working in the outpatient setting. It just seemed to have so many benefits. I've heard stories of patients who've had both pedal access and femoral access and they come back to see their doc and they might need another intervention. So, they literally demand pedal access just because their patient experience is so much better.

And so, I think, from an outpatient setting it just has so many benefits. But, getting started, I didn't want any bad outcomes, so I was very particular in terms of my case selection. The best starter case for me, personally, was an obese patient with kind of a hostile groin and had an isolated tibial disease. It was easy to get in. It wasn't easy but it was relatively easy to get in: balloon angioplasty, give my post-injection and be done. And so, I think that, to me, was an ideal case to start out with.

Do you guys have any suggestions on people who want to get started and maybe are a little bit hesitant?

[Jim Melton]
Yeah, you nailed it Aaron. I think, at the end of the day those people are just high risk to stick a groin. The radial's an option if you talk it through, but the radiation difference is drastic, to say the least.

I think that, at the end of the day, your ideal candidates for your first cases are two or three vessel runoff and a total SFA with an ulcer. Those are your best ones to practice on. The below the knee disease is good. There's a lot of techniques that we try to teach when the docs come about up and over from PT to AT or AT to PT, or interosseous, either one. And so, we do those also without sticking the groin. But, at the end of the day, the best cases and the most satisfying cases are the ones you can't get to from the top but you just fly through them from the bottom to heal an ulcer. So those are really good cases.

When you're a Critical Limb Ischemia Center of Excellence or that's what you want to be, you don't see a lot of those. But, at the end of the day, those are really good cases to practice and get a lot of confidence with.

[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. Now if I can't or for some reason--just their anatomy is too steep, whatever. You just 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.

[Jim Melton]
You talk about the collaboration. I knew what a microcatheter was but that thing is like cheating. It overwhelms things. It's really easy to get, even with steep angle stuff, it's really easy if you've got the right microcatheter and the ability to shape it to do that technique. Those are great things that I've learned from him.

[Blake Parsons]
And we found some certain catheters will make it easier to get there 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. We also, I'll use like a saw and I'll just cut it off to where it makes kind of like a mini rim and use that to be able to get up and over. 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.

[Jim Melton]
If any companies want to sponsor us, Aaron, we'll all three go together and be happy to build them catheters if they want us to.

[Aaron Fritts]
Well, besides visiting you guys, are there any other resources for guys out there wanting to start this that you know of?

[Jim Melton]
I think that, as far as industry goes, both of us are on the teaching faculty for Terumo, Phillips, and Spectranetics which are the same, and Abbott. So if you use any of those products in your toolbox, you'll be able to get to us as industry does it anytime you want. There's courses all through the year and if we can help in any way, obviously, we'd love to help at least get you another opportunity to treat your CLI patients.

[Blake Parsons]
And then, we occasionally have time to, or offer to give presentations at different conferences. Obviously, anyone can contact us at any point. Obviously, Twitter's a huge part of it. We're more than happy to always help. If someone calls with a question--what do we like to use in a certain instance--we're always there and willing to help in any way we can.

[Aaron Fritts]
Well, cool. That's all the questions I have. Do you guys have anything or words to the wise, any closing remarks?

[Blake Parsons]
From me, coming as an IR doc, some people are going to be like, "Why the hell would you join forces with a vascular surgeon?" And I'll be honest. There's a huge benefit. Like I said, I got to see it firsthand in my fellowship. I mean, it happens every single week where I do an angiogram on a case or I get access and I'm going through and I'm like, "You know, I don't think this is a great endorevasc case. I think we're going to jeopardize future bypass options or treatment options."

Then it's great for me as an IR doc because I've got a guy right here, as my partner, that we go over cases all the time, go over imaging and say, "Hey, you know, from a surgery standpoint what are your thoughts here?" And so, I think, from a patient care standpoint it's great. There're a lot of places where they don't have that and so you feel a lot bigger push to go ahead and try fixing someone endovascular because that's the option that you have. When maybe that may not be the best option. For me, anyway, it's been great. It's been good just to continue to always understand too, from a surgery point of view, what's he looking for? What's he thinking for future treatment options also?

[Aaron Fritts]
Well, hey guys, I really appreciate you guys coming on the podcast. Again, it's a unique setup you guys have and I hope that we see more of it, more collaboration amongst endovascular specialties in the future. I just want to, again, thank our audience for tuning in. And also, thank you to our sponsor, RADPAD. So that about wraps it up guys. Thanks again.

Podcast Contributors

Dr. Jim Melton

Dr. Jim Melton is a practicing Vascular Surgery Specialist in Oklahoma City.

Dr. Blake Parsons

Dr. Blake Parsons is a practicing Interventional Radiologist in Oklahoma City.

Dr. Aaron Fritts

Dr. Aaron Fritts is a Co-Founder of BackTable and a practicing interventional radiologist in Dallas, Texas.

Cite This Podcast

BackTable, LLC (Producer). (2020, June 22). Ep. 69 – Retrograde Pedal Access [Audio podcast]. Retrieved from https://www.backtable.com

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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.