Pedal Loop Reconstruction Syllabus

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6/6/2016

Pedal Loop Reconstruction: A Crash Course in 60 minutes
“Pedal-Plantar Anatomy”

Anand Prasad, MD, FACC, FSCAI, RPVI
Associate Professor of Medicine
Freeman Heart Association Endowed Professor in Cardiovascular Disease
Associate Program Director Cardiovascular Diseases Fellowship Program
Associate Editor Catheterization and Cardiovascular Interventions
Interventional Cardiology and Vascular Medicine
University of Texas Health Science Center San Antonio

Disclosures
Research Funding:
Osprey Medical
Mike Hogg Fund
Freeman Heart Association
Medtronic
Speaking Honoraria:
St Jude Medical
AstraZeneca
Gilead

Why is it important to know tibial and pedal anatomy?
• Implications for targeting angiosome guided therapy.
• Understanding anatomic variants which may be congenital and non-pathologic
• Avoiding confusing branches or collaterals with true vessels – which may lead to
complications.
• Intact pedal plantar loop allows for the most robust filling of the distal vessels.
• Rates of healing appear to be higher with an intact pedal plantar loop
(Rashid H et al J of Vasc Surgery 57(5):1219-1226, 2013. and Manzi M et al J Cardiovasc Surg, 50(3):331-7,2009.)

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Tibial and Popliteal Anatomy: Implications for the Pedal Circulation

Tibial anatomy  Pedal Anatomy
Vast majority of individuals have (at birth) three primary tibial
vessels:
 Anterior tibial artery  anterior circulation
 La teral originating vessel – represents first branch off of P3 segment of popliteal artery.
 Superiorly passes through tibialis anterior and extensor hallicus longus muscles.
 Li es in the anterior compartment – therefore perforations have implications for compartment syndrome.
 At the l evel of the ankle, crosses under extensor retinaculum and supplies dorsum of the foot at the dorsalis pedis.
 Posterior tibial artery  posterior circulation
 Ori ginates off tibo-peroneal trunk.
 Li es in the deep posterior compartment.
 Tra verses behind the medial malleolus and then divides into medial a nd lateral plantar vessels.
 Peroneal artery  communicating branches to the primary tibial vessels, calcaneal perfusion
 Ori ginates off tibo-peroneal trunk.
 Li es in the deep posterior compartment but supplies blood to the lateral compartment.
 Important source of collaterals when primary tibial vessels are occluded.

Mousa et al. JANUARY 2012 I SUPPLEMENT TO ENDOVASCULAR TODAY

Tibial anatomic variations
“Normal”

Tibial “shared” origin

Tibial high take off

Kim D et al. Ann. Surg. - December 1989

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Tibial anatomic variations

Congenitally hypoplastic tibial vessels

Kim D et al. Ann. Surg. - December 1989

Pedal Anatomy

Pedal-Plantar Loop

Deep plantar arch:
• Receives supply from the anterior circulation (dorsalis pedis)
• And the posterior circulation (lateral plantar artery)

Foot Posterior Tibial Artery. Source: classconnection.s3.amazonaws.com

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Pedal-Plantar Loop

Anatomy of Left Foot and Ankle. Source: www.medicalexhibits.com

Posterior Circulation

Authors: Rick Buckley, Andrew Sands, https://www2.aofoundation.org

Anterior Circulation

 Lateral tarsal artery and plantar
arteries have communications

Authors: Rick Buckley, Andrew Sands, https://www2.aofoundation.org

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Lateral Oblique View

Posterior Tibial

Anterior Tibial

Malleolar arteries

Dorsalis Pedis

Calcaneal

Medial Plantar

Lateral Tarsal
Lateral Plantar

Communication

5th Meta -tarsal bone
mus t be separated
Manz i et al. RadioG raphics 2011; 31:1623–1636

Anterior Posterior View
Lateral Plantar
Dorsalis Pedis
Medial Plantar
Lateral Tarsal

1st Meta tarsal space
mus t be visible
Manz i et al. RadioG raphics 2011; 31:1623–1636

Metatarsal access

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Pedal Anatomy: Occlusions, Collaterals, Variations

Pedal Plantar Loop: Connections and Collaterals
Posterior Tibial

Anterior Tibial

Dorsalis Pedis

Calcaneal
Lateral Tarsal
Medial Plantar

Lateral Plantar

Superficial
Branch of
Medial
Plantar

Manz i et al. RadioG raphics 2011; 31:1623–1636

Pedal Plantar Loop: Connections and Collaterals

Medial Plantar fills Lateral Tarsal
and anterior pedal circulation

Anterior circulation is occluded and the
medial plantar provides sole pedal
blood flow.

Manz i et al. RadioG raphics 2011; 31:1623–1636

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Pedal Plantar Loop: Connections and Collaterals

Posterior circulation is occluded but
fills from anterior circulation

Manz i et al. RadioG raphics 2011; 31:1623–1636

Pedal Plantar Loop: Anatomic Variation

Anatomic variation:
 No dorsalis pedis: Lateral tarsal
artery is the dominant anterior
vessel: 6-12% individuals.
 The arcuate artery which normally
originates from the dorsalis pedis is
missing: ~ 30% of individuals.

