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Successful Below-the-Knee Intervention using Deep Retrograde Tibial Access Technique
- Operator: Seung-Whan Lee, MD
Case Presentation
This 71-year old women was admitted to our hospital for the treatment of the gangrenous wound at right 4th toe which spontaneously occurred 3 weeks ago. She had diabetes and hypertension and has been bedridden for over 8 years because of the sequelae of cerebral infarction. Her right hip joint was stiffened in an external rotated position while the right knee joint had flexion contracture. The right ankle-brachial index value was severely decreased (0.48) and the lower extremity CT angiography showed severe degree of stenosis and calcification from the SFA to the below-the-knee arteries.
Baseline Peripheral Angiography
The right SFA showed multifocal stenosis from the proximal to mid portion and was totally occluded at the distal portion ( Movie 1). Beyond the patent short segment of the proximal popliteal artery (P1), the TP trunk, posterior tibial artery, and the peroneal artery revealed to be totally occluded while the anterior tibial artery was reconstructed from the proximal portion by the collaterals ( Movie 2, Movie 3, Movie 4).
Procedure
A 6F sheath was inserted into the left femoral artery for the contralateral retrograde approach. After angiography, the sheath was exchanged to the 6F Ansel guiding sheath. With the support of Armada 35 2.0(80) balloon, the antegrade intimal tracking to the popliteal artery (P1) was successfully done with the Regalia XS 1.0/0.014 inch-300cm peripheral-guidewire. The whole SFA was sequentially dilated using SAVVY 5.0/220mm balloon (Figure 1, Figure 2) which resulted in an optimal post-angioplasty result ( Movie 5). Further antegrade intimal tracking was attempted to open the ATA but this was impossible due to the superiorly directed take off of ATA from the distal popliteal artery making severe angulation. We decided to change our strategy to the retrograde tibial approach. Since the patient’s hip joint had external rotation contracture, we had to access the ATA from the medial portion of the lower leg (consider that ATA runs from the anterolateral of the lower leg to the front part of the ankle joint). Deep mid-ATA puncture using 7cm micropuncture needle was carefully done under the guidance of perpendicular angiographic views ( Movie 6, Movie 7). After a Command 0.014 inch-300cm guidewire was inserted through the ATA to the proximal peroneal artery, we succeeded to overcome the severe angulation using the Crusade double-lumen microcatheter ( Movie 8). The retrograde guidewire was advanced into the pre-treated proximal SFA, and was successfully externalized into JR diagnostic catheter which was inserted in the Ansel guiding sheath. Thereafter, the antegrade advancement of the Finecross 1.8F microcatheter into the proximal ATA was done through the externalized wire. The wire was further advanced into the dorsalis pedis artery and subsequent treatment of ATA, TP trunk and popliteal artery was done using Armada 14 2.0(40), peripheral cutting 3.0(150) balloons (Figure 3, Figure 4, Figure 5). Final angiogram showed a successful result and good blood supply to the right foot ( Movie 10, Movie 11).
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