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364 Complex lower extremity revascularization
will likely be an area for active investigation in the
coming years since it oers the potential of improv-
ing the results of existing denitive therapies.
When to worry about embolization
Embolization occurs in association with all types of
endovascular procedures. Fortunately, this becomes
clinically signicant in only a small percentage
of patients. Situations that are associated with an
increased risk of embolization include crossing long
occlusions, patients who present with embolization,
patients with aneurysmal disease, such as popliteal
aneurysms, and with the use of atherectomy. In
performing lower extremity interventions, it makes
sense to pay attention to the level of anticoagulation
and be sure that the patient is fully anticoagulated.
is is especially true if there is an indwelling sheath
A
B
C D
E F G
Fig. 25.16 Use of a cutting balloon to treat infrainguinal bypass graft stenosis. (A) A sheath is placed
in the artery proximal to the anastomosis. An 0.014-inch guidewire is passed into the bypass graft.
(B)An undersized cutting balloon is placed in the stenosis. (C) The cutting balloon is inflated to cut
the intimal hyperplastic lesion. (D) A standard angioplasty balloon, which is sized to the desired diam-
eter of the graft, is placed and inflated. (E) The cutting balloon is placed in the lesion. (F) The cutting
balloon is undersized in comparison to the graft diameter to avoid rupture. When the undersized
balloon is inflated, the lesion is cut in several places. (G) After standard balloon angioplasty, the lumen
assumes a much larger configuration.
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Tibial artery occlusive disease 365
for an extended period of time, there is slow ow,
or there is already very compromised outow. In
managing long occlusions, it is possible that some of
the material in the occluded segment could embo-
lize. Another higher risk situation to consider is in-
stent restenosis. e material that has accumulated
within the stent is also potentially embolic mate-
rial. Consider using a distal protection device when
performing atherectomy or when treating in-stent
restenosis.
TIBIAL ARTERY OCCLUSIVE DISEASE
Angioplasty for limb salvage
Most tibial angioplasty is performed for limb sal-
vage, for the indication of critical limb ischemia.
Tibial angioplasty is discussed in Chapter 24. In
this section, we review more complex issues in tib-
ial reconstruction. e methods available to treat
tibial arteries are somewhat limited. At the pres-
ent time, plain balloon angioplasty and atherec-
tomy are approved for tibial vessels. Drug-coated
balloons for tibial arteries are approved outside
the USA. ere are no specic stents approved
for the tibial vessels in the USA but they are avail-
able in other countries. ese are typically coro-
nary stents, either bare metal or drug-eluting
stents, which are used o-label in the tibial vessels.
Worldwide, plain balloon angioplasty is the most
common method of revascularization.
e most important features of success in tibial
interventions is strategy followed by attention to
detail. e patient must be fully anticoagulated.
Inow lesions must be treated aggressively. e
sheath must be placed as close as can safely be
achieved to the location where the infrapopliteal
intervention will be performed. If ipsilateral ante-
grade femoral sheath access can be achieved, that
is usually best. Almost always, there are multiple
vessels involved, and picking the best targets can
be a challenge. One might consider going aer
the simplest tibial lesion that will bring more ow
to the foot. Secondarily, if there is another ves-
sel involved that can bring more blood supply to
the wound-related artery, which would be correct
from an angiosome point of view, then typically
that one is also opened.
Tibial lesions are approached from an ante-
grade direction, either through an ipsilateral ante-
grade femoral access or a contralateral femoral
up-and-over access. A contralateral approach
is acceptable for lesions involving the proximal
two-thirds of the tibial arteries, especially if there
are signicant inow iliac or femoral–popliteal
lesions that must be treated. A long sheath, 90 or
110cm, may be placed over the aortic bifurcation.
If an antegrade femoral access is possible, and any
remaining inow disease can be treated through
this access, this is the best way to gain the most
control over the procedure. If angioplasty at the
ankle and foot is anticipated, an antegrade access
may be necessary to complete the case because
of the distance from the access site. e tip of
the sheath is placed in the popliteal or even the
tibial artery. Inow lesions of the iliac artery and
SFA are treated aggressively. With the tip of the
sheath close to the lesion, less contrast is required
for interval arteriography and less time and fuss
is necessary for exchanges of catheters. An ipsi-
lateral antegrade approach is direct and helps to
maintain control of guidewires and catheters.
