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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3823_Библиотеки_им_академика_М_И_Перельмана
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Figure 12.1 Lateral view of the ankle shows the distal
AT artery and PT artery. The dorsalis pedis artery is a
continuation of the AT artery. The PT artery bifurcates
into the lateral plantar artery and medial plantar artery.
Source: [6] Higashimori et al. (2017), Reproduced from IntechOpen.
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Figure 12.2 The anterior circulation consists of dorsalis
pedis artery, lateral tarsal artery, and arcuate artery.
Source: [6] Higashimori et al. (2017), Reproduced from IntechOpen.
The pedal arch is the arterial connection between the
anterior and posterior circulations of the foot in which
the dorsalis pedis and lateral plantar arteries connect via
the deep plantar. The pedal arch can have several
anatomic variations which are clinically relevant to
wound healing (Figure 12.4) [7, 8]. A complete pedal
arch, as compared to interrupted pedal arch, has been
associated with increased rates of wound healing and
shorter time to healing in patients with CLI [9–11]. The
presumed benefit of a complete pedal arch is the ability
to collateralize adjacent angiosome territories resulting
in the observed improvement in healing; however, the
association of pedal arch quality and amputation‐free
survival for CLI has reported mixed results [10, 12].
Controlled investigations are needed to assess the
association of anatomic pedal subtypes on clinical
outcomes. While subject to publication bias, initial
observational series of pedal arch intervention have been
promising. In single center and multicenter registries,
endovascular angioplasty of the transpedal arch has
resulted in favorable outcomes, with technical success
rates of 75–88% [9, 11, 13], limb salvage rate of 88%, and
amputation‐free survival rate of 73% at one year [9].
When care is taken to avoid injury to a potential
infrapopliteal surgical target vessel, an endovascular first
approach has not shown negative impact to surgical
pedal bypass outcomes [14].
Figure 12.3 The posterior circulation consists of the
medial plantar artery and lateral plantar artery.
Source: [6] Higashimori et al. (2017), Reproduced from IntechOpen.
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Figure 12.4 Pedal arch subtypes: Type 1: both dorsalis
pedis and plantar arteries are patent; Type 2A: only
dorsalis pedis artery is patent; B: only plantar artery
patent; 3: both dorsalis pedis and plantar arteries are
occluded.
Source:[7] Kawarada et al. (2012), Reproduced from John Wiley & Sons.
Endovascular intervention of the pedal arch has been
shown to be a safe and effective approach to treatment
and has become an important intervention target in
select CLI cases. This chapter will focus on the unique
challenges and a systematic approach to pedal arch
intervention.
Indications for Pedal
Revascularization
Current guidelines do not differentiate pedal from
infrapopliteal revascularization recommendations in the
setting of CLI. The goals of transpedal arch intervention
are to improve outflow of the tibial arteries, to improve
flow to an adjacent angiosome, and to open a conduit for
retrograde intervention of an additional infratibial vessel
to achieve in‐line flow in CLI. Procedural failure may
result in worsening foot ischemia, so appropriate patient
selection is crucial. When care is taken to avoid injury to
a potential surgical target vessel, an endovascular first
approach has shown to not have a negative impact on
surgical pedal bypass outcomes (Figures 12.5 a–h and
12.6a–d) [14].
Technical Considerations
Pedal arch intervention is best approached via the
ipsilateral antegrade approach. The pedal vessels are
small in caliber and take a more tortuous course than the
larger and more proximal leg vessels. An antegrade
approach with a long sheath maximizes the ability to
push and transmit torque for wire and catheter
manipulation. A long sheath will also allow the use of
shorter length catheters, devices, and wires, which can
become a significant limitation of alternative access
strategies. Placing the sheath in the most distal disease‐
free segment of the superficial femoral artery (SFA) can
maximize support. A 5 Fr system will enable passage of
equipment needed for the small caliber infratibial and
pedal vessels, though if there are plans to use a closure
device that requires a larger arteriotomy, a 6 Fr system is
also commonly used.
Access
1. Obtain antegrade ipsilateral common femoral artery
access via modified Seldinger technique under direct
ultrasound guidance utilizing a micropuncture
access kit.
2. Place a 5 or 6 Fr × 23 cm length or longer sheath
over a 0.035 stiff wire with soft tip (Hi‐Torque
Supra Core – Abbott, Santa Clara, CA, USA).
Advance the sheath tip to the most distal
nondiseased SFA vessel segment.
3. After sheath placement, administer unfractionated
heparin with a goal activated clotting time (ACT) of
250–300 seconds.
Lesion Crossing
Non‐chronic total occlusion (CTO) Lesion Subtype:
1. For non‐CTO lesions, a workhorse wire can be used,
though given the small caliber and tortuosity, often
a hydrophilic or polymer jacketed 0.014 tapered
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wire such as a Fielder XT (Abbott, Santa Clara, CA,
USA) is required to navigate the distal vessels.
2. A 0.014 microcatheter may be required for crossing
support (Corsair–Asahi Intecc, Irvine, CA, USA),
CXI (Cook, Bloomington, IN, USA), Quick‐cross
(Philips, San Diego, CA, USA), Turnpike LP
(Teleflex, Morrisville, NC, USA).
CTO Lesion Subtype
See chapter on CTO crossing for technique.
Techniques used for lesion crossing in the distal
infratibial and pedal vessels are similar to those
used for coronary CTO intervention.
Subintimal crossing should be approached with
caution as extension of a subintimal plane can
occlude branch vessels of the arch with potential
worsening perfusion that can lead to tissue or limb
loss. True lumen crossing is essential for
maximizing tissue perfusion.
