Modified bare-back micro-retrograde tibial arterial access to facilitate peripheral endovascular therapy

Abstract

Patients with critical limb threatening ischemia often present with complex segmental peripheral arterial chronic total occlusions, which might not be amenable to traditional antegrade revascularization techniques. For these patients, alternative retrograde revascularization techniques could be necessary. In the present report, we describe a novel modified retrograde cannulation technique using a bare back technique that eliminates the need for conventional tibial access sheath placement and, instead, facilitates distal arterial blood sampling, blood pressure monitoring, retrograde administration of contrast agents and vasoactive substances, and a rapid-exchange strategy. This cannulation strategy can serve as part of the armamentarium in the treatment of patients with complex peripheral arterial occlusions.

Keywords: Adductor hiatus; Chronic total occlusion; Endovascular recanalization; Endovascular surgery; Superficial femoral artery.

Fig 1

A, Materials needed for modified bare-back micro-retrograde pedal arterial access. From top to bottom: an access kit, including a microsheath, the Tuohy-Borst adapter, and a 0.018-in. wire and catheter. B, Successful vessel cannulation with the 4F microsheath. C, Successful vessel cannulation with a 0.018-in. microcatheter placed over the 0.018-in. crossing wire. D, Successful maintenance of arterial access with 0.018-in. wire and 4F microsheath with attached Tuohy-Borst with flush syringe secured in place.

Fig 2

A and B, An example patient with complex, long segment chronic total occlusion (CTO) of the superficial femoral artery. C, A 0.018-in. wire and microcatheter were used to cross the CTO. D, The wire was snared from an antegrade access. E and F, The CTO was then treated from the antegrade access with balloon angioplasty and stenting.