An antegrade approach is also preferred when
the aortic bifurcation is hostile, but is dicult in
patients who are obese.
Selective catheterization is described in
Chapter 9. Tibial and pedal arteriography is dis-
cussed in Chapter 11. Longer guidewires, usually
300 cm, are used to perform selective tibial artery
catheterization. is will provide enough length so
that exchanges can be made outside the vascular
system with a 140-cm coaxial catheter if needed.
Heparin (75–100 U/kg) should be administered
prior to tibial artery catheterization. If spasm
occurs in the tibial arteries, nitroglycerine is
administered through the access catheter.
Aer the sheath is in place, a low-prole wire,
either 0.014-inch or 0.018-inch, is advanced across
the lesion. e best way to cross the lesion is to use
the rapid rotation or drilling method for an occlu-
sion (see Chapter 16). Aer the lesion has been
crossed, a long low-prole balloon is advanced over
the wire. If the chosen wire is too imsy to per-
form the angioplasty or is not a strong enough rail,
a CTO catheter can be used to exchange for a stier
low-prole wire. Aer the catheter is advanced, a
small amount of contrast can be administered to
more clearly evaluate distal runo if this was not
possible previously. Aer the wire is in place, the
balloon is advanced. Usually, an over-the-wire bal-
loon is best if it is a long lesion and quite distal and
especially if it is an occlusion. If it is a focal lesion or
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366 Complex lower extremity revascularization
placed more proximally, arapid exchange balloon
may be acceptable. Aer the balloon is in place, it
is inated slowly until the waste of atherosclero-
sis is resolved. Balloon ination is maintained for
2–3 minutes. During this time the patient should
be well anticoagulated. Sizing the balloon usu-
ally requires a little bit of art. If there is medial
calcication visible, the size of the balloon can be
matched with the calcium. In general, the apparent
lumen is not an accurate guide of the correct size of
the balloon and it is common to undersize the bal-
loon. is is because of the diuse accumulation of
disease in the tibial vessels.
If the 0.014-inch guidewire requires support, a
low-prole CTO catheter or a 4- or 5-Fr catheter
with a Tuohy-Borst adaptor is used along with the
wire. e combination of the angled tip on the
catheter and the steerable, angled tip on the guide-
wire make it possible to reach artery branches with
all kinds of angles, when needed, including the
acutely angled origin of the anterior tibial artery.
e angiographic catheter also provides support
for the long guidewire. If the lesion is a stenosis,
a low-prole guidewire can usually be placed by
leading with the tip of the wire with a gentle angu-
lation at the tip. If the lesion is an occlusion, an
extra eort should be made to obtain good images
of the runo arteries distal to the occlusion. e
wire is placed with a bend at the tip and it is usu-
ally best to support the wire with a catheter. Place a
low-prole exchange catheter with a sti tip. Aer
the wire enters the occlusion, the catheter tip is
advanced into the occlusion. When the catheter tip
meets resistance, do not push any further and de-
nitely do not buckle the catheter. Rotate the wire
as it makes slow forward progress. Advance the
exchange catheter to support the wire. Continue
this alternating push or “hopscotch” maneuver
until the guidewire breaks into the true lumen on
the distal end. is maneuver is usually success-
ful in recanalizing tibial artery occlusions. If the
guidewire passes outside the adventitia, it is only
rarely of any clinical signicance, but it also may
be a challenge to get the wire oriented into the true
lumen. Pull the catheter back a bit and see if the
catheter tip can be advanced into a slightly dier-
ent pathway.
How many tibial arteries should be
treated?
As mentioned previously, one strategy is to treat
the simplest or most focal stenosis or occlu-
sion that will improve perfusion to the foot and
thento go aer any additional vessels, as needed.
If there is a second artery that will bring more
perfusion to the wound-related artery or to the
appropriate angiosome, this should be considered.
