Infrapopliteal Arterial Recanalization: a True

Home , Fibular artery

Diagnostic and Interventional Imaging (2015) 96, 423—434

REVIEW /Cardiovascular imaging

Infrapopliteal arterial recanalization: A true

advance for limb salvage in diabetics

∗

J.-M. Pernès , M. Auguste, H. Borie, S. Kovarsky,

A. Bouchareb, C. Despujole, G. Coppé

Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France

KEYWORDS Abstract The world is facing an epidemic of diabetes; consequently in the next years, crit-

Diabetes mellitus; ical limb ischemia (CLI) due to diabetic arterial disease, characterized by multiple and long

Critical limb; occlusions of below-the-knee (BTK) vessels, will become a major issue for vascular operators.

Ischemia; Revascularization is a key therapy in these patients as restoring adequate blood supply to the

Angioplasty wound is essential for healing, thus avoiding major amputations. Endoluminal therapy for BTK

arteries is now a key part of the vascular specialist armamentarium. Tibial artery endovascular

approaches have been shown to achieve high limb salvage rates with low morbidity and mortal-

ity and endovascular interventions one should now consider to be the ﬁrst line treatment in the

majority of CLI patients, especially in those with associated medical comorbidities. To do so, the

vascular specialist requires detailed knowledge of the BTK endovascular techniques and devices.

The ﬁrst step decision in tibial endovascular therapy is access. In this context, the anterograde

ipsilateral approach is generally preferred. The next critical decision is the choice of the ves-

sel(s) to be approached in order to achieve successful limb salvage. Obtaining pulsatile ﬂow to

the correct portion of the foot is the paramount for ulcer healing. As such, a good understanding

of the current angiosome model should enhance clinical results. The devices used should be

carefully selected and optimal choice of guide wire is also extremely important and should be

based on the characteristics of the lesion (location, length, and stenosis/occlusion) together

with the characteristics of the guide wire itself (tip load, stiffness, hydrophilic/hydrophobic

coating, ﬂexibility, torque transmission, trackability, and pushability). Passing through chronic

total occlusions can be quite challenging. The vascular interventional radiologist needs there-

fore to master the techniques that have been recently described: anterograde approaches,

including the drilling technique, the penetrating technique, the subintimal technique and the

parallel technique; subintimal arterial ﬂossing with anterograde-retrograde procedures (Safari);

the pedal-plantar loop technique and revascularization through collateral ﬁbular artery vessels.

∗

Corresponding author.

E-mail address: [email protected] (J.-M. Pernès).

http://dx.doi.org/10.1016/j.diii.2014.09.002

424 J.-M. Pernès et al.

characteristic of progression of atherosclerosis, gradually

Critical ischemia and diabetes: the

reducing the lumen of the artery. The assessment of cal-

current situation

ciﬁcations, their severity and distribution is an important

stage of the underlying thinking to decide on the method of

Chronic lower limb critical ischemia (CI) causes pain in

endovascular recanalization, whether transluminal or extra-

patients when they are lying down, trophic problems and

luminal, as described below.

gangrene following a major deterioration in foot perfusion.

