Immad Sadiq, MD and Kurush Setna, MD*
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
IntroductionAdvanced 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. Case 2. A 72-year-old male with severe intermittent claudication (Rutherford Class 3), with the left leg worse than the right, underwent noninvasive arterial testing, which revealed bilateral femoro-popliteal occlusive disease that appeared amenable to endovascular intervention. He underwent angiography via a right femoral access, which confirmed the above findings. The aorto-iliac arteries were noted to be free of significant disease. The left SFA was noted to be heavily calcified throughout its entire length. It was occluded just beyond its origin and reconstituted at the Hunter’s canal (Figures 5 and 6). A few attempts were made via the right femoral artery to cross the occlusion with an angled Glidewire. The wire became subintimal in the proximal SFA, entered a spiral plane, and could not be redirected towards the distal lumen. At this point, we decided to obtain retrograde popliteal artery access in the supine position. The method for this, as in the first case, is outlined below. At the conclusion of the case, the patient had excellent flow through the left femoro-popliteal and runoff arteries (Figures 7A and 7B). He tolerated the procedure well and was discharged home the following day.
TechniqueThe patient’s affected leg (left leg in both cases) was prepared with betadine wash, all surfaces, thigh to toes, in a thorough surgical fashion. The leg was then exteriorized on the table through a hole in the drape. This leg was elevated and flexed at the hip and the knee at 120 degrees, with the calf horizontal. An assistant holding this leg makes this job easier. The popliteal fossa was identified and local anesthesia was administered in the standard fashion. Using live angiography (instead of “road-mapping”), a 4 Fr micropuncture kit (21-gauge) needle was used to puncture the left popliteal artery in a retrograde fashion (Figures 8, 9A and 9B). Once the artery was cannulated, the 4 Fr micropuncture sheath was introduced without difficulty. The leg was placed back on the table with two pillows under the distal left calf to allow easy access to the popliteal sheath. The wire was removed and an intraluminal position was confirmed on angiography. A straight stiff Glidewire (0.035 inch, 260 cm length) was then advanced retrogradely without difficulty across the occluded segment and into the CFA. This wire was switched out for a 260 cm J wire through a 4 Fr Glidecath. The latter wire was then exteriorized via the right femoral sheath. Endovascular intervention of the femoropopliteal arteries was then carried out in a standard fashion. Balloon angioplasty in the popliteal artery was performed and the retrograde sheath removed with satisfactory hemostasis.
DiscussionTraditional retrograde popliteal artery access involves turning the patient supine, prone, and often supine again for the completion of the final intervention. This adds to the patient’s anxiety, is uncomfortable, and often prolongs the duration of the procedure due to the logistical considerations. It also complicates the operator’s job due to the difficulty of handling the femoral arterial sheath on which the patient is lying when prone. Additionally, this approach is not feasible in patients who are obese, have impaired respiratory function, and other conditions that may interfere with positioning them in a prone or lateral decubitus position. In our cases, eacg patient remained supine throughout the procedure. This eliminated the additional steps of turning the patient in a “rotisserie” fashion and allowed direct visualization of both arterial access points. Additionally, due to the easy simultaneous access to both of these sheaths, the time spent exteriorizing the wire was reduced as well. Overall, this technique resulted in less fluoroscopic time for the case than it otherwise would have. However, live angiographic visualization of the popliteal artery at the time of popliteal access led to suboptimal radiographic shielding due to the elevation of the leg, albeit for a brief duration (References
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