Figure25.17 includes examples of strategy around
determining how many tibial arteries should be
treated. Attention is paid to the collaterals between
the various tibial arteries, especially when consid-
ering the peroneal artery as an essential part of the
runo, even though the collateralization between
A B
Fig. 25.17 How many tibial arteries should be treated? (A) This is a lateral view of the foot in a patient
with a heel lesion. There is a focal lesion in the peroneal artery and a good collateral between the
peroneal artery and the distal posterior tibial artery. In this case, consider treating the more straight-
forward and focal lesion in the peroneal artery followed by the longer occlusion in the posterior tibial
ar ter y. (B) In this case the patient has a forefoot wound and an intact pedal arch. All three tibial arter-
ies have long associated occlusions. Either the anterior tibial artery or the posterior tibial artery can
be recanalized, or both.
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Angiosomes of the lower leg and foot 367
the peroneal artery and the foot is highly variable.
e quality of the pedal loop is also important in
that a complete pedal loop can bring blood supply
to the rest of the foot. At the present time there is
conicting data about how many tibial arteries it
is most appropriate to treat. In patients with larger
wounds or wounds that cross various angiosomes,
by denition, more than one tibial artery should
be recanalized, if possible. In the case of open sur-
gery, typically the best target for receiving a bypass
is chosen. Open bypass is a bit dierent in that the
perfusion aorded by the bypass is more robust
than can be achieved with the typical recanalized
tibial vessel. One major advantage of the endovas-
cular approach is the ability to open more than one
conduit to the foot.
ANGIOSOMES OF THE LOWER LEG
AND FOOT
In healthy patients with normal anatomy, it can
be assumed that there is signicant collateral-
ization between the tibial vessels and also at the
pedal loop. In diabetic patients and especially
those with renal failure, the ow typically becomes
compartmentalized. Although there may still be
some collaterals, they are typically not of the same
quality as in the normal anatomy. e concept of
angiosomes of the foot then becomes important if
each of these areas are isolated or nearly isolated
(Fig ure 2 5.18). It may signicantly aect the choice
of which tibial artery to revascularize. An idealis-
tic view of the angiosome concept assumes that
there are separate areas that must each be treated.
e truth is that there is signicant variation from
patient to patient and the angiosome concept can
be used as a guide but is not a guarantee. If you
focus on the wound-related artery, the odds are
that perfusion will be improved in the correct
location. ere are multiple disadvantages of the
angiosome concept including the variability, the
fact that it does not really work with the peroneal
artery because the collaterals cannot be assessed,
and that it may not be important for patients with
rest pain or very small wounds. ere are multiple
retrospective studies suggesting that direct revas-
cularization to the correct angiosomes results in
better wound healing. ere are other studies sug-
gesting that it does not make a dierence in a large
majority of patients.
DPA + MPA
Lateral plantar
artery
Peroneal
artery
Calcaneal
branch of posterior
tibial artery
Medial plantar
artery (MPA)
Dorsalis
pedis
artery (DPA)
DPA + MPA
Fig. 25.18 Angiosomes of the foot. The anterior tibial, peroneal, and posterior tibial arteries all
serve the foot. In the healthy pedal vasculature, there are usually several anastomotic connections
between these vessels. In patients with severe pedal artery disease, and especially among diabetic
patients, the anastomotic connections may become interrupted. The pedal blood supply may become
compartmentalized, with separate angiosomes, or segments of the pedal vasculature, served by
different tibial vessels.
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368 Complex lower extremity revascularization
When to do a pedal puncture for
retrograde access
One of the main challenges with an antegrade
guidewire direction is that in an occlusion, if the
wire goes into the subintimal space, it is oen not
possible to achieve re-entry. In this case, a pedal
puncture or retrograde access may be of value. It is
usually best to decide ahead of time how much time
and energy will be spent in an attempt to pass the
wire from the proximal direction. Aer the ante-
grade tibial crossing approach has been tried, it is
best to go straight to a retrograde approach. Aret-
rograde puncture or access may be performed at
the dorsalis pedis or posterior tibial arteries in the
foot or at the ankle, and it may also be performed in
the tibial arteries anywhere distal to their origins.
is is most helpful in situations of popliteal or
tibial artery occlusion that cannot be crossed from
an antegrade direction. In the case of tibial artery
subintimal passage, there is no re-entry device or
reproducible option for success in re-entry and a
retrograde wire is the best option. Very oen, the
distal cap of the occlusion is soer than the proxi-
mal cap. Whereas the downward sloping direction
of the collaterals of the popliteal and proximal tib-
ial arteries is such that the antegrade wire is highly
likely to follow one of these vessels rather than the
true lumen, a retrograde wire does not face this
challenge. e runo vessels are treated carefully.
