Pedal when and how
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Transcript of Pedal when and how
Presentazione di PowerPoint
Dr. M. Manzi
Interventional Radiology UnitFoot & Ankle ClinicPoliclinico Abano TermeRegional Center of Reference for Diabetic Foot TreatmentPedal Access: When and How to do it
DISCLOSURE:Marco Manzi, MDAbbott Vascular: Consultant/Advisory Boarder
BARD: Consultant
COOK: Consultant
Covidien/EV3: Proctor
Boston Scientific: Proctor
Medtronic-Invatec: Consultant/Proctor
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Our Technical Strategies for Revascularization
Combine all these strategies (antegrade retrograde for successful endovascular therapy in diabetics with CLI
RESCUE SOLUTION Pedal Puncture after Failed Subintimal Dissection
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Pedal Puncture after Failed Subintimal DissectionRESCUE SOLUTION
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Pedal/Metatarsal punctureWiring the arteryRetrograde foot or/and tibial arteries recanalizationPTA + haemostasis
Retrograde Digital Artery Access
After antegrade recanalization failure Absence of pedal / plantar sites for puncture Retrograde pedal / plantar access failureIndications and Purposes of Pedal and Arch/Metatarsal Access
Correct projection criteriaCorrect RX Projections for Pedal and Arch/Metatarsal Access
Digital artery punctureVerapamil [5 mg/ 2 ml] diluted to 10 ml, inject 9 ml of this solution intra-arterially, close to the foot. Local anaesthesia is administered in the subcutaneous tissue along with 1 ml diluted Verapamil to avoid spasms.
First/Second Dorsal digital branch are the best option
Chose the best digital branch for access
Correct Radiological Projections
Prepare for the stick
STICK the arteryUse calcifications or CM injectionTechniques for Pedal and Arch/Metatarsal Access
Short Tip
21G Needle Micropuncture Set
Needle and ArteryMust be Allined!Techniques for Pedal and Arch/Metatarsal Access
2. Wiring the Digital branchDeploy the sheath and the support catheter after retrograde wiring of the target foot artery
Intraluminal wiring and recanalization of digital branch and pedal arch 0.018-in guide wire provide good support
Through the first dorsal branch reach the pedal arch
Micro-sheath and support catheter
Techniques for Pedal and Arch/Metatarsal Access
0,018 Dedicated Wire (Cook)/ V18 cw Ready to be Introduced
Dedicated Micro-Sheath (CooK) permits wires exchange, support catheters and balloons introduction;
Wiring the Digital Branch
3. Retrograde recanalization
Intraluminal wiring and recanalization of digital 0.018-in and 0.014-in guide wiresCombined intraluminal and subintimal technique
Rendez-vous with the antegrade catheter
Antegrade wiring
Techniques for Pedal and Arch/Metatarsal Access
4. PTA and Haemostasis
1.5 mm in diameter at nominal pressure Low-profile-OTW catheter balloon PTA for 3-5 min.
Long-balloon for definitive PTA in the foot and tibial vessels
Technical aspects: Haemostasis and Angioplasty
C.S. 75 yoDiabetes, HypertensionCLI, TcPO2 =11 mmHgPrevious apex amputation I toeGangrene IV toeTUC 3CPrevious AT antegrade failure
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Baseline Angio
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Intervention Movie
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PREPOSTAcute Angio Result
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Follow up @ 1 month/3monthswell demarcated gangrene with surrounding granulation , no infection, TcPO2 = 40 mmHgAfter amputation very goodwound TcPO2= 45mmHg
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(Admission)
M.G. 66 year oldDiabetesHypertensionCLI, TcPO2 =3 mmHgPrev apex 1 and 2 ampTUC 2C
Baseline Angio
Retrgrade Loop Puncture
Angio & Clinical Result
CONCLUSIONS 1Consider Retrograde Pedal/distal approach as a RESCUE Procedure Consider the retrograde techniques when there are the right anatomical conditions
Antegrade Plantar and Pedal accesses
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CONCLUSIONS 2The retrograde distal approach combined with all the other advanced techniques could improve our success rate in CLI
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THANKS FOR YOUR ATTENTION