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6 Arterial Revascularization
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6.1.2.1 Conclusion
Successful aortoiliac revascularization in AIOD
is vital for achieving limb salvage. Familiarity
with various endovascular techniques and proper
execution can translate to improved clinical outcomes. Advances in endovascular technologies
and improved prociency continue to provide
alternatives to open surgery in TASC C and D
lesions, especially in poor open surgical
candidates.
6.1.3 When toConsider
Aortobifemoral andFemoroFemoral Bypass?
DanielK.Han
6.1.3.1 Aortobifemoral Bypass
Endovascular interventions for aortoiliac occlusive disease (AIOD) have good patency rates, and
as such, the number for aortobifemoral bypasses
(ABFs) that are being performed today has substantially decreased, as they are a more invasive
procedure with higher rates of perioperative morbidity and mortality.
• For patients with limited areas of disease
(short-segment iliac or aortic disease),
angioplasty with stenting can lead to high
technical success and long-term patency.
• Especially when considering that patients
with isolated AIOD often present with claudication, an ABF that requires an open laparotomy/retroperitoneal incision can be considered
overly aggressive.
For patients with critical limb ischemia or signicant life-limiting claudication, an ABF has
excellent long-term patency and can provide a
very durable result. In well-selected patients,
ABF can have a mortality rate as low as 2% and
a 10-year patency rate of around 75%.
Consideration for ABF should include the
following:
• Anatomic Considerations
– Extent of Disease.
ABF should be limited to those patients
with extensive AIOD. While TASC II
guidelines have made suggestions for
what “extensive” means, in today’s
practice, several lesions that are considered TASC C and D can still be effectively treated using endovascular
options. Lesions that are challenging for
endovascular intervention include the
following:
• Small caliber iliac arteries.
• Extensive calcication of the iliac
arteries.
• Long-segment CTO of the external
iliac, common iliac, and distal aorta.
• Prior failed endovascular
intervention.
• Patients with ulcerated plaques at
high risk for distal embolization.
– Inow.
ABF is typically considered for patients
who have a clampable portion of the
infrarenal aorta.
If the common iliac artery and internal
iliac arteries are patent, the surgeon may
consider performing an end-to-side
anastomosis to maintain antegrade ow
into the pelvic circulation.
If the common iliac arteries or the internal iliac arteries are occluded, an endto- end anastomosis allows for better
sitting of the bypass graft in the
retroperitoneum.
– Outow.
The common femoral artery is the most
common target for an ABF.
While disease in the distal supercial
femoral and popliteal arteries may be
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I. Ali et al.
acceptable, the profunda is important
for the long-term patency of the ABF.
• As such, many surgeons will perform
an extended profundaplasty at the
time of the distal anastomosis to
ensure adequate outow.
• The ability to reconstruct a diseased
profunda artery at the time of revascularization is another benet of
ABF over endovascular
interventions.
– Patient Factors.
Medical comorbidities limiting general
anesthesia.
Age and life expectancy.
Prior abdominal surgery: The loss of
normal surgical planes from prior surgery can lead to longer operative times
and increased complication rates.
Body habitus: In addition to providing
technical challenges from body habitus,
obese patients have signicantly
increased wound complication rates.
Given that most ABFs are performed
using a bifurcated prosthetic conduit, an
infection of the prosthetic graft can be
catastrophic.
Patient preference: A thorough discussion of risks and benets of all revascularization approaches should be had
prior to selecting ABF as the treatment
of choice.
Take Home: ABF may be the preferred revascularization option in good risk younger patients
with extensive AIOD.
6.1.3.2 Femoro-Femoral Bypass
A fem-fem bypass is not as durable as an ABF
and reported that 5-year patency rates range
around 60–70%. With the increasing experience
and success of endovascular revascularization for
AIOD, the number of fem–fem bypasses performed for PAD has decreased in recent times. In
fact, the most common indication for a fem–fem
bypass today may be in the setting of an endovascular aortic aneurysm repair with an aorto-uniiliac device.
