Pedal Approach in a Difficult Contralateral Case

A 67-year-old diabetic smoker was seen by a vascular surgeon and was told his symptoms were not “bad enough” for surgery and angioplasty “wouldn’t work.” He has resting pain and an ankle-brachial index (ABI) of .6 on the left.

Video 1. This angiogram performed via the contralateral approach shows the flush occlusion of the superficial femoral artery (SFA).

Video 2. Because of tortuosity, we could not pass the 6 Fr Ansel (Cook Medical) all the way into the common femoral artery on the left side, but we were also unable to pass a stent into the iliac stenosis. We were only able to balloon dilate the area of stenosis.

Video 3. This is the balloon dilation.

Video 4. Because of the inability to access either the iliac stenosis or the flush SFA occlusion, our options included the popliteal approach or the post-tibial approach. Because of this patient’s morbid obesity and chronic obstructive pulmonary disease, I did not feel safe having the patient in a prone position, so we went in the posterior tibial artery, using the contralateral injection as a road map. In this view, it looks as if I am close to the posterior tibial artery.

Video 5. In this angle, you can see that I have impinged the posterior tibial artery and will get access.

Figure 1. This is the micro-puncture wire into the SFA distal to the occlusion.



Video 6. This angiogram from above confirms that I am in the SFA.

Video 7. We now went up with a 5 Fr Avinger device (The Wildcat) to cross the total occlusion.

Video 8. After crossing the chronic total occlusion (CTO) with the Wildcat and passing a .014 Whisper Wire (Abbott Vascular), we exchanged for the ViperWire (CSI) and then passed the orbital atherectomy device (CSI).

Video 9. The AngioSculpt balloon (AngioScore) was dilated at the site of the original CTO.

Video 10. Now we are deploying a self-expanding stent (Medtronic) via the left posterior tibial artery. In this case, we did the whole procedure sheathless.

Video 11. This angiogram is after deployment of the stent and simple balloon angioplasty with the AngioSculpt at the site of the original CTO.

Figure 2. Several balloon procedures were done in the popliteal and infrapopliteal vessels with the same AngioSculpt balloon.



Video 12. The final result. We then pulled the wire and applied manual pressure for 3 minutes on the pedal site.


When the angiogram shows good filling of a pedal vessel, the supine approach accessing the posterior tibial is a safe option in some patients. As is seen with the popliteal method, approaching a lesion in a retrograde manner is often an effective interventional technique.

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