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16 Interventions forFemoropopliteal Disease
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standard 4 or a 5 Fr sheath, a 12–15min MC is probably sufcient, and VCD appear unnecessary. When working with a
6 Fr sheath or more, VCD is probably useful to decrease the
time of compression and allow faster ambulation [70]. A
controversy remains about the superiority of VCD over MC
for FP interventions [71, 72], but recent data tend to show
that a VCD could decrease complications [73].
Conclusion
The toolbox for femoropopliteal interventions is now large
and allows to obtain technical success in nearly all cases. A
step-by-step planning and approach helps to standardize these
procedures and clarify the role of the different devices [49].
Case Presentation
The following technical approach was planned: (1) access
the arterial system through the left contralateral common
femoral artery due to disease at the origin of the supercial
femoral artery; also plan a bail-out retrograde access through
the dorsalis pedal artery in case of intraluminal crossing failure (lesion classied CTOP type 2); (2) perform a crossover
and bring a 7Fr 45cm long sheath down to the right common
femoral artery to recanalize the femoropopliteal occlusion
intraluminal; (3) cross the occlusion with a dedicated 0.018″
or 0.014” CTO wire; (4) prepare the vessel using a debulking
device (rotational atherectomy) if crossing is clearly intraluminal; (5) use drug-coated balloons with bail-out spot stenting in case of localized dissection. In case of extensive
dissection, plan B would be to use a self- expandable covered
stent for the supercial artery segment and an interwoven
self-expandable stent for the popliteal segment, and (6) close
the puncture point with a vascular closure device since the
sheath is quite large (>6 Fr).Intraoperatively, steps 1 and 2
went easily. Under potentialized local anesthesia, a crossover
was performed through left contralateral common femoral
access. A 7Fr 45cm sheath was brought down to the right
common femoral artery. The initial angiogram (Fig.16.16a,
b) conrmed the long FP occlusion. Due to impossible
anterograde crossing, a retrograde access was performed
through the dorsalis pedal artery, and a V18 wire (Boston)
over a CXI support catheter (Cook) allowed intraluminal
recanalization (Fig.16.16c). The recanalization went so easily that it was decided not to use atherectomy and just perform a prolonged angioplasty (5 min) with a long 5 mm
Armada-35 (Abbott) balloon (Fig.16.16d, e). The result of
vessel preparation looked ne in the supercial femoral
artery part (Fig. 16.17a) but not in the popliteal part
(Fig. 16.17b), and another prolonged angioplasty with a
larger balloon (6mm in diameter) was decided (Fig.16.17c).
Completion angiography with two incidences demonstrated
Fig. 16.16 Case resolution. The initial angiogram (Fig.16.15a, b con-
rmed the long FP occlusion. Due to impossible anterograde crossing,
a retrograde access was performed through the dorsalis pedal artery and
a V18 wire (Boston) over a CXI support catheter (Cook) allowed intra-
luminal recanalization (Fig.16.15c). The recanalization went so easily
that it was decided not to use atherectomy and just perform a prolonged
angioplasty (5 min) with a long 5 mm Armada-35 (Abbott) balloon
(Fig.16.15d, e)
160
cd
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R. Coscas
a good result of the preparation without dissection or residual stenosis (Fig.16.18), so 6mm drug-coated balloons (In.
Pact, Medtronic) were inated for 3min to avoid restenosis.
Fig. 16.17 Case resolution.
The result of vessel
preparation looked ne in the
supercial femoral artery part
(Fig.16.16a) but not in the
popliteal part (Fig.16.16),
and another prolonged
angioplasty with a larger
balloon (6mm in diameter)
was decided (Fig.16.16c)
abc
No stent was necessary. A vascular closure device (Prostyle,
Abbott) was used, and the patient left the hospital the same
day with a pedal pulse.