However, the common femoral arteries are
readily accessible with a surgical cutdown, and a
fem–fem bypass can be performed with general,
regional, or even local anesthesia. As such, a
fem–fem bypass is an important option in the
armamentarium of a vascular surgeon for extraanatomic iliac artery reconstruction across many
different pathologies.
Similar to the discussion above for ABF, the
decision to perform a fem–fem bypass for peripheral arterial disease must take into account the
following considerations:
• Anatomic Considerations.
– A fem–fem bypass is considered for
patients with unilateral iliac artery occlusive disease. Similar lesions may provide a
challenge for endovascular intervention:
Small caliber iliac arteries.
Extensive calcication of the iliac
arteries.
Long-segment CTO of the external iliac
and/or common iliac arteries.
Prior failed endovascular intervention.
Patients with ulcerated plaques at high
risk of distal embolization.
• Inow and Outow.
– The success of fem–fem bypass depends
on the presence of a patent aorta and single
iliac artery to serve as the inow vessel for
both lower extremities and free of hemodynamically signicant lesions.
– Similarly, the donor common femoral
artery needs to be free of disease. In
cases of signicant CFA disease, a concomitant endarterectomy can be performed. The same holds true for the
recipient CFA.
Similar to an ABF, the profunda artery is
important for patency of a fem–fem
bypass. In cases of signicant profunda
origin disease, an extended profundaplasty can be performed at the time of
the fem–fem bypass.
The impact of distal SFA disease on the
patency of a fem–fem bypass is unclear
in the setting of a patent profunda
artery.
6 Arterial Revascularization
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The nal thing to consider is that a fem–fem
bypass can limit access options for future lower
extremity interventions. While the bypass graft
can be accessed directly, repeat access of a
prosthetic bypass can lead to pseudoaneurysms
or graft infection, which can lead to suboptimal outcomes and signicant morbidity in a
patient.
6.2 When toChoose Alternate
Access
6.2.1 Pedal Approach
BlakeP.Parsons and JimG.Melton
6.2.1.1 Why Choose Pedal Access
forPeripheral Arterial
Intervention?
There are many benets when performing peripheral intervention from a primary pedal approach.
Benets include the following:
1. Decreased risk of bleeding/access
complications.
(a) Common femoral artery access, espe-
cially in high BMI patients, can increase
the risk of bleeding complications. Tibial
artery access signicantly lowers access
bleeding/vascular risk. Tibial artery
access can safely be performed with less
than 0.5% risk of major vascular injury,
similar to radial artery access.
2. Decrease in radiation exposure to you and the
patient.
(a) Tibial artery access limits the need for
increased uoroscopy time and dose over
the pelvis as associated with traditional up
and over access from a contralateral common femoral artery approach. This can
contribute to a signicant reduction in
radiation dose to the patient and physician. This also equates to a signicant
reduction in procedure time.
3. Decrease in contrast utilization and increase
ability to cross difcult atherosclerotic
lesions.
(a) There is increased ability to gain access
through difcult atherosclerotic lesions
secondary to increased pushability and
access of the soft cap of atherosclerotic
plaque. This decreases the need for mapping angiography. Utilization of intravascular ultrasound can also signicantly
decrease the need for angiography. Cases
can routinely be performed with less than
40cc of contrast.
Clinical Evaluation
There is no signicant change in the clinical evaluation of peripheral arterial disease patients when
comparing pedal approach for access versus traditional common femoral artery access.
Evaluation is still focused on a good clinical
examination that is supplemented with noninvasive vascular testing that was described in previous chapters.
• However, evaluation of the tibial arteries can
be difcult with noninvasive testing especially
if performed by technicians who are not comfortable with its evaluation and patients with
medial calcinosis.
• Clinical evaluation with palpation of the
abdominal aorta and bilateral common femoral arteries, supplemented with handheld
Doppler interrogation of the popliteal artery,
proximal and distal anterior tibial artery, proximal and distal dorsalis pedis artery, distal
peroneal artery, and distal posterior tibial
arteries (Fig.6.10) are crucial in determining
arterial options for access and likely distribution of patient’s disease.
