Debra L. Beck
Hollywood, FL (January 25, 2020) – Tibio-pedal artery access is being used with increasing frequency in lower-extremity arterial intervention, but it can be “a very complicated thing,” said interventional radiologist Brett Wiechmann, MD. He proposed to offer International Symposium on Endovascular Therapy (ISET) attendees a “Cliff Notes version” on the topic, replete with dos and don’ts.
“The number one thing I would suggest is make sure you position yourself for success--make the patient comfortable and make yourself comfortable,” said Wiechmann, the medical director at Vascular & Interventional Physicians in Gainesville, FL.
This means no torqueing the neck dramatically to see a monitor, placing all equipment in a position readily visible to the operator, and keeping hands out of the path of the image intensifier.
Equally important is making sure the patient is comfortable and steady. To this end, the foot and ankle should be placed in the proper position and steadied and the knee should be slightly flexed for comfort and supported with towels or pillows underneath. “We put the hip at a slight external rotation, which is the natural position anyway, supported with towels or pillows,” said Wiechmann.
Knowing what equipment will be needed and training staff in pedal access are also key. “The last thing you want to see when you want to do a pedal access is to see them roll their eyes or give a sigh…You want to avoid all that from the outset,” said Dr. Wiechmann.
Dr. Wiechmann prefers to limit the number of equipment exchanges. “When you're dealing with pedal vessels, they can be prone to spasm, and exchanges just take more radiation and more time. So, plan ahead and know what you need for inventory,” he said.
Imaging guidance for obtaining access into the target vessel is either by ultrasound or fluoroscopy. When using ultrasound, Wiechmann typically uses either a high frequency 12 MHz linear probe or a hockey stick probe.
“The nice thing is that you can visualize everything around target. We prefer transverse image for access, which is not subject to random patient movement for the most part as compared to roadmapping. And you can use ultrasound to follow the guidewire up to the point of obstruction if you are working with a technologist in the room,” he said.
Roadmapping and fluoroscopy is a better option at times, but it requires a cooperative patient. “If you’re doing roadmapping and the patient is sedated and moving all over the place, that’s not going to be of any value to you, he said.
Another potential issue with using roadmapping and fluoroscopy-guided access, “is that your hands are in the beam quite frequently and I would just caution against that,” said Wiechmann.
There are a number of access systems to choose from, some of which are pedal specific. Dr. Wiechmann said he tends to use a 014 or 018 wire.
Once access is accomplished, there are yet more decisions to make. “Are you going to use the wire and support catheter for crossing only or are you going to intervene from below? If the latter, use vasodilators liberally,” said Wiechmann.
Dr. Wiechmann concluded his short talk with a top 5 list: 1. “One is to take care of yourself…Set yourself up and the patient up for success.” The second, “learn to be facile with ultrasound but be prepared for using both fluoroscopy and ultrasound.”
His third tip was to keep access as small as possible to minimize complications, followed by a suggestion to “give your version of cocktail once the micropuncture system is in place” and “use vasodilators liberally.”
And, finally, said Dr. Wiechmann, is to “always know what your exit strategy is going to be.”