Disclosures This is How I Do It Bard Peripheral Vascular - - PowerPoint PPT Presentation

4/18/2015 Disclosures This is How I Do It • Bard Peripheral Vascular - Research, Consultant Rertrograde Tibio-Pedal • Cardiovascular Systems, Inc. - Research, Consultant Access • Cook Medical - Research, Consulting • Covidien – Consulting Fadi Saab MD, FACC, FASE, FSCAI • Terumo – Consulting Clinical Assistant Professor- Michigan State University School of Medicine • Spectranetics – Research, Consulting Department of Internal Medicine- Metro Heart and Vascular Metro Health Hospital Peroneal lateral Proximal to mid Mid to distal Calcaneal branches Tibial runoff Tibial runoff Popleteal ( Pop) Anterior Tibial PTA Artery (ATA) DP PrTA TibioPeroneal Trunk ( TPT ) ATA Peroneal (Pr) Posterior Tibial Medial calcaneal branches Posterior Tibial Artery (PTA) Lateral Medial plantar Calcaneal branch Medial Dorsalis Pedis Lateral plantar Plantar Lateral plantar 1

4/18/2015 AT Tibioperoneal trunk TPT PT Pr PT AT TPT PERONEAL Vein Tibial Vessels Evaluation and Access C • Leg Orientation D B A • Probe Selection • Utilization of US in delivering therapy RLE A=AT B=TPT C=PT D=Pr 2

4/18/2015 Technique Technique • Assessing the ideal spot for • Arterial spasm decreases the retrograde tibiopedal arterial access site is mainly done by likelihood of success, especially ultrasound. when the vessel lumen is • The operator can evaluate the already compromised. vessels with color and pulse-wave • At our institution we use the Doppler in multiple planes. • This is of paramount importance as Philips linear 15i7 MHz hockey it decreases the likelihood of stick probe and the Philips iU22 venous puncture, venous sheath X-Matrix (Philips Electronics, placement, AV fistulas, and tibial Andover, MA). artery spasm. AMP Group, 2012 AMP Group, 2012 Technique Technique • It is imperative to avoid accessing beyond the gastrocnemius • As we move the probe cranially, it is easy to heads in order to decrease the likelihood of a complication visualize how the tibial veins start to separate resulting in compartment syndrome, which in turn can lead, to from the tibial arteries, allowing easier cannulation of the tibial vessels in a spot where emergent surgical intervention and in rare occasions even the veins are not located in the planned needle amputation. trajectory. • While moving cranially, it is essential to keep in • Arterial access below the gastrocnemius heads, allows the mind the four major anatomical compartments operator to have complete control to address potential bleeding below the knee. complications during and after tibial access procedures. • These compartments lay within the gastrocnemius muscle and most of the time • A vascular technologist is present during the access process. end at the insertion points of the distal gastrocnemius heads. 3

4/18/2015 Technique Technique • It is our practice to visualize the wire under US • guidance while traveling inside the vessel. The short and long access views of these vessels will reveal the access point. • Once access is gained into the tibial vessel, the • The operator will monitor the introduction of the access needle . micro sheath is introduced into the vessel. • Retrograde tibial access will identify a hibernating lumen of these vessels not otherwise identified with traditional angiography due to proximal vessel occlusion. • Tibial lesions also can be distal and easy to identify on US evaluation. Angiographic Confirmation Anterior Tibial Artery Access • The tibial vessels are accessed • We then inject contrast to confirm our in the following fashion: intraluminal position. • Typically the foot is prepped • If the patient blood pressure allows, and draped separately. we inject 300-400 micrograms of • The orientation of the foot is nitroglycerin into the tibial vessel. adjusted depending on the • Depending on the operator, usually a target tibial vessel. 4 French micro sheath will be inserted into the tibial vessel. Saab et al Saab et al 4

4/18/2015 Anterior Tibial Artery Access Vessel Interrogation • In cases of the dorsalis pedis (DP) or the distal anterior tibial artery (AT), the foot is maintained in natural orientation with the heel of the foot on the mattress with slight dorsiflexion Saab et al Saab et al Posterior/Peroneal Tibial Artery Vessel Interrogation Access • To access the posterior tibial artery (PT) the foot is rotated laterally and the leg will be bent slightly at the knee level for patient comfort. • To access the peroneal artery the foot needs to be rotated laterally further to separate the fibula and tibia. This maneuver will facilitate direct cannulation of the artery. Saab et al Saab et al 5

4/18/2015 The Operater will choose a lower frequency Probe to image the tibial vessels as they dive into the major Compartments Ultrasound Guided Tibial- Pedal access procedure Saab et al J.A.Mustapha, MD J.A.Mustapha, MD 6

4/18/2015 The science of tibial access 60-70 Degrees 45 B 45 A J.A.Mustapha, MD J.A.Mustapha, MD J.A.Mustapha, MD J.A.Mustapha, MD 7

4/18/2015 J.A.Mustapha, MD J.A.Mustapha, MD Needles Saab et al Saab et al 8

4/18/2015 Saab et al 12 11 1 10 2 9 O’clock 3 O’clock Figure X: the best ultrasound guided entry points into the tibial artery - 12 O’clock is the best entry point into the tibial artery - 1 and 11 O’clock are the 2 nd best entry points into the tibial artery - 2 and 10 O’clock are the 3 rd best entry points into the tibial artery Saab et al 9

4/18/2015 Extra Vascular Ultrasound EVUS • The process of using US to obtain, guide and deliver therapy Saab et al 10

4/18/2015 Wires Reverberation artifacts appear as multiple equally spaced lines Why is this better than contrast?? Saab et al Saab et al No Contrast Yet Saab et al Saab et al 11

4/18/2015 Catheters Catheters Saab et al Saab et al Longitudinal view of the “white stop sign” A C Popliteal cross sectional view White Stop Sign B D Popliteal longitudinal view Short access view of the “white stop sign” J.A.Mustapha MD J.A.Mustapha MD 12

4/18/2015 Flouro Time with Our Experience TAMI and EVUS 33.09 • The Tibio-Pedal Arterial Minimally Invasive 35 27.4 Retrograde Revascularization Technique (TAMI 30 22.3 25 Technique) has been established at our 15.43 PV 20 TAMI institution since 2011 15 10 • Extra vascular ultrasound in the cath lab (EVUS) 5 0 has been established at our institution since 2011 2012 2013 Time in minutes Saab et al Thank You Fadi.saab@metrogr.org 313-590-5902 13