• Doppler arterial examination enables not only
determination of access point patency but
helps determine the likelihood of a proximal
lesion given the audible sound of monophasic,
biphasic, or triphasic signal. All aspects of the
physical examination and clinical evaluation
will determine whether a primary pedal
approach is appropriate.
Access
The use of ultrasound is key to successful access
into the tibial arteries. Ultrasound is carefully uti-
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I. Ali et al.
abc
Fig. 6.10 Typical location for hand help Doppler interrogation of (a) anterior tibial artery. (b) Posterior tibial artery.
(c) Peroneal artery
lized to evaluate patency of both the anterior tibial and posterior tibial arteries.
• Upon rst becoming comfortable with pedal
access, it is preferred to attempt on patients
with patent two- or three-vessel runoff.
• Determining access of the tibial artery should
consider the angiosome of the underlying
pathology and vessel size and degree of
atherosclerosis.
• Access can be performed into an occluded
tibial artery with attempt to recanalize, therefore decreasing the possibility of vascular
injury and/or injury to single patent tibial
artery.
• Upon becoming more comfortable with tibial
artery approach, access can be gained on
patients with single-vessel tibial artery runoff
for the potential of increased successful
revascularization.
Evaluation of the tibial artery should be per-
formed within 4–6 cm of the ankle joint
(Fig. 6.11). Accessing the tibial arteries more
proximally will be limited secondary to tibial
artery depth/visualization.
Fig. 6.11 Access into the left anterior tibial artery with
5/4 Fr slender sheath and posterior tibial artery with 6/5 Fr
sheath
ab
6 Arterial Revascularization
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Fig. 6.12 (a) Ultrasound evaluation of tibial artery (solid
white arrow) with paired tibial veins (open white arrows).
(b) Ultrasound evaluation of tibial artery with mild com-
• There is also increased risk of bleeding with
access in a more proximal location. Ultrasound
evaluation demonstrates a tibial artery with a
pair of tibial veins (Fig.6.12).
pression demonstrating compression of tibial veins (open
white arrows) with patency of tibial artery (solid white
arrow)
advanced intra-arterially with subsequent
arterial runoff performed for visualization of
arterial runoff below the ankle and evaluation
of the pedal loop (Fig.6.13).
• There is increased success in access and
decreased risk of injury with tibial arteries
2mm or larger.
• The overlying skin is anesthetized with 1%
Slender sheaths are preferred for tibial artery
access. Typical sheaths utilized are thinnedwalled 4/5 Fr and 5/6 Fr.
lidocaine, and ultrasound-guided access is
made with direct ultrasound visualization of
the needle tip intraluminal. Access using a
4cm 21-gauge micropuncture needle is preferred. A 0.018″ access wire should then successfully be advanced intraluminally under
ultrasound and uoroscopy. Angiography can
then be performed through vascular sheath or
transitional dilator.
• If there is concern for small vessel disease, the
inner dilator of a 3 Fr introducer sheath can be
• 6/7 Fr sheaths can be placed when needed for
patients with minimal calcication and vessel
diameter greater than 3.5mm.
• Braided sheaths are preferred given some
issues with kinking at the access site.
• A cocktail is administered consisting of heparin and nitroglycerin.
– Typical cocktail administered includes
3000units heparin and 200 mcg nitroglycerin through the indwelling sheath.
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Fig. 6.13 Digital subtraction angiography of left foot
performed through posterior tibial artery access and
placement of the inner dilator of 3F access sheath
– Heparin is then dosed through peripheral
IV on a weight-based scale per the performing physician.
6.2.1.2 Primary Pedal Intervention
Upon review of patient’s physical examination
and retrograde angiogram, physician should have
a good idea of the disease location.
• If intervention will likely be warranted in the
aortoiliac distribution or femoral–popliteal
distribution, a 5/6 Fr thin-walled sheath should
be utilized.