Revascularization is the only solution which reperfuses

It differs from acute ischemia because it is longstanding,

the territory of the wound and allows it to heal. Until the end

present for more than 15 days and represents stages 4 to

of the 1990s, the only revascularization technique for distal

6 of the Rutherford classiﬁcation which has been accepted

arteries was bypass surgery [16]. The endovascular options

since the production of the TASC2 consensus document in

which developed for other anatomical areas were hindered

2007 [1]. Distal perfusion often becomes suddenly disrupted

at the time by materials which were inappropriate for the

after many years of progression of unrecognized or even

morphological features of subpopliteal obstructions. From

undiagnosed chronic disease. The natural history of this

the start of the millennium, however, the technical feasibil-

type of resting ischemia without ‘‘aggressive’’ treatment

ity of endovascular methods with non-speciﬁc devices has

is extremely poor, as 1 year after nocturnal pain or ulcer-

been demonstrated clearly by the pioneers Dorros et al. and

ation have developed, 50% of patients are either dead or

Söder et al. [17,18]. In later years, technological research

have been amputated [2—4]. It is estimated that one million

directed towards creating dedicated angioplasty materials

amputations are carried out annually throughout the world,

has logically been accompanied by an improvement in the

i.e., one every 30 seconds, half of which are performed ﬁrst

technical success rate and this treatment method is being

line with no prior diagnostic assessment [5]. Diabetes and

used for increasingly complex lesions [19—21]. As a result,

its comorbidities, primarily neuropathy, are the predomi-

endovascular revascularization has now become the ﬁrst line

nant risk factor for developing CI [6,7]. The disease is part

choice to treat tibial obstruction in diabetic patients with

of a genuine pandemic with a prevalence of 4% in France,

CI [22—25]. This strategy is based on the superior periop-

i.e., a ﬁgure consistent with the 4 million diabetic patients

erative safety of results compared to surgery. Results are

recognized; 7% of these suffer or have suffered from a foot

at least equivalent in terms of efﬁcacy, with a limb salvage

wound once in their life (between 75,000 and 150,000 annu-

rate at 1 year similar to that of surgery [26—28]. In 2008,

ally). More than 70% of healed diabetic wounds recur within

Romiti et al. [29] made a meta-analysis including 30 studies

5 years, explaining the high frequency of amputations due to

on infrapopliteal vessel angioplasty (2557 cases) and found a

this disease or between 10 and 15,000/year, half of which

primary patency rate of 48% at 3 years, secondary patency of

are estimated to be avoidable as they have been preceded

62%, limb salvage of 82% and a survival rate of 63%. No signif-

by unrecognized ulceration [8,9]. Not all diabetic wounds

icant difference was found between the subgroups in which

are ischemic but compared to neuropathic or mixed ulcers,

angioplasty was only used for the distal vessels and those

they are the ones which carry the worst prognosis with a

combined with proximal treatment and no difference was

5-year survival of 40% (65% for neuropathic ulcers) and an

also found between endo- and subintimal intentional angio-

amputation rate of 28% (10% in the neuropathy group) [10].

plasty. Ferraresi et al. [30], in 2009, described 101 diabetic

Looking for obstructive arterial lesions is therefore a

patients with CI treated by angioplasty for exclusively sub-

fundamental stage in the optimal management of a dia-

popliteal disease and found a limb salvage rate of 91% at

betic wound, guided by clinical examination and Doppler

3 years, 9% of patients having died at 1 year, and a restenosis

ultrasound. One of the fundamental features of diabetic

rate of 42% with only 3 patients undergoing a further angio-

CI is the predominance of diffuse and extensive disease

plasty because of recurrence of the CI. In 2013, Park et al.

along the subpopliteal tibial arteries either in isolation

[31] described a technical success rate of 93%, a limb sal-

or concomitantly with proximal femoro-popliteal obstruc-

vage rate of 91% at 1 year and a primary patency rate of

tive lesions [11—13]. Graziani et al. [14] showed through

75% in 63 patients in a clinical population similar to that of

angiography that 417 diabetic patients with ischemic trophic

Ferraresi.

disorders had 2893 lesions, 55% of which were obstructive.

Healing is a phenomenon which is directly related to

These involved the iliac arterial system in 1% of patients

arterial ﬂow and the basic approach as the ideal revas-

but were present in 74% of patients at the asubpopliteal

cularization strategy therefore aims to maximize perfusion

level, 66% of leg lesions were obstructive and 50% were over

of the foot. Until recent years, the preferred endovascular

10 cm in length. All three arterial systems were involved

approach was to seek direct anterograde blood ﬂow in one

in 28% of patients whereas in 55%, at least one distal

of the three leg arterial systems (according to the princi-

artery remained patent. The authors found a morphological

ple that one patent vessel is better than nothing), generally

increase in severity classiﬁcation and noted that category 4

deﬁned as the artery which was most technically accessible

(2 obstructed arteries associated with multiple tibial-ﬁbular

to recanalization. A second chronological stage designed to

and/or femoro-popliteal stenosis) was the most often rec-

optimize limb salvage aimed to achieve as complete revas-

ognized (36% of patients).

