Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3609_Библиотеки_им_академика_М_И_Перельмана

Infrapopliteal arterial and pedal arch steno-occlusive disease commonly affects subjects with diabetes leading to progres­sive deterioration of foot perfusion and eventually to tissue loss with or without gangrene dened as chronic limb­threatening ischemia (CLTI), which without prompt revascu­larization will eventually lead to limb loss and increased 1-year mortality risk [1]. Notably, CLTI patients demonstrate signicantly higher mortality rates compared to those with

is performed after descending the anterior or posterior tibial artery and navigating the guidewire across the pedal-plantar loop with or without the “plantar-loop” technique (e.g., ret­rograde recanalization of the anterior tibial after descending the posterior tibial and across the arch, or vice versa). The uoroscopic projections during pedal arch navigation include both the ipsilateral cranial-antero-posterior (image intensi­er parallel to the foot dorsum to allow imagining of the rst metatarsal space) and the contra-lateral oblique (“Charlie Chaplin” projection) for the visualization of the connection dorsalis pedis-deep perforating artery-pedal arch, and the bifurcation of the common plantar artery [15]. Prolonged, 3–6 frames per sec, selective DSA imaging, after nitroglyc­erin administration, is recommended for the accurate visual­ization of collateral network and target vessels and to minimize motion artifact. Dedicated infrapopliteal angled hydrophilic guidewires 0.014′ in diameter and 300mm in length are recommended for steerability during arch naviga­tion, supported by 2–2.5mm infrapopliteal low-prole bal­loons or dedicated 0.014″ microcatheter systems, which also enable selective contrast injection and roadmap use to guide arch crossing, avoiding side-branches. Of note, straight guidewires can also be used, depending on the anatomy, which can also be bended accordingly to allow “individual­ized” arch navigation. Support catheters measuring 0.018″ can be used for initial CTO crossing as this enables easier guidewire exchange and better selective angiographic imag­ing. Low-weight CTO 0.014′ or 0.018″ hydrophilic guide­wires can also be used for initial access within the occlusion, subsequently exchanged with normal-weight guidewires for around the arch navigation. Notably, subintimal recanaliza­tion of the entire pedal arch is not indicated at it would result in occlusion of the digital arteries, resulting in aggravating ischemia. Therefore, guidewire manipulation must be gentle, preferably using torque movements and gentle pressure for advancement, rather than strong pushing. In cases of ante­grade intraluminal recanalization failure, an additional ultrasound- guided retrograde pedal puncture and retrograde lesion crossing with the SAFARI technique can be attempted, using dedicated pedal access or micropuncture sets [16]. Nominal pressure, prolonged 2–4 min ination is recom­mended to achieve maximum luminal gain and minimize dissections. Small 1.5–2mm diameter short-length (20mm) balloon catheters can be used for initial crossing and dilation of hard atherosclerotic lesions, subsequently upsized accord­ingly. Finally, if lesion crossing with a balloon is not feasi­ble, usually due to hard calcied lesions, orbital atherectomy could be considered, by analogy to coronary lesions. The use of metallic stents is not recommended due to fracture and deformation issues correlated with vessel occlusion and amputation, while the use of paclitaxel-coated balloons is not supported by evidence and safety issues have also been raised [17–19].