ab
Fig. 16.18 Case resolution. Completion angiography with two incidences (a–d) demonstrated a good result of the preparation without dissection
or residual stenosis
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Percutaneous Revascularization
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oftheTibial Arteries
KonstantinosKatsanos
17
Case Presentation
A 76-year-old male patient presented to the outpatient vascular clinic and complained of rest pain of the left foot, worsening during bed rest. He had a past medical history of
drug-controlled hypertension and non-insulin dependent diabetes over the last 10years and had undergone two coronary
artery bypass grafts (CABG) 3 years ago because of signicant left main coronary artery disease. He was a past smoker
and was on a prescription of Clopidogrel 75mg once daily
(o.d.) and a statin 20mg once daily. He had had a vascular
diagnosis of <150meters intermittent claudication on the left
side over the last year and had been instructed to exercise
regularly. However, his symptoms deteriorated over the last
month and a diagnosis of critical limb ischemia (CLI) of the
left foot was made based also on a positive Buerger’s test and
pulseless foot at the level of the ankle. A color-Doppler ultrasound was urgently performed that showed patent left iliac
and femoropopliteal arteries with occasional <50% stenoses
and a three-vessel occlusion below the left knee. Given the
high Charlson Comorbidity Index and the absence of a suitable vein conduit, the patient was offered the option of endovascular revascularization of the left lower limb to relieve
foot ischemia.
Continued at page 169
bined with aortoiliac and/or femoropopliteal inow disease
and is the leading cause of critical limb ischemia (CLI) most
often related to old age, diabetes and renal insufciency [2].
In line revascularization to the foot remains the guidelinerecommended treatment to achieve relief of ischemic symptoms and promote wound healing. Compared with
femorodistal bypass surgery that may be technically challenging or not indicated because of underlying comorbidities
or absence of a suitable vein conduit, balloon angioplasty
and metal stenting of the tibial arteries have emerged as the
primary mode of treatment for safe, timely and less invasive
revascularization of the foot [3]. In the interest of prevention
of limb loss, various complex techniques of recanalization of
the small infrapopliteal and foot arteries have been developed and several dedicated balloons, stents and atherectomy
devices have been engineered with promising results [4].
Most importantly, transcatheter balloon angioplasty may
allow for recanalization of two or even three native arteries
to the foot, often in conjunction with pedal arch angioplasty,
and has been shown to achieve limb salvage rates that are
equivalent to bypass surgery despite lower patency rates and
more frequent re-interventions because of symptomatic
restenosis [5].
Background
Critical limb ischemia is one of the most challenging manifestations of systemic atherosclerosis with increasing worldwide prevalence alongside diabetes. CLI is associated with
signicant morbidity, mortality and healthcare costs because
of high rates of recurrent ischemia, hospitalization episodes,
and amputations [1]. Infrapopliteal arterial occlusive disease
may present either in isolated fashion or more often com-
K. Katsanos (*)
School of Medicine, Patras University Hospital, Rion, Greece
e-mail: katsanos@med.upatras.gr
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
G. Geroulakos et al. (eds.), Mastering Endovascular Techniques, https://doi.org/10.1007/978-3-031-42735-0_17
Indications forTreatment
Well-accepted indications for endovascular revascularization
of the tibial arteries include [1] Rest pain (Fontaine stage III,
Rutherford category 4), or [2] non-healing ulcer/gangrene
(Fontaine stage IV, Rutherford categories 5–6), or [3] a nonhealing ischemic ulcer following amputation or surgical
debridement of the foot with documented peripheral arterial
occlusive disease on ultrasound or angiographic imaging [3].
Balloon angioplasty of the anastomotic sites is also indicated
for the salvage of failing femorodistal bypass surgery based
on declining surveillance metrics. The procedure may be
contra-indicated in the case of a non-functional limb, limited
life expectancy, wet gangrene or sepsis mandating amputa-
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tion, absence of an identiable distal foot vessel and uncorrectable coagulopathy. In case of infected gangrene,
infrapopliteal revascularization is advocated shortly after
surgical foot debridement or minor amputation to prevent a
higher amputation level and promote wound healing. Overall,
the treatment plan for infrapopliteal arterial disease is individualized and often decided in the context of a multidisciplinary team meeting considering patient needs, surgical
risk, background comorbidities, anatomical complexity,
wound aftercare and need for further reconstruction or prosthetic rehabilitation of the lower limb [1, 3, 4].
