Combined Radial-Tibial Access Strategy With Radial-Tibial Reverse CART, Radial-Tibial Kiss, and Tibial-Tibial Kiss

J INVASIVE CARDIOL 2018;30(1):E4-E6.

Key words: radial access, tibial access, superficial femoral artery, reverse CART, radial-tibial kiss, peripheral intervention

A 45-year-old, 172 cm-tall, male smoker presented with extensive non-healing ulcerations of the left leg and left second toe (ankle-brachial index, 0.1). His arterial access options were limited; the right common femoral artery was occluded and the left forearm had contractures from a prior stroke. As a result, the following stepwise revascularization strategy was adopted:

1.    The right radial artery was accessed and selective left femoral angiography was performed via 6 Fr, 125 cm multipurpose guiding catheter. Extensive femoral and infrapopliteal disease was demonstrated (Figure 1). 

2.    The anterior tibial (AT) artery was accessed distally (5 Fr slender sheath), and the AT occlusion was successfully crossed retrogradely and treated with orbital atherectomy and angioplasty (Figure 2A). 

3.    After AT therapy, the diseased ostium of the posterior tibial (PT) artery occluded; PT was thereafter wired through the AT access using the “hook” of a 4 Fr internal mammary catheter (Figure 2B). Kissing-balloon angioplasty of the AT and PT was then performed with two 3.5 mm coronary balloons advanced through the AT sheath (Figures 2C, 2D, 2E).

4.    After infrapopliteal therapy, the superficial femoral artery (SFA) was retrogradely crossed transtibially using a 0.035˝ catheter and a 0.035˝ guidewire. The latter devices went subintimally at the level of the proximal SFA. 

5.    In order to allow retrograde femoral re-entry, additional 0.035˝ devices were advanced into the SFA antegradely through the transradial guiding catheter, attempting to create a radial-tibial rendezvous (Figures 3A, 3B). The subintimal SFA was then dilated antegradely using a 5 x 100 mm, 200 cm shaft monorail balloon (radial-tibial reverse controlled antegrade-retrograde tracking [CART]) (Figure 3C). This allowed re-entry of the retrograde devices into the true lumen of the common femoral artery. 

6.    The SFA was subsequently dilated through the AT access, and the profunda was wired and simultaneously dilated through the radial access (radial-tibial kiss) (Figures 3D, 3E). The SFA ostium was eventually stented through the AT access, and accurate stent positioning was ensured using transradial roadmap imaging.

At the end of the procedure, the AT access site remained widely patent on ultrasound imaging, the patient’s distal pulses became palpable, and the ankle-brachial index increased to 0.8; 1 month later, the ulcerations completely healed. 

This case illustrates the value of a combined radial-tibial access strategy in complex peripheral revascularizations with limited arterial access options. The tibial access was used as a primary recanalization access, while the radial access was adjunctively used to allow imaging, to treat the profunda, and to facilitate proximal re-entry of the transtibial devices, by way of antegrade subintimal balloon dilation (reverse CART).

From the Cardiovascular Section, Louisiana State University, New Orleans, Louisiana.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted May 24, 2017. 

Address for correspondence: Elias B. Hanna, MD, Cardiovascular Section, Louisiana State University, CSRB Bldg, 3rd floor, 433 Bolivar Street, New Orleans, LA 70112. Email: ehanna@lsuhsc.edu