• If patient’s disease is small vessel and involving primarily a tibial artery distribution, intervention can be performed through a 4/5 Fr
thin-walled sheath. Upon evaluation from a
retrograde angiogram from your tibial artery
access, guidewires and crossing catheters are
advanced centrally. Typical working wires are
I. Ali et al.
similar to wires utilized in a standard antegrade fashion.
A primary pedal approach can routinely be
utilized for interventions of the iliac arteries,
supercial femoral artery/popliteal artery, and
tibial arteries. By using a primary pedal approach,
multilevel arterial inventions can be performed in
a single intervention.
• Once retrograde angiography and evaluation
of the tibial arteries have been performed, a
0.014″ or 0.018″ guidewire is typically
advanced centrally.
• If chronic total occlusion is demonstrated
along the femoral–popliteal or iliac artery
distribution, standard crossing techniques
can be utilized as from an antegrade
approach.
• A 0.035″ catheter can be advanced into the
distal abdominal aorta to allow pelvic angiog-
raphy. The catheter can then be retracted into
the iliac arteries with angiography of the
intended leg and visualization of peripheral
arterial disease.
• The use of intravascular ultrasound is highly
recommended for evaluation of plaque mor-
phology, subintimal versus intraluminal loca-
tion, dissection, and precise intervention to
disease segments only.
– By utilizing intravascular ultrasound, this
will signicantly decrease your total contrast utilization and radiation exposure to
you and the patient.
Re-entry devices such as Pioneer (Philips) and
Outback (Medtronic) can be used from a retrograde approach. All atherectomy devices that
accommodate a 6 Fr vascular sheath can be utilized. These include rotational, orbital, directional, and laser and lithotripsy options. If stent
placement is warranted within the femoral–popliteal territory, all intra-arterial stents that accommodate a 6 Fr vascular sheath can be utilized.
• By coming from a retropedal approach, pre-
cise SFA stent placement at the femoral bifur-
cation can be easily accomplished, minimizing
6 Arterial Revascularization
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risk of compromise to the profunda femoris
artery.
• Stents will need to be placed from proximal to
distal fashion so that there is no risk of passing
a secondary stent through an initial stent causing stent migration and/or inability to advance
the secondary stent centrally.
• If iliac artery intervention is warranted it
should be performed initially, prior to intervention in the femoral/popliteal or tibial arterial territory. Iliac artery intervention can be
safely performed from a tibial artery access.
However, all precautions and preparation
should be taken if urgent femoral artery access is
needed and/or cover stent placement is warranted
for underlying vascular injury.
• The largest balloon-expandable stent that can
be deployed through a 6 Fr sheath is a 9mm x
28mm Herculink (Abbott). However, 8mm
balloon-expandable stents are routinely utilized and can be overdistended to 9mm when
warranted.
• If iliac arteries are larger in size warranting
larger stent sizes, then common femoral
artery access may be warranted in a staged
fashion.
• External iliac artery disease can be easily
treated with self-expanding nitinol stents up to
12 mm through a 6 Fr vascular sheath.
Angioplasty balloons on 0.018 platforms such
as Sterling (Boston Scientic) will allow you
utilize up to 10mm diameter balloon through
a 6 Fr sheath.
• Angioplasty balloons on 0.035 platforms will
allow treatment up to 12mm through a 6 Fr
vascular sheath. However, removal of larger
balloons can be tight through tibial arteries
and 5/6 Fr thin-walled sheaths.
Interventions on the tibial arteries and the
pedal loop can be performed from a retropedal
approach.
• An up and over-approach can be utilized from
the anterior tibial artery into the peroneal
artery or posterior tibial artery and posterior
tibial artery access into the anterior tibial
artery.
• A modied 4 Fr SOS Omni Select catheter or
90-degree Berenstein (Fig.6.14) can be used
to easily cannulate the intended tibial artery.