cularization as possible on the basis that 3 open vessels were

Calciﬁcations are very common [15]; and are a combina-

better than 2, which were better than one! In 2010, Peregrin

tion of those which are relatively speciﬁc for diabetes (and

et al. [32] therefore showed that complete revascularization

chronic renal impairment), due to calcium deposition in the

of the leg arterial system in diabetic patients with CI had a

interstitium of media (Mönckeberg medial calciﬁc sclerosis),

1 year limb salvage rate of 56% if direct patency was not

which have long been the predominant lesion and spares

obtained in at least one vessel (0 vessels open) and 73%,

the lumen of the artery and intimal classiﬁcation which is

80% and 83% if one, 2 or 3 vessels became patent again

Infrapopliteal arterial recanalization: A true advance for limb salvage in diabetics 425

respectively. In 2005, Faglia et al. [33] carried out ﬁrst (‘‘direct’’ revascularization) had been achieved technically

line angioplasty in 993 diabetic patients with CI and found a and to those in which this did not apply and when ‘‘indirect’’

major amputation rate of 2% at 2 years, with a 5-year limb revascularization involved one or more other vessels (sal-

salvage rate of 88%. He also found that angioplasty of tib- vage rate 69%).

ial arteries (anterior and posterior) produced better results This attractive concept should nevertheless be used with

than when angioplasty was limited to the ﬁbular artery. caution in ‘‘real life’’ as it has a number of absolute

A new relatively recent principle which has emerged is limitations: the published studies on the subject are all

direct reperfusion of the artery supplying the wound terri- retrospective, invariably contain methodological bias and

tory (‘‘wound-related artery’’ for English speaking authors) severe deep infected losses of tissue are rarely conﬁned to a

is based on the concept of the angiosome which is an single angiosome, interruption of the connections between

composite, multi-tissue, anatomical unit (skin, subcuta- different arterial systems is often found in situations where

neous tissue, fascia, muscles and bone) which is vascularized forefoot amputation is justiﬁed, hence the need for the most

by a major vessel and represents a single skin territory (there complete possible revascularization carrying a hope of post-

are 40 of these in the human body). Taylor et al. [34,35] amputation healing [41]. Finally, direct revascularization is

conﬁrmed that 5 were located on the feet and ankle and cor- more or less useful depending on the quality of the col-

responded to the three leg arteries: anterior tibial, posterior lateral supply. Varela et al. [42] showed equivalent results

tibial and ﬁbular (Fig. 1). in terms of healing and limb salvage for revascularization

Attinger et al. [36] highlighted the importance of this of the wound territory through the large collaterals which

concept in the initial work on plastic reconstruction surgery were still present and functional (plantar and ﬁbular) and

in the leg and Neville et al. [37] conﬁrmed higher heal- those which developed as a result of restoring ﬂow in the

ing and limb salvage rates after distal bypass surgery to corresponding angiosome artery.

the artery supplying the ischemic angiosome. Alexandrescu In summary, the quest for complete and/or direct revas-

et al. [38] used this model in 2008 to guide endovascular cularization, whilst desirable, cannot be dogmatic and the

procedures at the different supra- and subinguinal levels endovascular procedure considered must be adapted for

in diabetic patients suffering from CI and achieved excel- each patient in the light of ‘‘realistic’’ technical options

lent results on a retrospective analysis in 98 patients (73% of and the patient’s overall clinical situation (Fig. 3).

patients were alive without amputation at 3 years). In 2011,

the same group reported 3-year results in 213 patients with

CI from a historic comparison, before (89 patients) and after Conventional leg blood vessel

(134 patients) introduction of the concept of ‘‘angiosome-

recanalization techniques in 2014

guided’’ endovascular revascularization [39]. This appeared

to be superior in the group in which revascularization was The initial crucial stage of endovascular revascularization

based on the concept of the angiosome (salvage rates: is passing an angioplasty guide through the occluded area.

89%/79%). In 2010, Iida et al. [40] conﬁrmed better results The ﬁrst line technique remains the anterograde translumi-

in 177 patients, (4-year limb salvage rate of 86%) when the nal crossing method, (through the lumen of the true artery

angioplasty of blood vessels supplying the ischemic area which is now obstructed) which is recommended particularly

Figure 1. The 5 angiosomes of the feet and ankle correspond to the 3 leg arteries: posterior tibial (1: color orange), its collaterals and

common terminal branches (2: color orange) and lateral (3: color yellow), anterior tibial arteries and its branches (4: color green), and

ﬁbular (5: color black).

