Percutaneous Retrograde Revascularization of Lower Extremity Vessels by Using the Dorsalis Pedis Artery: Two Case Reports

Peripheral artery disease (PAD) is commonly found in association with coronary artery disease (CAD) and is also considered a marker for CAD.^1,2 There has been an increase in the treatment options for PAD with an increasing number of endovascular options becoming available.³ PAD involving the lower extremities usually presents with claudication, or in more severe cases, with chronic limb ischemia. Endovascular therapy for PAD in the lower extremities requires angiography of the affected vessel, followed by appropriate percutaneous intervention, if indicated. The commonly used access sites for lower limb interventions include the contralateral femoral artery, antegrade ipsilateral femoral artery, retrograde popliteal artery and sometimes even the brachial artery. The pedal arteries have also been rarely used for access.^4,5,6 Their use, however, has been limited to crossing lesions in a retrograde manner, followed by antegrade snaring and completion of the procedure^4,5 or performing of below-the-knee intervention.⁶ We present a report of 2 patients who had retrograde needle access of the dorsalis pedis artery. Thereafter, retrograde revascularization of popliteal and superficial femoral arteries (SFA) was performed without antegrade snaring. This report highlights the benefits and problems with a percutaneous retrograde approach as compared to a retrograde approach with antegrade snaring^4,5 and a retrograde approach with cutdown access.⁶ Case Reports Case #1. The first case involves an 87-year-old male with a history of PAD with severe left leg claudication on minimal exertion. Angiography revealed complete occlusion of the Left SFA from its ostium. The left popliteal artery reconstituted from collaterals just above the knee. Thereafter, the popliteal artery had 90% stenosis (Figure 1). In addition, there was a 90% stenosis in the tibioperoneal trunk. There was straight-line flow to the foot from the anterior tibial artery with occlusion of peroneal and posterior tibial arteries. The patient had aneurysmal bilateral common iliac arteries, and left SFA intervention with contralateral access could not be performed. Also, since the SFA was occluded at the ostium, an antegrade approach could not be used. The retrograde popliteal approach was not employed, as there was not a sufficient segment of the popliteal artery for the intervention. Thereafter, the dorsalis pedis artery was accessed under fluoroscopy guidance (Figure 2), and using a radial micro puncture kit (Cook, Inc., Bloomington, Indiana), a 4 Fr sheath was inserted. The sheath was sequentially upsized to 6 Fr without difficulty. The patient was given 5,000 units of heparin and the activated clotting time maintained between 250–300 seconds. A 0.014 mm Mailman guidewire (Boston Scientific, Natick, Massachusetts) was advanced to the popliteal artery, and SilverHawk™ ES and SS atherectomy devices (FoxHollow Technologies, Inc., Menlo, California) were used in the popliteal artery, with good results. For the tibioperoneal trunk, an ES SilverHawk atherectomy device was used, followed by 4.0 x 15 mm Cutting Balloon (Boston Scientific), with good results (Figure 3). At the end of the procedure, the sheath was removed and manual pressure was maintained. Postprocedure, the patient had a good pedal pulse and has no claudication on 2-month follow up. Case #2. The second case involves a 52-year-old male with a history of CAD, severe PVD and severe claudication of the left leg. Angiography revealed long segment of 100% proximal SFA occlusion (Figure 4) to just above the knee where the popliteal artery was reconstituted from collaterals with single-vessel (anterior tibial) runoff below the knee. A stent had been previously implanted in the mid and distal SFA, which was 100% occluded. Since the patient had similar arterial anatomy as the first patient, and other access sites were not feasible, the left dorsalis pedis artery was accessed with a micro puncture kit and a 4 Fr sheath was inserted. The sheath size was sequentially increased to 7 Fr, and an angiogram was performed (Figure 5). Next, a 0.014 mm Choice® PT wire (Boston Scientific) was advanced in the popliteal artery, then into the occluded stent in the SFA. Thereafter, a 0.9 mm laser catheter (Spectranetics Corp, Colorado Springs, Colorado) was advanced through the occluded SFA stent. After traversing the stent in the distal SFA, the wire was advanced subintimally and a Pioneer Catheter™ (Medtronic Inc., Minneapolis, Minnesota) was used. Using the pioneer device, the wire was passed into the true lumen of the SFA and into the common iliac artery. Subsequently, a 2.0 mm laser catheter was advanced over the wire in the SFA. Thereafter, an LX SilverHawk atherectomy device was advanced and atherectomy was performed in the SFA. Next, a 4 x 10 cm Savvy™ balloon (Cordis Corp., Miami, Florida) was used to dilate the residual stenosis in the SFA stent at 6 atm for 33 seconds. A 5.0 x 100 mm x 135 self-expanding Absolute™ stent (Guidant Corp., Indianapolis, Indiana) was then deployed in theSFA overlapping the previous stent. The stent was postdilated at 5 atm for 25 seconds with good results (Figure 6). Subsequently, another 5.0 x 60 mm self-expanding Absolute stent (Guidant) was deployed in the proximal SFA and postdilated at 6 atm for 25 seconds. Following the procedure, the initial attempt to remove the sheath was aborted due to vasospasm. The patient was given papaverine intravenously, verapamil and nitroglycerin intra-arterially and subsequently, the sheath was successfully removed. Postprocedure, the patient had a good pedal pulse and no claudication on 2-month follow up. Discussion These two cases highlight the technique of percutaneous retrograde intervention in the SFA and popliteal artery using the DP artery. Previous reports by Spinosa and Botti have described access to both anterior and posterior tibial arteries, however, they used the access to advance a wire that was snared antegradely, and the procedure was completed in an antegrade fashion.^4,5 Iyer and colleagues described a cutdown approach of the posterior and anterior tibial arteries in 5 patients, with revascularization being limited to below-the-knee arteries.⁶ Our patients had a SFA occlusion and stenosis in the popliteal artery (Case #1) and an occluded SFA artery with prior stent occlusion (Case #2). These patients had complex interventions with atherectomy, PTA, laser and stenting performed through the dorsalis pedis approach with good final and short-term results. The major advantage of this approach is the ability to perform complex interventions retrogradely which decreases procedure time compared to the combined retrograde-antegrade technique. In addition, it avoids cutdown access, which may increase procedure time and the potential for infection. The major limitation of this technique is the sheath size that can be used. In our opinion, the technique works best with devices up to 6 Fr in size. Larger sheath sizes cause vasospasm which can cause pain during the procedure and could result in potential postprocedure complications. If vasospasm is encountered, vasodilators can be used to successfully overcome it. In conclusion, this technique can be used for interventions on lower extremity vessels. In our experience, it was safely used with 6 Fr devices and may be extremely useful for revascularizing popliteal and below-the-knee vessels, especially in those patients where antegrade access is not feasible.

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