• 0.018″ and 0.014″ microwires are preferred
for below-knee tibial artery intervention.
• 90 cm crossing catheters such as Rubicon
(Boston Scientic) or Quick-Cross (Philips)
can be used to provide ample support and gain
access through dense calcication within the
distal tibial arteries and into the forefoot/pedal
loop.
• Atherectomy devices, such as Rotablator
(Boston Scientic), Excimer Laser (Phillips),
1.5 mm Phoenix (Philips), and Orbital
Diamondback (CSI) can be used in the tibial
arteries from up and over-approach.
Angioplasty is performed from 0.014″ and
0.018″ balloon platforms, and 90 cm length
balloon shafts are preferred for ease of use.
Tibial artery stent placement can be performed
if warranted with a variety of coronary and
dedicated peripheral arterial stents.
Postoperative Care
If there is concern for arterial spasm, nitroglycerin can be administered prior to removal of the
tibial artery sheath.
• The vascular sheath should be removed with
relative light to moderate traction. Hemostasis
can be achieved using manual pressure and or
banding.
• While pressure is being applied to the access
site, periodic interrogation with handheld arterial Doppler is recommended on the distal
tibial arteries in comparison with preoperative
evaluation.
• Manual pressure is typically performed for
15–20min. One of the postoperative benets
of tibial artery access is that the patient can
immediately sit up in postoperative recovery
and eat and drink once appropriately recovered from sedation.
• After hemostasis has been achieved, the
patient will be evaluated for 20min followed
by the patient being positioned on the edge of
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ab
cd
I. Ali et al.
Fig. 6.14 (a) 4 Fr SOS Omni Select catheter. (b)
Modied 4 Fr SOS Omni Select catheter with cut made at
descending portion. (c) 4 Fr 90° Berenstein catheter (d)
the bed with leg in a dependent position for
another 20 min. If there is no concern for
bleeding/hematoma, the patient is then
walked to ensure adequate hemostasis prior to
discharge.
Modied 4 Fr 90° Berenstein catheter with cut made
1–2mm from distal tip
tine common femoral artery access procedures.
During follow-up clinical visitation, the tibial
arteries, specically the access artery, should be
evaluated with handheld arterial Doppler distal
to site of access to ensure patency. Arterial
duplex ultrasound can also be performed if
Postoperative care with antiplatelet therapy
needed.
and clinical evaluation is unchanged from rou-
6 Arterial Revascularization
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Postoperative Complications
Inability to remove a tibial artery access sheath
secondary to arterial spasm is extremely rare.
However, administration of nitroglycerin and/or
verapamil through the tibial artery sheath and
topical nitroglycerin can be performed with light
continuous manual traction.
• If access into a single tibial artery runoff was
performed, there may be issues with
vasospasm/small periarterial hematoma and
decreased perfusion to the foot.
• Typically, this will resolve without any intervention over the next 10–15min as vasospasm
resolves.
• If there is continued concern, topical nitroglycerin paste can be placed over the access
artery and placing the lower leg and foot in a
warm blanket.
• If ischemia persists and there is concern for
further damage, repeat angiography from an
antegrade approach and potential angioplasty
across the access site may be warranted.
Approximately 30% of patients will have
some mild postoperative soreness within the area
of access, which will typically resolve over the
next 3–4days.
• Postoperative pain is most commonly secondary to small hematoma formation along the
neurovascular bundle. The risk of major vascular injury is less than 1%.
6.2.1.3 Use ofExtra-Vascular
Ultrasound (EVUS) forPedal
Access andGuiding Therapy
AbigailMize, JihadA.Mustapha,
and FadiA.Saab
The use of ultrasound has historically been used
for diagnostic evaluation of arterial disease in the
lower extremities, in addition to a multitude of
other diseases throughout the body.