Manz i et al. RadioG raphics 2011; 31:1623–1636

Pedal Plantar Loop: Anatomic Variation

Anatomic variation:
Anterior and Posterior circulations do
not communicate: ~ 10% of individuals.
Manz i et al. RadioG raphics 2011; 31:1623–1636

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Summary
 Ti bial and pedal anatomy i n the majority of patients will be reproducible, however variations exist that can
i mpact interpretation of angiograms.
 Identification of primary ti bial vessels, perfusion to the wound angiosome, a nd understanding of collaterals is
key to planning interventions.
 Important arteries and landmarks include the first metatarsal space, the medial and lateral plantar course, the
l a teral tarsal branch off of the dorsalis pedis, and the union of the lateral plantar with the dorsalis pedis to
complete the pedal plantar loop

THANK YOU

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With Pedal Loop Reconstruction,
Any Need For Angiosome
GuidedTherapy?
John H. Rundback MD FAHA FSVM FSIR
Medical Director, Interventional Institute
Holy Name Medical Center, Teaneck, NJ

Angiosomes
• First described by Taylor in
2007
• Not specifically intended to
describe pedal arch
vessel
• In fact, the pedal arch is the
terminal distribution of the
named angiosomes
• The extent of name pedal
vessels is limited

Al exandrescu. J
Endovasc Ther 2011

Angiographosomes
• A better term for angiographically mediated revascularization
• Requires distal injections, vasodilator, AP and lateral projections
• Goal is to assess regional and wound specific PERFUSION
• Most pedal wounds are watershed…
• Multivessel contribution including pedal arch branches supply
ischemic tissue

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Angiographosome
AP

LAT PT

LAT DP

Case 1
• Lateral calcaneal foot ulcer
• Prior posterior tibial intervention
• Normal posterior tibial ABI, normal hallux TBI

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PRE

POST

Case 2
• Distal hallux wound in March revascularized peroneal with PT
continuation, and AT PTA with sluggish flow.
• Had Distal hallux amp with plantar flap
• Presents with Regional Ischemia, rest pain, cellulitis on dorsum of foot

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Prior angio

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Complete plantar arch

Case 3. Pedal Arch
wound supply

Partial arch – dorsalis pedis
Partial arch – plantar artery

P=0.012

Absent plantar arch

Case 4. Wound blush – watershed –
multivessel contribution – methylene blue angiography
ANT TIB
INJECTION

POST TIB
INJECTION
(PROX TO
COLLATS)

Conclusion
• ANGIOGRAPHOSOMES – angiographically mediated revascularization
remains relevant for pedal arch interventions
• Wound blush is the main objective measure
• Methylene blue or indocyanine green (Luna systems) can further
define patterns of pedal arch perfusion
• Evolving perfusion systems will provide more optimized
determination of real time interventional success

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2D Perfusion
-time
-AUC
-opacification

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Pedal loop reconstruction: what are the tools?
Lawrence A. Garcia, MD

Chief, Section Interventional Cardiology
and Vascular Interventions
Director, Vascular Medicine
St. Elizabeth’s Medical Center
Tufts University School of Medicine
Boston, MA

Case PT
• 88 year old female with history HTN, HLP,
DM and PVD with L great toe ulceration and
chronic pain with infection at site with MRSA
• Non-invasive work-up included ABI/duplex
with non-compressible. Pre-occlusive Doppler
in all tibial vessels distally with outflow
appearing to be PT
• Angiography planned and images taken

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What do you need?
•
•
•
•
•

Access tools
Sheaths
Wires
Support catheters
Ballloons
– Non-DCB
– DCB

• Stents
– Balloon expandable
– SES
– DES

• Athrectomy

Access tools
• Access and “bear
back” your wire and
support catheter
• Can use angiocath
– Simple IV catheter

• Cook systems checkflo 4 Fr
• Larger sheaths have
been used (5-6 Fr)

Wires
•
•
•
•

Depends on your tastes
0.035” rarely used in the tibial circulation
0.018” useful and supportive
0.014” most commonly used

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Industry Name

Support

Tip Wt

Use

Abbott

SpartaCore

Strong

<1.0 gm

WorkHorse

Command/Winn
series

Medium

Up to 10 gm

Crossing

Connect

Strong

Up to 30 g

Crossing

SteelCore

Strong

<1.0 gm

WorkHorse

Regalia

Low

1.0 gm

Crossing

Astato 20

Medium

20 gm

Crossing

GrandSlam

High

<1.0 gm

Position

Treasure/Astato 30

Medium

12-30gm

Crossing

V14

High

3 gm

Crossing

V18

Medium

3-6 gm

Crossing

Victory 14/18

Medium

12,18,25,30 g

Crossing

Asahi

BSC

Support catheters
• Either for position or
increase force of distal
wire
• 0.018” and 0.014”
systems most often
used
• Straight or angled

Devices
• Balloons
– POBA
– DCB?

