The Upstairs-Downstairs Approach to Critical Limb Ischemia

By Richard R. Heuser, MD; Hassan S. Makki, MD; Robert C. Candipan, MD

Patient History

An 85-year-old Hispanic female presented with a nonhealing right heel ulcer. She was found to have a total occlusion of her distal popliteal artery in her right lower extremity with no infrapopliteal runoff to the foot. Attempted antegrade approach was unsuccessful. Two days later, she presented with continued critical limb ischemia and intervention was approached via pedal access on the right.

Intervention

Using ultrasound interrogation, access was successful with a micropuncture needle. A 5 Fr sheath was placed as well as the .014 Estado (Asahi Intecc). With inability to cross, we performed contralateral access. An Ansel catheter (Cook Medical) was placed from above and a QuickCross catheter (Spectranetics) was utilized with a .035 Glidewire (Terumo Medical). We successfully crossed the tibial peroneal trunk from above placing the .035 wire in the peroneal vessel. We then passed the Estado wire in the peroneal vessel from below. A Chocolate balloon (TriReme Medical) was utilized from above and below with a kissing technique. At the end of the procedure, TIMI 3 flow was restored and there was two-vessel run-off of the anterior tibial and peroneal vessels (see video).

Discussion

We have increasingly utilized the pedal approach in difficult-to-treat CLI patients. The antegrade-retrograde technique utilized in this case is similar to what we use in coronary CTOs. The maintenance of the bifurcation is important and utilizing two sheaths of small size from two separate access approaches makes this possible. We suspect the ulcer to heal in the next few months.

Figure 1. Angiogram from the antegrade approach.

Figure 2. After ultrasound guided access, we have now approached the total occlusion of the tibial peroneal trunk.

Figure 3. The contralateral approach was successful utilizing the pedal wire as a road map.

Figure 4. We have now obtained pedal access into the peroneal vessel and contralateral access into the same vessel.

Figure 5. Using an upstairs-downstairs approach, we utilized the kissing balloon technique.

Figure 6. Final angiogram revealed excellent two vessel runoff.

Angiography videos accompanying this blog post depict the anatomy, access, and final results of this case. Video 1 shows an the antegrade approach defining the anatomy. Video 2 reveals that the peroneal vessel is the largest vessel going to the foot; however, we were able to access the anterior tibial vessel by ultrasound. Video 3 shows access of the peroneal vessel from above with excellent position in the anterior tibial vessel from below. Video 4 reveals excellent two-vessel run-off.