426 J.-M. Pernès et al.

Figure 2. a: severe critical ischemia of the right foot due to very tight stenosis at the origin of the anterior tibial artery and occlusion of

the tibioﬁbular trunk before and after angioplasty; b: intraluminal recanalization of the posterior tibial artery followed by angioplasty of

the anterior tibial stenosis; c: near complete healing at 4 months with restored patency of the anterior and posterior tibial arteries.

if extensive calciﬁcation is present in the vessel. Ipsilat- is performed using the ‘‘crossover’’ technique across the

eral femoral arterial puncture, possibly ultrasound-guided, aortic bifurcation. Puncture is then more straightforward,

is the preferred approach for most operators as it optimizes carries less risk of iatrogenic bleeding but requires the

guide-catheter couple manipulations [43]. A long 4F Desilet use of long angioplasty devices which are certainly avail-

introducer (45 cm) is advanced to the lower popliteal artery, able (4F, 90 cm), although are slightly more difﬁcult for

providing satisfactory support from the outset. The limita- the user. This trans- (or intra-) luminal recanalization via

tions of the approach are morbid obesity and the presence the guide are facilitated by concomitant use of a miniatur-

of proximal iliac or common or superﬁcial femoral disease, ized ‘‘support’’ catheter (2.6 F), which is reinforced (with

in which case a retrograde contralateral femoral approach a stainless steel mesh), may be angulated and is a genuine

Figure 3. Endoluminal recanalization of the anterior tibial artery by a 0.014 guide using the ‘‘drilling’’ technique before, during and post-angioplasty.

Infrapopliteal arterial recanalization: A true advance for limb salvage in diabetics 427

new arrival into the modern armamentarium, together with

a dedicated guide of diameter of 0.014 or 0.018 inches, the

manufacturing technology for which has been derived from

an adaptation of the technology for recanalization of chronic

coronary artery occlusions [44—47]. Each model of guide is

based on a compromise between support from the catheter

(the bore) and capacity to cross the occlusion, which is

related to the rigidity of its distal tip. There is now a wide

range of increasing rigidity guides available with polymer

coatings which offer good capacity to cross the occlusion,

some of which have a very high penetration potential using

the principle of crossing the obstruction through the old true

former lumen which is now occluded and reaching the true

lumen immediately beyond the obstruction (Fig. 2). Usu-

ally, the procedure is started with the ‘‘drilling’’ technique

using 0.014 intermediate rigidity hydrophilic guides aim-

ing to rotate fairly quickly with alternating clockwise and

anticlockwise movements ‘‘pushing’’ gently: the direction Figure 4. Technical principles of the ‘‘drilling’’ (guide rotation)

of recanalization is dictated by the artery itself, probably and ‘‘penetration’’ technique (the operator applies a degree of

because of the presence of areas of lower resistance in the pushing force on the guide).

occlusion which ‘‘attract’’ the sliding of the guide (Fig. 3).

If this method does not cross the occlusion and if the

obstruction is not too long, the next step involves taking J 0.035 guide dedicated for this purpose. This technique is

a second more rigid 0.014 guide (the ﬁrst guide can be known as subintimal angioplasty and was designed by Bolia

left in parallel in the subintimal space) or a 0.018 guide et al. [51]. It can also be considered ﬁrst line when it is

to attempt deliberate perforation maneuvers which involve said to be ‘‘intentional’’. This was for many years the only

more ‘‘forcing’’ of the guide. In this case, the path of the option before the development of miniaturized guides. If

guide is dictated by the operator and no longer by the artery the obstruction is not calciﬁed (Fig. 5), the estimated suc-

(Fig. 4). cess rate is equivalent to that of intraluminal recanalization

Failure of these methods, (failures usually occur if the [52]. The technical failure rate due to the guide failing to

occlusion is very long), are due to massive calciﬁcation re-enter to the true lumen beyond the occlusion is around

which deﬂect the guide from its intraluminal path, an 20% when the artery contains little calcium or is uncalciﬁed.