Implementation of the modality for interventional procedures to directly visualize vascular
structures provides additional safety and information to promote better outcomes for patients
with cardiac and vascular disease. To standardize
the approach of treating chronic total occlusions
(CTO), we will describe multiple techniques for
the utilization of ultrasound within the interventional suite, referred to as extra-vascular ultrasound (EVUS). EVUS is used for safe access of
tibial arteries, crossing CTOs, treating lesions,
and placing devices within vessels. These techniques require good understanding of how the
vessels and devices appear under ultrasound.
This section focuses on the use of EVUS to dene
CTO parameters and how to utilize EVUS to aid
in crossing these lesions.
Introduction
The use of ultrasound for interventional procedures was a natural evolution of the current technology and has been established as a time-honored
tool that decreases rates of complication and
increases accuracy [22–26].
• Patients with CLI can require an average of
1.9–2.4 procedures each to achieve complete
revascularization [27]. All these factors expose
patients to higher rates of complications that
may offset the benet achieved from
revascularization.
• Utilization of ultrasound to obtain femoral
access for revascularization procedures has
been shown to decrease the rate of complications and improve accuracy [26]. Due to disease complexity and comorbidities
surrounding CLI patients, the next step in
ultrasound utilization is to incorporate it into
treatment strategy.
• The term extra-vascular ultrasound (EVUS)
refers to the use of transcutaneous ultrasound
imaging to visualize vascular structures and
equipment during the interventional procedure. The modality provides live feedback for
the operator to plan and adjust their treatment
plan.
This chapter will provide the vascular inter-
ventionalist with essential information required
to incorporate EVUS into their practice. Terms
described here are new and reect the novelty of
the concept. The authors believe the utilization of
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I. Ali et al.
EVUS in revascularization of patients with CLI
and PVD will be essential as our patient population becomes older and more complex.
Ultrasonic Features ofArteries
To understand how to use EVUS to deliver therapy, the operator must develop a clear understanding of how these vessels appear under
ultrasound. Traditionally, interventionalists
depend on angiography to dene the vascular
lumen. This has pushed a lot of operators to
describe imaging obtained via angiography as
“luminograms,” meaning the contrast denes the
inner borders of the lumen. Depending on the
location of the structure of interest, different
probes with different frequencies are utilized to
obtain the best image resolution possible.
• Larger vessels with greater than 3cm depth,
such as common femoral, supercial femoral,
and popliteal arteries, are imaged with a standard vascular linear ultrasound probe, with
frequencies ranging from 9 to 12MHz.
• Smaller supercial arteries, such distal tibial
and pedal arteries, are imaged with a higher
resolution vascular ultrasound probe, sometimes referred to as a “hockey stick” probe,
with frequencies ranging from 15 to 20MHz.
Varying frequencies of the ultrasound probes
depend on system manufacturer.
Ultrasound images are displayed on the screen
based on how quickly sound waves reect off
structures and return to the probe. Soft or uid-
lled structures display as dark or black on the
screen with more dense or calcied structures
displayed as bright white [28]. This concept
directly correlates to the visualization of the
artery wall layers on EVUS.
• The intimal layer of the artery is comprised
of the endothelial lining of the inner lumen
and appears as a thin bright white line on
EVUS.
• The medial layer is made up of smooth muscle
cells with heavy blood saturation, creating a
dark echolucent appearance.
• The collagenous adventitia appears as a mixed
echogenic outer later just beyond the dark
adventitia.
• Lower extremity arteries can have plaque formation across the three vascular layers, and
EVUS can be used to clearly dene plaque
position to inuence treatment decisionmaking and device placement (Fig.6.15).
EVUS forPedal Access
When utilizing EVUS for tibial artery access, the
vessels can be identied in a short-axis (transverse) view. The distal posterior tibial artery is
best identied just posterior to the medial malleolus and the anterior tibial artery is best identied
in the top of the ankle. Choosing the best access
point depends on the location of treatment
required.
• Tibial access should be obtained in the distal
third of the calf, approximately 3–4 nger
a b
Fig. 6.15 (a, b) Long- and short-axis extra-vascular ultrasound (EVUS) image of a tibial artery with denition of all
three arterial walls
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