e tibial vessels or pedal vessels are accessed with
a micropuncture needle. Aer the micropuncture
needle is in place using either uoroscopic or ultra-
sound guidance, a 0.018-inch diameter guidewire
is advanced with a bent tip for drilling purposes.
e wire is usually supported by a CTO catheter
such as a Quick-Cross
™
support catheter or a CXI
®
support catheter.
How to do pedal or distal puncture
for retrograde access
e strategy for retrograde access is shown in
Figure 25.19. e attempt is always made from
an antegrade direction. As mentioned earlier, an
antegrade crossing may fail either because the
A
B C
Fig. 25.19 Strategy for retrograde access. (A) This patient presents with occlusion of the tibial artery
trifurcation. A sheath is placed antegrade into the popliteal artery. Retrograde access sites may
include the anterior tibial, dorsalis pedis, posterior tibial, or peroneal arteries. Adequate working
room must be established between the intended access site and the distal cap of the occlusion.
(B)Inthe case of a popliteal artery or distal SFA occlusion, retrograde access sites may include the
proximal or distal segments of any of the tibial arteries. (C) In the situation where single vessel runoff
is present, the operator attempts to preserve it, but retrograde puncture can still be performed using
a proximal patent segment of one of the occluded tibial arteries. In this case, the retrograde access
site is the proximal patent stump of an occluded anterior tibial artery.
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Angiosomes of the lower leg and foot 369
wire tends to follow collaterals or because it goes
subintimal and cannot be brought back into the
true lumen. A retrograde puncture may be per-
formed at multiple dierent locations, depending
on the situation. If there is a way to avoid access in
the best runo artery, that is usually best. Access
in the anterior or posterior tibial arteries is bet-
ter than in the peroneal artery because these can
be easily compressed aerward, and the peroneal
artery is more dicult since it is in a deep com-
partment. e puncture site should be in a vessel
that is of adequate size to handle the microsheath
if one is necessary. e access site should provide
at least 5 cm of working room prior to encounter-
ing the occlusion so that there is an adequate plat-
form for entering and crossing the lesion from the
retrograde direction. With a popliteal artery occlu-
sion, any of the tibial vessels can be accessed. If it
is specically a tibial artery occlusion that is being
considered for crossing, then the specic tibial
artery intended for crossing should be accessed.
If it is possible to access the stump of an occluded
vessel, this is also a realistic approach to help avoid
any compromise of the distal runo.
Retrograde access may be guided uoro-
scopically or by ultrasound (Figure 25.20). With
ultrasound-guided access the tendency of the
artery to roll underneath the needle can be care-
fully eliminated. A hockey stick-shaped probe is
used and the micropuncture needle is advanced.
Either a longitudinal or cross-sectional view can
be used, but a longitudinal view typically helps to
show the needle entering the vessel and the wire
being advanced. Typically, there are paired tib-
ial veins. Ultrasound can be used to avoid going
through the vein and into the artery. If ultrasound-
guided access is not successful, uoroscopically-
guided access can be considered (Figure 25.21).
e advantage of uoroscopically-guided access
is that the artery can be lled with contrast from
above and can be used as a real-time, true life road
map. e exact location along the artery, some-
times even in between lesions, can be chosen this
way. e needle is placed in line with the artery
A B
C
Fig. 25.20 Ultrasound-guided retrograde access. (A) The posterior tibial artery at the ankle is identi-
fied as the intended site of retrograde access. (B) A small ultrasound probe is used, in this case a
hockey stick probe, for transcutaneous ultrasound. In this position just posterior to the medial mal-
leolus, a longitudinally placed probe works best. The probe is lined up with the artery in the center of
the view on the monitor and the probe is placed just proximal to the intended puncture site. (C) On
the ultrasound image, the tibial artery will usually exhibit some evidence of calcification. It is typically
relatively non-pulsatile since it is distal to an occlusion. The accompanying tibial veins are usually
visible. Sometimes, the tibial veins are nearly empty, usually owing to the ischemic nature of the limb,
other times they may be relatively full due to the patient’s hemodynamic condition (e.g., congestive
heart failure or dialysis dependent). The tip of the needle is observed entering the artery at an angle,
and the wire tip may also be observed advancing into the artery.