attempt can then be made to cross the occlusion using a The failure rate is increased in massive calciﬁcation and as a

subintimal approach [48—50]. This can be carried out either result, this method should be used by default in this anatom-

using the same guide which spontaneously or intentionally ical situation. The small diameter of the lower leg vessels

has a characteristic loop at the entrance to the subinti- do not enable the ‘‘re-entry’’ commercial mechanical sys-

mal space or after changing materials and using a small tems (such as ‘‘Outback-Cordis’’, ‘‘Pioneer’’, ‘‘Medtronic

Figure 5. Intentional subintimal angioplasty of the lower femoral popliteal and posterior tibial arteries with a dedicated 0.035 J guide.

428 J.-M. Pernès et al.

catheter’’ or ‘‘Off-road-Boston’’) to be used. Inﬂation of 4 mm; conical balloons whose diameter differs by 0.5 mm

a balloon next to the assumed re-entry area or ‘‘home- between the proximal and distal ends have been produced

made’’ fashioning of a diathermy cutting tip for a diagnostic speciﬁcally for distal arteries; ‘‘active’’ balloons impreg-

catheter can be used to traumatically cross the dissection nated with paclitaxel are available in a wide range of lengths

membrane and return subsequently into the true lumen and diameters and appear to offer a better late patency

(Fig. 6). The current technical success rate of intentional rate than is obtained with uncoated balloons [54,55]; this

or unintentional intra- or extraluminal anterograde crossing technology in principle offers better future prospects than

of the occlusion is around 80% [53] (Fig. 7). stents (auto-expanding Nitinol stents or expandable balloon

The next stage involves inﬂating an angioplasty catheter on a steel or cobalt chrome stent) which are only justiﬁed

balloon, the proﬁles of which have also improved consider- in this site when suboptimal simple angioplasty results are

ably. acceptable (residual stenosis or dissection). Liistro et al.

Coaxial balloons which are compatible with 0.014 and recently published a randomized study [55] which compared

0.018 guides offer greater capacity to cross the occlusion the effect of an active coated balloon with an uncoated

than those belonging to the monorail systems and should balloon (Debate-BTK study) in 132 diabetic patients with CI

be used in preference. They are available in a wide range and a long occlusion (14 cm) of the subpopliteal vessels and

of lengths (from 20 to 220 mm), with diameters of 1.5 to found a 1-year angiographic restenosis rate of 27% in the

Figure 6. A tip if re-entry fails after an attempt at subintimal angioplasty to create an intimal breach: using the ‘‘sharpened’’ end of a

catheter and inﬂating an undersized balloon.

Figure 7. a: high occlusion of the anterior tibial artery and at several levels in the posterior tibial artery; b: subintimal recanalization of

the posterior tibial artery; c: endoluminal recanalization of the anterior tibial artery with a 0.018 guide, introduction of a long balloon and

immediate result.

Infrapopliteal arterial recanalization: A true advance for limb salvage in diabetics 429

coated active balloon group and 74% for the balloon, a 17% technological reﬁnements of the materials in the form of

reocclusion value compared to 55% and a revascularization retrograde access to the occluded vessel using different

rate of the target lesion of 18% compared to 29%. These methods.

encouraging results have not, however, been conﬁrmed in

a more recent multicenter, randomized study (the as yet

The dual or interventional ‘‘femoro-distal

unpublished results of the In-Pact Deep study) which was

stopped prematurely because of failure to meet the safety telepheric approach’’

requirement and a considerably higher amputation rate was

found in the active balloon group. It is not therefore possi- This procedure requires combining a conventional ipsilat-

ble at present to propose the ﬁrst line use of this technology eral femoral approach with direct puncture of the leg vessel

(or at least the type of active balloon used in the study in distal to the obstruction where it is still patent from rich col-

question) for subpopliteal angioplasty. There are no coated lateral supply and which could not be reached anterogradely

stents as yet dedicated to the lower limb vessels and the in order to cross the occlusion backwards. This is now pro-

good results from their use compared to the uncoated stents posed immediately after proximal approaches have failed,

seen in the occasional published studies in the literature the introducer and guide being left in place [59—62]. The

have been obtained using coated coronary stents [56—58]. target artery is punctured under radioscopy control with a

