ARRS 2022 Abstracts

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E1906. Retrograde Pedal Access for Treatment of Critical Limb Ischemia: A Review of Interventional Techniques
Authors
  1. Steven Meng; University of Rochester Medical Center
  2. Devang Butani; University of Rochester Medical Center
  3. Ashwani Sharma; University of Rochester Medical Center
  4. Andrew Cantos; University of Rochester Medical Center
Background
Critical limb ischemia (CLI) is the end-stage of lower extremity peripheral artery disease (PAD), defined by rest pain and often irreversible tissue loss. Endovascular interventions are often used to treat patients with CLI, especially in non-surgical candidates. Traditional access through femoral or radial arteries allows for antegrade crossing of lesions followed by interventions. Retrograde pedal access is an alternative technique, utilizing three main arteries: the dorsalis pedis (DP), the anterior tibial (AT), and the posterior tibial (PT) arteries. Here, we review indications and contraindications for retrograde pedal access, techniques used to gain access, and interventions that can be used in conjunction with the technique.

Educational Goals / Teaching Points
This exhibit provides an overview of CLI, basic clinical work-up, and common severity scoring systems including wound ischemia and foot infection (WIFI), Rutherford, and PREVENT III. The goals of this exhibit are to understand indications and contraindications for retrograde pedal access for CLI and technique for gaining access and troubleshooting with occluded vessels; introduce various interventions that can be used with retrograde pedal access, including primary retrograde ballooning, subintimal arterial flossing with antegrade-retrograde interventions (SAFARI), confluent two-balloon technique, and gunsight technique; and understand limitations and common complications from retrograde pedal access and subsequent interventions.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
This educational exhibit will review the anatomy of retrograde pedal access, including DP, AT, PT, and peroneal artery access. Pathophysiology of CLI and CTO lesions will be reviewed, especially plaque morphology that facilitates retrograde access. Interventional techniques reviewed include: retrograde pedal access in non-occluded and occluded vessels; primary retrograde ballooning; SAFARI; confluent two-balloon technique; and gunsight technique.

Conclusion
Retrograde pedal access is a powerful technique that can be beneficial in patients with CLI with complete total occlusions (CTO lesions), favorable lesion morphology, and nonsurgical candidates for a limb salvage. There are a variety of interventional techniques that can be paired with retrograde pedal and antegrade access to cross complex lesions.