Preoperative Preparation
Timing ofIntervention
CLI is typically characterized by a non-healing foot ulcer or
rest pain for more than 2weeks with an ankle pressure of less
than 40mmHg [6]. Timely revascularization of infrainguinal
and infrapopliteal arteries is therefore essential to avoid
superinfection, limit the extent of tissue loss and improve
functional prognosis of the whole limb. In line with cerebrovascular disease, ‘time is tissue’ and hence, ‘time to treatment’ is directly associated with the risk of limb loss and
time to wound healing [7]. It is advocated that endovascular
reconstruction of the tibial arteries is performed in an urgent
manner and generally within 2 weeks of admission to the
hospital.
Baseline Imaging
nostic or proper angioplasty procedures [8]. Planning and
success of tibial revascularization is heavily dependent on
the patency and quality of run-off arteries in the foot, as well
as the patency of the pedal arch. Hence, selective intraarterial angiography at the popliteal level may occasionally
be useful to decide the most appropriate distal target in conjunction with the angiosome theory and the geography and
extent of the wounds [9].
Patient Work-Up
Routine pre-interventional patient work-up includes a thorough past medical history and peripheral vascular examination including recording of ankle-brachial indices, presence
of dorsal and posterior tibial artery pulses, and often recording of TcPO2 or toe or skin pressures or other kind of perfusion monitoring as described later. Patients, who are often
diabetic, need to be assessed for the extent of ischemia, presence of infection and autonomic neuropathy [6]. In addition,
a thorough wound assessment in the presence of tissue loss
and surgical consultation in case of wet gangrenous sites is
recommended. The latest guidelines endorse the use of
Wounds, Ischemia, and foot Infection (WIfI) system for
staging of the severity of limb ischemia and prediction of the
risk of limb loss [10]. A full blood count, renal function
(eGFR), glucose, electrolytes, and coagulation prole are
mandatory prior to procedure and anticoagulant therapy
(coumadin or direct oral anticoagulants) need to be ceased
and/or bridged per local hospital policy and international
guidelines [11].
CLI is usually associated with multi-vessel, multi-level disease and Duplex ultrasound is often inadequate for preoperative imaging of the tibial arteries that suffer from
extensive calcications because of dialysis or diabetes.
Cross-sectional imaging of the peripheral arteries with noninvasive CT angiography (CTA) or time-resolved, contrastenhanced MR-angiography (CE-MRA) is recommended to
allow for mapping of the extent and anatomical complexity
of the disease and help with decision making in terms of
access site and target lesions/vessels [1, 3, 6]. CTA may be
hindered from renal insufciency and imaging conspicuity
may be compromised from vessel wall calcications. MRA
may offer superior quality in assessing run-off arteries of the
foot and the patency of the pedal arch. Non-contrast SSFP or
subtractive TSE techniques are also recommended for
patients with impaired renal function or on established
hemodialysis to avoid CIN and eliminate the risk of nephrogenic systemic brosis. Invasive intra-arterial Carbon dioxide imaging is often used instead of iodinated contrast to
reduce the risk of contrast-induced nephropathy during diag-
Best Medical Therapy
Most patients, unless urgently admitted or on a new CLI
diagnosis, are usually prescribed on best medical therapy
with a list of antihypertensive, beta-blocker, statin, and antiplatelet medications by the general practitioner or vascular
physician/cardiologist/angiologist to reduce the overall risk
of cardiovascular morbidity and mortality [1, 3]. Data on
pre- procedural antiplatelet therapy are not concrete, but
patients undergoing complex peripheral arterial procedures
like small artery tibial recanalization are routinely pre-loaded
with dual antiplatelet therapy 5days prior to the procedure or
receive a loading dose of 300–600mg Clopidogrel the same
day [3]. Antibiotic therapy should be continued in cases of
infected wounds/ulcers or after debridement or documented
gangrene, especially in the case of osteomyelitis. Emphasis
is required on patients with poor renal function that are at
risk of contrast-induced nephropathy and increased in-hospital morbidity. Generally, patients at risk of CIN (eGFR
<30 mL/min/1.73 m2) should receive intravenous saline
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0.9% 1mL/kg/h for several hours before and after contrast
medium administration or intravenous sodium bicarbonate
as an alternative, according to the ESUR guideline recommendations [12].