21 G needle (4 to 7 cm), assisted by possible landmarking of

calciﬁcations and the use of radiological ‘‘road-mapping’’

mode, less commonly under ultrasound guidance. The punc-

How to push back the boundaries and

ture is usually made at the ankle and is relatively simple for

increase the feasibility of crossing the

the pedal artery, slightly more difﬁcult for the retromalle-

occlusion: the merits of retrograde olar portion of the posterior tibial artery, or higher on the

arterial approaches ﬁbular artery or even the anterior tibial [63—67] (Fig. 8).

A 0.018 guide is then used to cross the upstream occlusion

We have seen the technical failure rate using the tradi- countercurrent, facilitated by the routine use of a relatively

tional anterograde approach to be around 20% with modern rigid 2.6 F support catheter (several commercial systems are

devices although if the patient population is not carefully available), and avoiding the use of an introducer, which are

selected, this ﬁgure rises signiﬁcantly (in a number of situa- indeed contained in a 3F version but which can cause a

tions, these anterograde approaches which are attempted degree of trauma. There are then two possibilities: either

cannot recanalize the artery when chronic obstruction is the 0.018 guide crosses the whole length of the tibial occlu-

present without a visible proximal stump). In order to min- sion throughout the lumen and therefore reaches the true

imize the risk of failure of endovascular revascularization, proximal popliteal lumen, or it passes through the subintimal

new solutions have become possible, mostly as a result of space at some time during the navigation and does not end

Figure 8. a: failed anterograde recanalization of a ﬁbular occlusion (the only artery visible) with subintimal navigation of the 0.018 guide;

retrograde puncture of the ﬁbular artery; b: retrograde catheterization of the 0.018 guide recovered in the 5 F anterograde catheter; c:

result after anterograde inﬂation of a long balloon.

430 J.-M. Pernès et al.

up in the true proximal lumen. In the ﬁrst scenario, the solu- space too far away and incompatible with returning the ret-

tion is relatively simple and involves recovering the guide rograde guide into the proximal catheter. At the end of the

through the femoral introducer. A 6F angulated catheter or procedure, hemostasis can be facilitated at the distal punc-

removable valve introducer can be used in order to allow ture site by low inﬂation pressure of a balloon against the

catheterization of the lumen and removal with the ret- puncture site although the manual pressure after removing

rograde guide. A home-made or commercial lasso system the materials is usually sufﬁcient and effective and local

is another option to remove the guide from the patient complications such as thrombosis are very rare.

in ‘‘telepheric’’ mode. Once the guide has been recov- The technical success of this approach using retro-

ered, the balloon angioplasty is performed from a superior grade puncture after anterograde failure is estimated to be

approach: dilatation material cannot be introduced from around 80%, [69,70] (Fig. 9). Even in 124 patients (12% of

distally because of potential procedural problems avoiding 1035 people treated with infrapopliteal angioplasty for CI

damaging a tortuous fragile artery by inserting an introducer between 2007 and 2010), in which anterograde recanaliza-

of inappropriate size or removing the balloon after inﬂation tion failed, Gandini et al. [71] reported a technical success

(hence the justiﬁcation of the dual approach). rate of 96% using this dual approach with a limb salvage rate

In the second scenario in which the retrograde guide of 83% at 6 months and a 10% mortality rate during clinical

and its support catheter pass into the subintimal space, the follow-up, with 26% repeat procedure and 16% amputation

Safari technique (acronym for Subintimal arterial ﬂossing rates.