• Stents
– DES
– SES (BMS/DES)

• Atherectomy
– Directional
– Orbital
– Rotational

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• To date there are no meaningful data
regarding outcomes with atherectomy in the
pedal loop
• Definitive LE
– 78% patency 6 cm LL CLI

• LIBERTY 360
– To be presented 2016

Primary Patency in Subgroups
Subgroup

Claudicants (n=743)

CLI (n=279)

Patency
(PSVR < 2.4)

Lesion
Length (cm)

Patency
(PSVR < 2.4)

Lesion
Length (cm)

All (n=1022)

78%

7.5

71%

7.2

By Lesion Length
< 4 cm (n=318)

81%

2.2

84%

2.3

4-9.9 cm (n=418)

83%

6.5

62%

6.6

≥ 10 cm (n=283)

67%

14.4

65%

15.1

SFA Only By Lesion Length
< 4 cm (n=184)
78%

2.3

82%

2.3

4-9.9 cm (n=253)

83%

6.5

60%

6.9

≥ 10 cm (n=232)

65%

14.6

63%

15.5

Primary Patency in Subgroups
Subgroup

All (n=1022)

Claudicants (n=743)

CLI (n=279)

Patency
(PSVR < 2.4)

Lesion
Length (cm)

Patency
(PSVR < 2.4)

Lesion
Length (cm)

78%

7.5

71%

7.2

Lesion type

Stenoses (n=806)

81%

6.7

73%

5.8

Occlusions (n=211)

64%

11.1

66%

10.3

SFA (n=671)

75%

8.1

68%

8.6

Popliteal (n=162)

77%

6.0

68%

5.4

Infrapopliteal
(n=189)

90%

5.5

78%

6.0

Lesion Location

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LIBERTY 360
• Prospective, observational, multi-center clinical study to
evaluate acute and long-term clinical, functional and economic
outcomes of endovascular device intervention in patients with
distal outflow peripheral arterial disease (PAD)
• No inclusion and exclusion
• Independent core laboratory analyses and adjudications
–
–
–
–

Angiographic
Duplex Ultrasound
Six Minute Walk Test
Health Economics

• Includes separate analyses for
– Claudicants
– Critical limb ischemia (RB4 and 5)
– Critical limb ischemia (RB6)

Conclusions
• Pedal loop reconstruction is an attractive intervention for
limb salvage and foot preservation
• Devices and selection of method of intervention remain at
the discretion of the operator
• Access and contemporary interventional approach allows a
myriad of technologies and devices for ultimate
revascularization
• Issues that remain

– Still may be too aggressive to the pedal loop without
current long term data seems an important issue
– Is drug elution/delivery an important part of the
intervention?

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Pedal Loop Reconstruction
Step by Step Case
Presentation
Fadi Saab MD, FACC,FASE,FSCAI
Associate Director of Cardiovascular Laboratories
Co-Director of Pulmonary Embolism and Deep Venous Thrombosis Services
Clinical Assistant Professor-Michigan State University
School of Medicine
Metro Heart and Vascular
Metro Health Hospital

Disclosures
• Bard Peripheral Vascular - Research, Consultant,
• Cardiovascular Systems, Inc. - Research, Consultant,
• Cook Medical - Research, Consulting
• Covidien – Consulting

• Terumo – Consulting
• Spectranetics – Research, Consulting

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Advantage of Retrograde Tibial
Access
Increase success rate of crossing
Shorten treated segment

Preserve options of therapy : Surgery, atherectomy
Utilize hibernating lumen
Preserve tibial vessels flow
Saab et al

Pedal Loop Reconstruction
Antegrade Approach

•
•
•
•

Critical Limb Ischemia patients
Patients with Short Pedal CTO’s
Requires at Least 5 Fr Sheath
Adequate Flow through the opposite
vessel (PT or AT)

Retrograde Approach

•
•
•
•
•

Usually for longer CTO’s
Requires a Tri-Axial system
Usually safer
At least a 6 Fr sheath
Retrograde crossing under
Flouroscopy with a 0.014 loop
technique

Saab et al

Pedal Loop Reconstruction
Wires
•
•
•
•
•

Journey Wire (BSCN)
Regalia Wire (Asahi)
Glide Advantage (0.014) (Terumo)
Runthrough (Terumo)
Gladius (Asahi)

Saab et al

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Case Presentation
• 69 year old that presented
with a non healing wound over
the Plantar and dorsal aspect
of the great toe
• Risk factors include: HTN, DM,
Ischemic cardiomyopathy with
an EF of 40%
• Despite 6 months of wound
care, no healing
• Non compressible ABI’s

Antegrade
VS
Retrograde?

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Visual Illusion

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Retrograde Crossing

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Another Option

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Conclusion
• Pedal Loop reconstruction is the next phase in CLI therapy
• Current available plaque modification technology for the
pedal loop is expanding.
• Current technologies include Laser atherectomy, Orbital
atherectomy and Phoenix atherectomy
• Long term benefits will need to be tracked and
documented in trials and registries (PRIME Registry)

fadisaab17@hotmail.com
Fadi.saab@metrogr.org
313-590-5902

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