Endovascular Strategy andTechnique
Basic Toolkit andAccess
A standard endovascular kit for peripheral arterial balloon
angioplasty and stenting is necessary including microcatheter devices, low prole balloons and drug-eluting stents dedicated for the small infrapopliteal arteries as outlined below.
Antegrade ipsilateral common femoral artery access is recommended to improve negotiation of catheters and instruments and ultrasound guidance is essential for safe access,
along with potential distal puncture sites for retrograde techniques. Routinely, a 6–7 Fr 0.035″ guidewire-compatible
short vascular access sheath is introduced in the common
femoral artery, and a 4 Fr 0.018″ guidewire-compatible short
sheath is preferred should a second distal retrograde access is
obtained. Intravenous sedation (with a combination of midazolam and opiates—fentanyl or pethidine) is occasionally
required to control rest pain or painful debrided foot wounds.
Unfractionated heparin is administered through the sheath
(usually 3000–5000 IU or a weight-adjusted dosage) to
maintain an activated clotting time of around 200–250s [3].
cross particularly brotic or brocalcic infrapopliteal
lesions. Standard curved 4 Fr angiographic catheters, dedicated 0.018″ microcatheters or low-prole balloons catheters
are recommended to support steering and advancement of
the guidewires across the lesions. Rarely, distal re-entry
devices may be employed [13].
Retrograde Access andPlantar-Loop Technique
In case of a failed antegrade attempt to cross a complex infrapopliteal CTO, alternatively a retrograde access or the
plantar- loop technique may be employed. A 21 G micropuncture set or dedicated pedal access kit may be used to
access the distal posterior tibial or dorsalis pedis artery just
beneath the level of the medial or lateral malleolus respectively [14]. The distal peroneal artery is accessed above the
ankle level. For both cases, road-map uoroscopy or ultrasound guidance is used, or a combination thereof. Dedicated
0.018″ vascular sheaths are inserted for transpedal (like tran-
sradial) access. In case of the plantar-loop technique, 0.014″
hydrophilic-tipped guidewires are forwarded from the anterior to the posterior circulation of the foot (via the pedal
arch) and vice versa to allow for retrograde crossing of hard
infrapopliteal lesions.
Balloon Angioplasty
Lesion Crossing andGuidewires
The Global Limb Anatomic Staging System (GLASS) has
been proposed for the classication of anatomical complexity of the infrapopliteal arteries (stages I–III) in order to predict technical success and corresponding limb salvage rates
[1]. Depending on the extent of stenoses or occlusions, the
presence of intimal or medial calcications and the condition
of distal run-off foot arteries, straight or angled 0.014″ or
0.018″ guidewires with various tip properties may be used
[3]. Hydrophilic-tipped guidewires are routinely used to
negotiate diffuse stenoses, whereas dedicated guidewires
with a variable tip weight and conguration are employed to
cross chronic total occlusions (CTOs). Infrapopliteal CTOs
are encountered in up to 50% of the CLI cases and may be
challenging to treat. In case of tibial CTOs, the preferred
technique of recanalization is intraluminal instead of subintimal dissection that often fails. Should subintimal tracking is
attempted, care is needed not to inadvertently dissect the
healthy target and extend the re-entry site too distally thereby
compromising potential sites of bypass surgery or retrograde
access. For the latter purposes, the guidewire tip may be
looped (Bolia or knunckle subintimal technique) to help
For the purposes of optimal mechanical effect and avoidance
of excessive barotrauma, it is recommended that the proximal tibial arteries are dilated up to 3.5mm, the middle third
of the tibial arteries up to 3.0 mm, and the distal third at
ankle level including the dorsalis pedis artery and proximal
plantar arteries up to 2.5mm [3]. The distal peroneal artery
and pedal arch are usually treated with 2.0mm balloon catheters. Low-prole 0.014″ balloon catheters with a transitionless tip and variable lengths (usually, 80–220mm in length)
are preferred with a 30-s to 2-min balloon ination period to
reduce risk of dissection. Kissing balloon angioplasty with
3.0–3.5mm balloons is applied in case of bifurcation lesions
of the origin of the anterior tibial artery or of the tibioperoneal bifurcation. The SAFARI balloon technique with undersized balloon diameters may be used in complex calcied
lesions with combined antegrade and retrograde access if
spontaneous true lumen re-entry fails. Liberal use of selective nitrates (300–500 mg) or papaverine (20–40 mg) is
advised to reduce frequency and severity of vasospasm. In
case of retrograde arterial punctures, hemostasis is accomplished by prolonged low-pressure balloon angioplasty
across the puncture sites. Multivessel-revascularization is
well established and associated with improved limb salvage
and wound healing outcomes [15]; however, the decision to
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recanalize more than one tibial arteries is patient-specic and
depends on a risk/benet analysis of patient age, renal function, wound assessment and arch patency. The theory of
angiosome-directed or wound-directed revascularisation
supports the reduction of time to wound healing, which is
important for limb salvage in patients with diabetes [16].