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370 Complex lower extremity revascularization
and it can then be reassessed on an orthogonal
view. Contrast is administered and the needle
advanced. Aer there is backbleeding, a 0.018-inch
diameter guidewire is advanced. Typically, the tib-
ial artery access site is protected using an exchange
catheter. e exchange catheter is advanced to sup-
port the artery. Aer the occlusion is entered, the
drilling method is performed. When the two wires
come together, the antegrade catheter is advanced
and the retrograde wire advanced into it. If the
two cannot meet along the length of the occlu-
sion, an angioplasty balloon is advanced from the
antegrade direction. Extensive angioplasty is per-
formed. is usually breaks up the tissue to the
point where the two wires can be brought together
in the same plane. is is described in the section
on femoral–popliteal angioplasty. If this is not
adequate, a balloon can be advanced from the ret-
rograde direction; this should be a microballoon
on a wire. is will help avoid enlarging the pedal
access site. Aer the wires are in the same plane,
the retrograde wire is advanced into the proximal
catheter. Aer the wire is brought through-and-
through, an angioplasty balloon is advanced from
the proximal direction and angioplasty performed.
A CTO catheter or microsheath should be placed
over the wire to protect the artery at the puncture
site as the through-and-through wire is advanced.
Aer complete access is obtained and the initial
angioplasty has cleared the way and removed fric-
tion, the through-and-through wire can be inter-
nalized. Aer the wire is internalized, a catheter is
advanced so that the wire can be reversed and the
so end of the wire advanced into the runo and
toward the foot. Aer internalization of the wire at
the distal puncture site, pressure is held manually.
Some operators like to use a blood pressure cu for
a period of time. It is also useful to use angiogra-
phy to evaluate the puncture site to make sure that
there is no ongoing extravasation or signicant
damage.
ere are several methods of approaching an
occlusion from the distal end (Figure 25.22). In the
discussion so far, the focus has been on the most
common method, which is pedal or tibial puncture
for retrograde access. In situations where the pedal
loop is patent, an occlusion can be approached
retrograde through a patent pedal loop. A 0.014-
inch guidewire is advanced into the pedal loop
supported by a catheter. e wire is then used to
attempt crossing of the occlusion through the dis-
tal cap. Another option is to use a transcollateral
A B C
Fig. 25.21 Fluoroscopically-guided retrograde access. (A) Contrast is administered through the
proximally placed sheath. The contrast travels through collaterals to the runoff artery considered for
retrograde access. In this case the posterior tibial artery is prepared for puncture. (B) The micropunc-
ture needle is lined up directly over the artery under fluoroscopic guidance. When contrast pools
inthe vessel, the needle is advanced into the artery. It is difficult to use a road map here because the
target is small and it is challenging to prevent any movement of the limb and the tissues. (C) In order
to check the trajectory of the needle, an oblique fluoroscopic view can be obtained, as needed.
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Angiosomes of the lower leg and foot 371
approach. A collateral from one tibial artery to
another may be used to pass a 0.014-inch wire into
the reconstituted segment of a distal tibial vessel.
If catheter support is required, a microcatheter is
best.
Below the ankle angioplasty
Below the ankle angioplasty should be done spar-
ingly and cautiously, since it is not clear what is
the short- or long-term patency of this procedure
(Figure 25.23). If a patient has an open foot wound,
the inow to the ankle has been revascularized,
and the tissue of the foot remains ischemic, below
the ankle angioplasty can be considered. is may
be performed through the posterior tibial vessels
and into the plantar arteries or the dorsalis pedis
and major tarsal branches. Angioplasty may also
be performed of the entire pedal loop, if neces-
sary. Kissing balloons can also be used between
the medial and lateral plantar arteries and also
between the dorsalis pedis artery and the rst large
tarsal branch. 0.014-inch diameter guidewires are
used. e lesions tend to be more focal than in the
tibial vessels. Shorter balloons are easier to pass
and therefore are frequently used, except when
an entire pedal loop is being treated. Wherever a
pedal artery is treated, however, is a location where
restenosis may occur. e usual diameters do not
exceed 2.5 mm. One major advantage of pedal
angioplasty is that it can extend treatment further
into the foot than a bypass is able to accomplish.
