Pedal Loop Reconstruction Syllabus

2016-06-06

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6/6/2016

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

Pedal Loop Reconstruction: A Crash Course in 60 minutes

“Pedal-Plantar Anatomy”

Research Funding:

Osprey Medical

Mike Hogg Fund

Freeman Heart Association

Medtronic

Speaking Honoraria:

St Jude Medical

AstraZeneca

Gilead

Disclosures

•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.)

Why is it important to know tibial and pedal anatomy?

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Tibial and Popliteal Anatomy: Implications for the Pedal Circulation

Anterior tibial artery anterior circulation

Lateral originating vessel –represents first branch off of P3 segment of popliteal artery.

Superiorly passes through tibialisanterior and extensor hallicus longus muscles.

Lies in the anterior compartment –therefore perforations have implications for compartment syndrome.

At the level of the ankle, crosses under extensor retinaculum and supplies dorsum of the foot at the dorsalis pedis.

Tibial anatomy Pedal Anatomy

Vast majority of individuals have (at birth) three primary tibial

vessels:

Posterior tibial artery posterior circulation

Originates off tibo-peroneal trunk.

Lies in the deep posterior compartment.

Traverses 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

Originates off tibo-peroneal trunk.

Lies in the deep posterior compartment but supplies blood to the lateral compartment.

Important source of collaterals when primary tibial vessels are occluded.

Mousa e t al. JA NUA RY 2012 I SUPPLEMENT TO END OVASCUL AR TODAY

“Normal” Tibial “shared” origin Tibial high take off

Tibial anatomic variations

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

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Congenitally hypoplastic tibial vessels

Tibial anatomic variations

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

Pedal Anatomy

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

Deep plantar arch:

•Receives supply from the anterior circulation (dorsalis pedis)

•And the posterior circulation (lateral plantar artery)

Pedal-Plantar Loop

6/6/2016

Anatomy of L eft Foot and Ankle. S ourc e: www.medicalexhibits.com

Pedal-Plantar Loop

Authors: Ri ck B uckley, Andrew Sands, https://www2.aofou nd atio n.org

Posterior Circulation

Authors: Ri ck B uckley, Andrew Sands, https://www2.aofou nd atio n.org

Anterior Circulation

Lateral tarsal artery and plantar

arteries have communications

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Malleolar arteries

Anteri or Tibial

Dorsalis Pedi s

Lateral Tarsal

Com mu nicatio n

Medial P lantar

Lateral Plantar

Calcaneal

Pos terior Tibial

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

5th Meta -tarsal bone

mus t be separated

Lateral Oblique View

1st Meta tarsal space

mus t be visible

Anterior Posterior View

Medial P lantar

Lateral Plantar

Dorsalis Pedi s

Lateral Tarsal

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

Metatarsal access

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Pedal Anatomy: Occlusions, Collaterals, Variations

Anteri or Tibial

Dorsalis Pedi s

Lateral Tarsal

Medial P lantar

Superficial

Branch of

Medial

Plantar

Pos terior Tibial

Calcaneal

Lateral Plantar

Pedal Plantar Loop: Connections and Collaterals

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

Anterior circulation is occluded and the

medial plantar provides sole pedal

blood flow.

Medial Plantar fills Lateral Tarsal

and anterior pedal circulation

Pedal Plantar Loop: Connections and Collaterals

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

6/6/2016

Posterior circulation is occluded but

fills from anterior circulation

Pedal Plantar Loop: Connections and Collaterals

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

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.

Pedal Plantar Loop: Anatomic Variation

Manzi 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.

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

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Summary

Tibial and pedal anatomy i n the majority of patients will be reproducible, however variations exist that can

impact interpretation of angiograms.

Identification of primary tibial vessels, perfusion to the wound angiosome, a nd understanding of collaterals is

ke y to planning interventions.

Important arteries and landmarks include the first metatarsal space, the medial and lateral plantar course, the

la 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

5/23/2016

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 Alexandrescu. 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

LAT PT LAT DP

Case 1

•Lateral calcaneal foot ulcer

•Prior posterior tibial intervention

•Normal posterior tibial ABI, normal hallux TBI

5/23/2016

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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Case 3. Pedal Arch

wound supply

Absent plantar arch

Partial arch –dorsalis pedis

Partial arch –plantar artery

P=0.012

Complete plantar arch

ANT TIB

INJECTION

POST TIB

INJECTION

(PROX TO

COLLATS)

Case 4. Wound blush –watershed –

multivessel contribution –methylene blue angiography

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

5/23/2016

2D Perfusion

-time

-AUC

-opacification

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

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 check-

flo 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

Industry

Name

Support

Tip

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

Asahi

Regalia

Low

1.0 gm

Crossing

Astato

Medium

20 gm

Crossing

GrandSlam

High

<1.0 gm

Position

Treasure/

Astato 30

Medium

-30gm

Crossing

BSC

V14

High

3 gm

Crossing

V18

Medium

-6 gm

Crossing

Victory

14/18

Medium

12,18,25,30 g

Crossing

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

•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 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

Lesion type

Stenoses (n=806) 81% 6.7 73% 5.8

Occlusions (n=211) 64% 11.1 66% 10.3

Lesion Location

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

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?

6/6/2016

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

6/6/2016

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

6/6/2016

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

Retrograde?

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Visual Illusion

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Retrograde Crossing

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Another Option

6/6/2016

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

Pedal Loop Reconstruction Syllabus

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