Drug-Coated Balloons
Numerous paclitaxel-coated balloons with different drug
densities and formulations have been shown to reduce the
risk of restenosis in the femoropopliteal artery. However, a
risk of long-term all-cause mortality has been raised, as well
as a risk of higher rates of major amputations when
paclitaxel- coated balloons are applied in the infrainguinal
arteries [17, 18]. Several RCTs have investigated the efcacy of paclitaxel- coated balloon technologies in the infrapopliteal arteries, but have broadly failed to show convincing
evidence of improved patency or wound healing/limb salvage outcomes [4]. Contrary to cytotoxic paclitaxel, the
delivery of cytostatic sirolimus has been proposed in parallel as an alternative drug-candidate for peripheral drugcoated balloons. Still, there is lack of randomized data to
support the use of sirolimus-coated balloons in the infrapopliteal arteries. Hence, the application of drug-coated balloons in the infrapopliteal arteries remains controversial and
for the time being should be limited to well-designed clinical research studies only.
failed to meet its primary effectiveness and safety endpoints
(Hans Over Hagen etal. oral presentation CIRSE 2022).
Debulking Atherectomy
Transcatheter atherectomy allows for debulking of peripheral chronic total occlusions, especially of those that are predominantly brotic or brocalcic and may improve acute
procedural success by reducing angioplasty barotrauma that
is inherently associated with the mechanical plaque disruption and displacement within the arterial wall during vessel
dilatation [23]. Transcatheter atherectomy achieves atherosclerotic plaque clearance by means of directional plaque
excision or rotational plaque removal or even laser plaque
ablation. It has been shown that debulking atherectomy
improves acute luminal gain and reduces the rates of plaque
recoil or dissection mandating permanent metal stenting. It
has also been argued that atherectomy may disrupt the calcium barrier and optimize drug transfer and delivery should
drug-coated balloons are applied [24]. Nonetheless, there is
still very limited evidence for the use of infrapopliteal atherectomy devices. Because of the small vessel size, the devices
with rotational plaque excision properties are favored if
deemed necessary. However, caution is warranted because of
the presumed higher rates of distal embolization and complications [3, 25].
Deep Venous Arterialization
Drug-Eluting Stents
In line with the paradigm shift of care in percutaneous coronary interventions, balloon-expandable drug-eluting stents
(DES) have been introduced to inhibit vascular restenosis of
the infrapopliteal arteries and are associated with signicantly improved clinical outcomes [4]. After positive initial
experience from several cohort studies, a few multicenter
randomized clinical trials (RCTs) investigating infrapopliteal sirolimus- or everolimus-eluting stents have shown
improved patency and consequently reduction of rates of reinterventions and major amputations with positive wound
healing effects as well [4, 19–21]. However, olimus-DES are
limited by their short length and applied only for bail-out or
for denitive treatment of focal to intermediate-length proximal infrapopliteal arterial lesions. Polymer-compound
absorbable everolimus-eluting stents have also been reported
in the tibial arteries with promising results [22]. On the contrary, a recent randomized study of a longer self-expanding
paclitaxel-eluting stent in the infrapopliteal arteries for CLI
In case of absence of target run-off foot arteries, especially in
cases with extensive calcic microangiopathy (aka nonoption cases), deep venous arterialization (DVA) has emerged
as a last resort procedure with promising initial results in
patients with an otherwise dismal prognosis [26]. The DVA
technique aims to create a percutaneous distal shunt between
a tibial artery—most often the posterior tibial artery, and a
deep venous channel—one of the two posterior tibial veins,
respectively—to progressively arterialize a deep vein of the
limb that will serve as an outow conduit and provide adequate distal foot oxygenation while promoting microvascular arteriogenesis of the foot [27].