A B C
Fig. 25.23 Below the ankle angioplasty. (A) Below the ankle angioplasty may be performed as an extension
of angioplasty of the distal tibial arteries, such as the posterior tibial artery extending into the common
plantar artery or the anterior tibial artery extending into the dorsalis pedis artery. (B) In this example, a single
balloon is used to treat a portion of the pedal loop. (C) In this example, kissing wires and kissing balloons are
used treat the common plantar bifurcation and the proximal medial and lateral plantar arteries.
A B
C
Fig. 25.22 Methods of approaching a tibial occlusion from the retrograde direction. (A) These
examples involve the posterior tibial artery, but they may be applied to any of the tibial vessels. An
occluded posterior tibial artery is approached using a retrograde puncture of the distal posterior
tibial artery. (B) An occluded posterior tibial artery is approached through a patent pedal loop from
the anterior tibial and dorsalis pedis arteries. (C) This example demonstrates one of the most common
options for a transcollateral approach. The posterior branch of the peroneal artery is used to access
the distal reconstituted segment of the posterior tibial artery.
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373
26
Salvage of previous reconstructions
INTRODUCTION
Endovascular intervention is essential in the sal-
vage of previous endovascular and open surgi-
cal reconstructions. e mechanisms of failure
of previous reconstructions, whether open or
endovascular, are similar. ese include failure
of inow due to new or residual lesions, failure
at the site of a previous intervention (usually
due to recurrent stenosis), or new lesions involv-
ing the outow. Failure at a site of previous bal-
loon angioplasty or surgical bypass may be due
to intimal hyperplasia during the early phase or
recurrent atherosclerosis if it occurs more than a
year later. Although the record of endovascular
intervention for intimal hyperplasia is variable,
this may be the method of choice in patients who
are poor candidates for open surgery. Cutting and
scoring balloons, debulking with laser or atherec-
tomy, and drug-coated balloons may play a role
in the endovascular treatment of intimal hyper-
plastic lesions. When a recurrent or progressive
lesion has worsened to the point where it has
become critical and ow-limiting, the previous
reconstruction may go on to thrombosis. In the
case of a bypass, the usual scenario is thrombo-
sis of the entire reconstruction since there are
no side branches. A caveat is that if the failing
bypass gra can be identied while in the act
of thrombosis, the thrombus may only be par-
tially occlusive. e same mechanism applies to
covered stents and stent–gras. Other types of
endovascular reconstruction, such as stents, may
thrombose but a portion of the artery may remain
patent because of collateral branches. ese issues
come into play when planning an approach to a
failed reconstruction. When thrombosis has
occurred, it may be appropriate to proceed with
chemical or mechanical thrombolysis, or both.
is is described in Chapter 20. Aer the acute
thrombus is removed, lesions are typically identi-
ed that require treatment.
PREVIOUS ENDOVASCULAR
RECONSTRUCTION
Drug-coated balloons, bare metal stents, stent–
gras, drug-eluting stents, and atherectomy may
all be used at dierent times to salvage a previ-
ous endovascular reconstruction. When recur-
rent stenosis occurs at a site of previous balloon
angioplasty, there are a variety of choices to con-
sider for repair. If the initial balloon angioplasty
failed, this was traditionally treated with repeat
balloon angioplasty and stent placement. Now
that drug-coated balloons and drug-eluting stents
are available, these should also be considered.
Arteriograms from the previous procedure should
be reviewed for evidence of untreated dissection
or residual stenosis that may have been evident
at the completion of the initial procedure. Care
should be taken to avoid passing the guidewire
into an area of partially healed dissection at the
intervention site. If the lesion is heavily calcied,
atherectomy or scoring balloons might be used to
prepare the target site and create a larger lumen
at the site of the lesion. Care should also be taken
to avoid compromising surgical options, such
as stenting at potential anastomotic sites. Avoid
large-bore or repeat punctures in femoral areas
that may require surgery. e initial approach
to access should be done with the possibility in
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