with anterograde retrograde intervention — Flossing being

the English term used to pass dental ﬂoss between the teeth

The ‘‘LOOP’’ technique

to remove tartar!) is used. This was described in 2003 by

Spinoza et al. [68] and involves recovering the 0.018 guide

This technique can be used to recanalize a target artery via

which is blocked in the sub-intimal space into the catheter

the plantar arcade or a sufﬁciently well-developed collat-

coming from superiorly, also in this space. A microlasso sys-

eral supply:

tem can be used to assist this and once this maneuver is

The ‘‘pedal-plantar loop’’ technique [72] may be pro-

successful, the complete unit is then removed in the femoral

posed when anterograde recanalization has failed and when

introducer and then angioplasty is then performed from

it is possible to carry out a direct distal retrograde punc-

above, using the ‘‘telepheric’’ technique. Failures are due

ture. This involves navigating the guide-catheter couple

to navigating both guides into the planes of the subintimal

through the plantar arcade between the plantar and dorsal

Figure 9. a: proximal occlusion of the anterior tibial artery, the only artery visible, returning at the ankle: failure of recanalization from

a superior approach; b: retrograde puncture of the anterior tibial artery at the junction of the pedal artery and attempted recovery of

the guide into the 6F femoral Désilet catheter left in situ; c: meeting of the 2 guides and effective Safari technique; d: ﬁnal result after anterograde balloon angioplasty.

Infrapopliteal arterial recanalization: A true advance for limb salvage in diabetics 431

circulation across the anastomosis which connects these provides access to the occluded target vessel (Fig. 11).

physiologically in the ﬁrst metatarsal space, creating a loop This is similar to the technique used during recanalization

and then advancing it retrogradely to come out into the of a coronary occlusion and allows better targeting of the

true lumen: if successful, this approach is then followed by entrance to the occlusion and therefore shortens attempts

angioplasty (Fig. 10). If there are difﬁculties progressing the to penetrate using speciﬁc guides [74].

catheter, a further anterograde attempt is made, borrow-

ing the new channel created by the retrograde guide, both

guides, usually size 0.014, travelling in the same ipsilateral

‘‘Extreme below-the-knee interventions’’

femoral introducer. The main indication for this approach

other than failure of an anterograde approach is its ﬁrst

If all of the techniques described above are unsuccessful or

line use when very distal interdigital disease is present, with

not possible, it is now technically possible to directly punc-

the hope of improving perfusion of the forefoot by restoring

ture the ﬁrst metatarsal artery or even the plantar arcade

missing connections in the toes and heels. In this speciﬁc sit-

and to undertake retrograde recanalization of the foot and

uation, recanalization of the foot arteries, Manzi and Palena

lower leg arteries through this approach [75]. Palena and

[73] described a technical success rate of 85% in 135 patients

Manzi [76] reported a technical and clinical success rate

(10% of a population of patients treated via an endovascular

of 85% at 6 months in 28 patients. Following local anesthe-

approach for CI over a period of 2 years).

sia and local administration of antispastic verapamil, the

Transcollateral angioplasty: the recanalization is per-

puncture is performed under radioscopy using a 21G needle,

formed through a highly developed collateral artery which

generally in the ﬁrst metatarsal artery (25/28), and in this

study, was associated with an increase in tcPo2 (12 mmHg

preprocedure, compared to 49 mmHg at 6 months) with 71%

of patients alive and not amputated at 6 months.

Conclusion

The range of technical endovascular revascularization pos-

sibilities for long tibial artery occlusions has recently

increased considerably enabling anterograde endoluminal

or even sub-intimal recanalization of occluded segments

in 80% of cases by miniaturized 0.014 or 0.018 guides. If

this approach fails, retrograde recanalization appears to be

effective in almost 80% of situations, mostly using distal

retrograde puncture and a dual femoro-distal ‘‘telepheric’’

approach, and less commonly by access through a collateral

or by the principle of the ‘‘pedal-plantar loop’’ technique.

Finally, even more distal punctures (of the ﬁrst metatarsal

Figure 10. Distal occlusion of the two anterior and posterior tibial

artery!) are proposed by some as the ultimate fallback and

arteries, recanalization through the plantar arcade using the ‘‘Loop

appear to produce good results.

Technique’’ principle.

Figure 11. Distal anterior tibial artery angioplasty via the ﬁbular artery.

432 J.-M. Pernès et al.

235 patients with critical limb ischemia: ﬁve-year follow-up.

Disclosure of interest

Circulation 2001;104:2057—62.

[18] Söder HK, Manninen HI, Jaakkola P, Matsi PJ, Räsänen HT,

The authors declare that they have no conﬂicts of interest

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