Perfusion Monitoring
Contrary to traditional contrast angiography that allows for
real-time assessment of vascular anatomy and morphology
and thereby guides peripheral endovascular procedures, several non-invasive modalities have been proposed for real-
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time functional evaluation of the microcirculatory
hemodynamics and blood supply to the foot. Real-time
quantication of foot perfusion during treatment is feasible
with 2D-perfusion angiography or indocyanine green (ICG)
uorescence angiography. Alternatively, diffuse speckle contrast analysis and near-infrared spectroscopy (aka NIRS)
have been proposed for probing of deep-tissue perfusion and
oxygenation, respectively [3]. There is still limited evidence
about the utility and benet of the aforementioned noninvasive methods for functional assessment of the perfusion
status of the foot, but intuitively they may help quantify
incremental gains in blood supply following infrapopliteal
angioplasty and potentially provide novel targets of therapy
and predictors limb salvage [28].
Anticipated Complications
Most frequent complications (<10%) include access-siterelated complications (vessel occlusion, puncture site hematomas, false aneurysms, and access site or retroperitoneal
bleeding) and treatment-site related ones (spasm, thrombotic
occlusion, and ow-limiting dissection). Application of femoral artery closure devices (e.g. Starclose, Angioseal, etc.) is
highly recommended to reduce the risk of access complications and expedite patient ambulation and procedural
throughput in the cathlab. Liberal use of selective nitroglycerin or papaverine is recommended to treat spasm and
improve microcirculatory run-off. Rarely, uncontrolled vessel perforation or development of high-ow arteriovenous
stula following angioplasty barotrauma may mandate coil
embolization or covered stent placement, respectively. The
risk of procedure-related major amputation is 1–3%.
tion, patients are routinely followed up with regular outpatient appointments for ongoing assessment of wound
healing. Adjunctive surgical debridement or minor amputations may be carried out shortly after a successful tibial
angioplasty.
Case Presentation
Continued from page 165
Under local anesthetic and ultrasound guidance, antegrade access in the left femoral artery was obtained and a 6
Fr sheath was inserted and 5000IU heparin were administered. A 4 Fr angled angiographic catheter was advanced to
the popliteal level and selective angiography of the left calf
and foot was performed. The angiogram identied a shortsegment occlusion of the tibioperoneal trunk with reconstitution of the proximal peroneal artery and long-segment
occlusion of the whole left anterior and posterior tibial artery.
Distal perforating peroneal branches communicated to a
poorly opacied dorsalis pedis artery providing the main
run-off artery supplying the forefoot (Fig.17.1). The decision was made on table to attempt an angioplasty of the tibioperoneal artery followed by the anterior tibial artery (ATA)
to achieve in line ow to the foot.
Patient Follow-Up
An “endovascular-rst” approach is predominantly advocated for the infrapopliteal territory based on a lower procedural risk and shorter recovery time. Recovery time from
endovascular procedures treating CLI is only 1–2 days and
in-hospital morbidity, and mortality is signicantly lower
than bypass surgery. In addition, most endovascular procedures, including revascularization of the tibial arteries, may
be conducted on an outpatient level [3, 6]. Patients are routinely prescribed on short-term dual antiplatelet therapy
following revascularization of the tibial arteries, usually for
a period of 6weeks–6months. Dual antiplatelet therapy, or
a combination of low-dose rivaroxaban and aspirin have
been both shown to reduce major amputations following
peripheral procedures for limb salvage [29, 30]. In addi-
Fig. 17.1 Selective antegrade contrast angiography (a) of the proximal
tibial arteries demonstrating a tibioperoneal CTO and long-segment
anterior and posterior tibial artery occlusions and (b) of the distal tibial
arteries and foot (anterior projection) that shows reconstitution of the
dorsalis pedis artery through perforating peroneal branches
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