Special Considerations of the Pedal
Intervention
Defining Pedal Anatomy: Selective angiography via long
sheath or through a microcatheter (e.g. 0.035 Navicross
– Terumo, or 0.018 Quick‐cross – Spectranetics) is
recommended to deliver concentrated contrast injections
to the infrapopliteal and pedal vessels for optimal
anatomic definition prior to and during intervention.
Standard views include AP with shallow cranial and
straight lateral views of the foot.
Lumen Crossing: Due to the branch and choke vessels
that arise from the pedal arch, subintimal crossing and
recanalization can lead to branch occlusion with the risk
of tissue or limb loss. Every effort should be made to
cross true lumen.
Anticoagulation Strategy: Given small caliber vessels
with diminished flow, anticoagulation levels must be
judiciously watched with a goal ACT between 250 and
300 seconds to avoid thrombus formation.
Vessel Tortuosity: Tortuosity can be a challenge in small
vessels. Difficult to cross lesions may be better defined
by taking additional, nonstandard oblique angiographic
views for better spatial understanding and directionality
of the vessel. In addition, plantar or dorsiflexion of the
foot may enable changes in vessel conformation to allow
wire or device passage through tortuosity near the ankle
[7].
Vasospasm: Small caliber vessels are more prone to
vasospasm. Liberal use of intraarterial vasodilators is
recommended. Verapamil dosed at 2.5 mg and
nitroglycerin dosed at 200 mcg are commonly used and
will be most effective when delivered via a microcatheter.
Angioplasty Technique and Balloon Sizing: Bailout
stenting below the ankle is not recommended, so care
should be taken to achieve optimal angioplasty result.
Low pressure, prolonged inflations (e.g. three minutes),
and 1 : 1 balloon sizing are recommended. Infrapopliteal
vessel sizing can be accomplished using an IVUS catheter
if vessel caliber allows. In practice, tortuosity and small
vessel caliber prevent the use of intravascular imaging
for vessels below the ankle. Most infrapopliteal vessels
will measure 1.5–2.5 mm. A 1.5–2.0 mm balloon is most
commonly used for the dorsalis pedis, pedal arch, and
plantar arteries. Angiography following administration
of vasodilators through a microcatheter can aid in
estimation of vessel caliber. When there is question of
sizing, the smaller of balloons should be chosen to
minimize risk of flow limiting dissection or perforation.
Calcification: Calcification of the pedal arch vessels
poses a challenge, particularly in tortuous vessels. The
pedal arch vessels are not large enough to accommodate
scoring balloons. In straight vessel segments, orbital
atherectomy can be performed using a 1.25 mm micro
crown (Cardiovascular Systems, Inc). Due to short
anatomic landing zone and small caliber vessels, distal
embolic filter protection is not possible. Similar to
coronary intervention, atherectomy runs must be limited
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in duration, ideally less than 10 seconds, to allow for
adequate washout to prevent the no‐reflow
phenomenon. Tortuosity increases the risk of vessel
dissection or perforation during atherectomy. In such
cases, a small coronary balloon can be utilized for focal
angioplasty at higher pressure if required for a
recalcitrant calcified lesion. Ultimately, calcification with
tortuosity increases the risk of the procedure and the
operator should reassess the risk and benefit of
proceeding.
Troubleshooting
Uncrossable Lesion: Standard CTO crossing techniques
including wire escalation can also be employed in the
foot. Subintimal crossing and reentry in these small
vessels is not recommended as this may result in
occlusion of branch vessels, and stenting in the foot for
bailout is not recommended.
Inability to Deliver a Catheter or Balloon: When
confronted with complex infrapopliteal and pedal arch
lesions, it is important to maximize access and sheath
support during preprocedural planning as described
previously. Next, use a low‐profile balloon such as a 1.5
mm Advance LP (Cook Medical) or 1.0 mm Sapphire
(Cardiovascular Systems Incorporated). If the
uncrossable lesion is at the level of the ankle, attempt a
different flexion, extension, or rotation of the foot to
change the geometric relationship between the balloon,
wire, and vessel. Using stiffer wires (e.g. Viper and
Wiggle) can also be effective, though the use of these are
associated with an increased risk of small vessel
perforation and this risk should be factored into the
decision to escalate.
Diffuse Small Vessel Disease: “Desert Foot” is a
challenging scenario in which there is minimal global
perfusion of the foot due to diffuse severe small vessel
disease. This entity is generally not amenable to
endovascular intervention, although in select cases it
may be possible to reconstruct the pedal loop if the
inflow vessels are of sufficient diameter.
Vessel Perforation: Perforation or severe dissection of a
small vessel in the foot should be controlled by
prolonged balloon inflation. Placing a coronary stent to
the foot is not recommended, given the flexion forces
and high risk for stent disruption and thrombosis.
Perforation of the below ankle vessels can typically be
managed by external manual compression. The limited
number of bailout strategies available and risk of vessel
closure in treating these complications should be
considered in the initial risk/benefit determination as to
whether the patient may benefit from intervention.
Summary
The quality of the pedal arch is an important predictor of
wound healing in CLI. Advances in endovascular
technique have allowed endovascular intervention of the
pedal arch to achieve good efficacy and safety outcomes.
With appropriate patient selection and technique, the
pedal arch can be a valuable intervention target in CLI.
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Case Example 1
A 65‐year‐old male with 5 × 5 cm left heel ulceration
with black eschar, concern for early osteomyelitis, and
a toe pressure of 12 mmHg (Wifi score: three
infections, two to three wound, one infection) (Figure
12.5a–h).
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