Cath Lab Digest

Immad Sadiq, MD and Kurush Setna, MD*

Abstract

The objective of this article is to demonstrate that supine retrograde popliteal artery access is feasible, safe and effective. No published reports of supine popliteal artery access exist in the English language literature. We define this technique and demonstrate with two cases the successful application of this method in femoropopliteal arterial percutaneous revascularization. This is a case report that outlines a new technique for arterial access. We have tried this technique in multiple patients and two cases are reported here for illustration. Conclusions. Supine access of the popliteal artery is feasible, safe and effective. Additionally, it may result in improved patient comfort, operator ease and shorter procedural times.

VASCULAR DISEASE MANAGEMENT 2010;7:E57–E60

Key words: peripheral arterial disease; femoropopliteal occlusion; popliteal artery; arterial access

Introduction

Advanced peripheral arterial disease is increasingly being managed utilizing an endovascular approach.¹ In the majority of cases of femoro-popliteal occlusive disease, percutaneous revascularization is achieved via contralateral common femoral arterial (CFA) access and antegrade canalization. However, when this conventional antegrade arterial approach does not allow satisfactory canalization and revascularization of the totally occluded superficial femoral artery (SFA), often retrograde access via a popliteal artery approach is necessary.² Traditionally, popliteal artery access is obtained with the patient in the prone or lateral decubitus position.³ A typical case of such complimentary popliteal artery access starts with the patient in the supine position in the beginning and the terminal part of the case, being turned prone or laterally in between for popliteal access and retrograde canalization of the occluded femoro-popliteal arteries (the “rotisserie” method). There are no reports in the English literature of supine popliteal artery access for the purposes of endovascular intervention.

We report here two cases of occlusive femoro-popliteal disease where endovascular intervention via a traditional antegrade femoral approach was unsuccessful, requiring popliteal artery access for successful revascularization. Uniquely, we obtained this access with the patients in the supine position (the “stirrup” method). This method resulted in the need to turn the patient prone and then back to a supine position, with all its attendant logistical headaches. If streamlined, the “stirrup” method in select patients can result in considerable time-saving, and allows wider applicability over the “rotisserie” method due to the reluctance on the operator’s part to indulge in the latter due to all the complexities involved.

Case 1. An 85-year old Caucasian male with a known history of hypertension, dyslipidemia, atrial fibrillation and coronary artery disease presented with ischemic rest discomfort and a nonhealing ulcer of the left foot. After a noninvasive vascular workup, percutaneous revascularization was planned. Due to his inability to lie flat secondary to back problems, monitored anesthesia care (MAC) was utilized instead of conscious sedation. He was prepared and draped in the standard sterile fashion. Initial arterial access was obtained via the right CFA using the modified Seldinger technique with an 18-gauge Cook needle (Cook Medical, Bloomingon, Indiana). A 6 French (Fr) arterial sheath was inserted thereafter. Distal abdominal aortography was performed with bolus chase runoff angiography. Initial findings are illustrated in Figures 1 and 2. In order to treat the left femoropopliteal occlusive disease a crossover sheath was inserted in the right CFA and crossed over the aortic bifurcation in the standard fashion. Subsequently, antegrade canalization of the occluded SFA was attempted with a straight Glidewire (Terumo Medical Corp., Somerset, New Jersey) supported by a straight Glidecath (Terumo Medical). Despite multiple attempts and changing the wire and catheter, successful canalization could not be achieved due to difficulty in crossing the “distal cap.” A decision was made to attempt popliteal artery access and retrograde canalization. Due to the administration of MAC anesthesia, the patient was not cooperative and was deemed unfit to be turned prone due to ventilation concerns. We thus performed supine retrograde access on the left popliteal artery as outlined below in the “Technique” section. The final angiographic result was very satisfactory (Figures 3 and 4), showing widely patent femoropopliteal arteries and adequate runoff to the foot. The patient tolerated the procedure very well and the right femoral sheath was removed in the standard fashion after his activated clotting time (ACT) dropped to less than 180 seconds. He was discharged home the next day.