2010

Below-the Knee: Below-the Knee: Anatomy, Angiography and InterventionAnatomy, Angiography and Intervention

Yoshiaki Yokoi, M.D.,FACC,FSCAI

Department of CardiologyKishiwada Tokusyukai Hospital

Osaka, Japan

Critical Limb Ends up by Major Amupatin

Different Diagnosis ofDifferent Diagnosis ofDiabetic FootDiabetic Foot

Skin Perfusion Pressurefor Severe Limb Ischemia

80% accuracy of skin perfusion pressure< 30 mmHg ; Non healin ulcer> 30 mmHg : Ulcer healing

Castronuovo et al. J. Vasc. Surg. 1997; 26: 629-637.

Critical Limb Ischemia by SPP

Adapted from Castronuovo et al. J. Vasc. Surg. 1997; 26:629-637.

Ischemic Woundhealing is unlikely(CLI)

MarginalIschemia(PAD)

NotIschemic Wound

Ischemic or Diabetic ？ 60 yo, male, Diabetus, Dialysis 、 64 yo, male, Diabetus, Dialysis 、

Diabetic vs. Ischemic60 yo, M, DM, HD 64 yo, M, DM, HD

SPP 90mmHg

SPP 25mmHg

SPP 75mmHg

SPP 20mmHg

Below-the KneeBelow-the KneeAwareness of anatomical variations for Awareness of anatomical variations for

infrapopliteral interventioninfrapopliteral intervention

Basic Knowledge of Infrapopliteal Artery

Anterior tibial a.

Dorsal pedis a.

Lateral plantar a.

Medial plantar a.

Posterior tibial a.

Anterior tibial a.

Posterior tibial a.

Tibioperoneal trunk

Peroneal a.

Anatomical variations of infrapopliteal artery

Type I-A Type I-B Type I-C

Kawarada O, Yokoi Y. Cathet Cardiovasc Interv,

Type I-A: Anatomical variations

1C ないですか？Type I-B: Trifurcation

Anatomical variations

Type II-A1 Type II-A2 Type II-B Type II-C

Anatomical variations- High ATA -

ⅡA2 、Ⅱ B 、Ⅱ C ないですか？Anatomical variations High ATA: TypellA-1

Anatomical variations High ATA: TypellA-2 ATA CTO attempted

Anatomical variations- Dominant Peroneal -

Anatomical variationsDominant Peroneal:Type lllA

Variation of Infrapopliteal Artery

High take off

ATA

PTAPeroneal

Dorsal pedis

ATA

Peroneal

Plantar

PTAATA

BTK AngiographyBTK Angiography

Angiography for BTK Intervention

• Puncture common femoral artery

- Two wires technique• Placing short sheath

- Femoropopliteal artery angiography• Placing 30cm sheath

- Infrapopliteal artery angiography• Placing 3-4Fr Multipurpose catheter

- Two ipsilateral views

- Two contralateral views

A B C D

Double Wire Technique

DFADFA

SFA0.025’0.025’

0.025’

4Fr sheath

87 歳、男性 , 、 Ruhterford 3SFA と DFA の分離

61 year, Male, Rutherford 4NIDDM, Resting pain

Stepping DSA for Femoropopliteal and Infrapopliteal Artery

How to take left BK angiogram LAO 30° RAO 30°

Left Infrapopliteal ArteryIpsilateral

Left Infrapopliteal ArteryContralateral

Distal Left Infrapopliteal ArteryPre and Post Angioplasty

Pre Post

Infrapopliteal Artery Angiography

• The most difficult artery for angiography

• DSA with a small amount of dye

• Separation of three tibial arteries

• Clarify: Anterotibial to dorsal pedis Poserotibial to plantar artery

• Proximal BK: Ipsilateral view

• Distal BK: Contralateral view

Antegrade BTK InterventionAntegrade BTK Intervention

Infrapopliteal arteryOne Vessel Run off: Peroneal

Infrapopliteal artery AngioplastyTwo Vessel Run off: Anterotibial

55 y/o Male Rutherford 6

• Tissue loss of right 2nd and 3rd toe

• Hemodyalysis×7 years 　　　　　　　　　　　　　　　　　　　　　　　　　

• Diabetus SPP 40/46 mmHg

Complete Revascularizationby balloon angioplasty

Pre Post

Pre

Post

2 months

Pre Post

65 y/o Female, Ruthrford 4

SPP 67 mmHg

SPP 18 mmHg

Pre

Post

Antegrade BTK InterventionAntegrade BTK Intervention

A CaseA Case

1. Antegrade access

■ 4Fr 30cm sheath

■ 4Fr MP catheter 80cm

2. Passage of the lesion

■ 0.014” runthrough 175cm (Terumo)

■ 0.014” NEOS Cruise 175cm (Asahi Intec)

■ 0.018” Treasure 175cm 12g (Asahi Intec)

■ 0.014” Miracle 175cm 12g(Asahi Intec)

3. Balloon dilatation

■ 2.0~2.5/40~100mm, 90cm OTW PTA balloon

　　　

- Approach and Devices -

How Do I Intervene BK CTO ( １ )- Do understand anatomy -

74 y/o, femaleDiabetusR-5

How Do I Intervene BK CTO (2)- Do understand anatomy -

74 y/o, femaleDiabetusR-5

How Do I Intervene BK CTO (3)- Super selective angiography through

OTW balloon - Super selective

angiogramAdvancing wire

0.018inc. Treasure 12gBalloon angioplasty

2.5X100mm

How Do I Intervene BK CTO (4)- Repeat angiography after initial dilatation -

Super selective angiogram

Crossing wire to dorsal pedis

Confirm the wire in the vessel

How Do I Intervene BK CTO (5)- From ATA to Peroneal Intervention -

74 y/o, femaleDiabetusR-5

How Do I Intervene BK CTO (6)- Take the complete BK angiogram –

- Proximal BK -

How Do I Intervene BK CTO (6)- Take the complete BK angiogram –

- Distall BK -

How Do I Intervene BK CTO (6)- Take the complete BK angiogram -

Pre Post

74 y/o, femaleDiabetusR-5

• Be aware of complex BK anatomy

• Wiring with OTW balloon 2-2.5mmX10cm

• Before wiring CTO, super selective angiographyshould be performed and map the distal vessel

• In wire selection, firstly soft 0.014inc wire

• Minimise the stiff wire negotiation length

• Judge the timing to intervene to another vessel

How Do I Intervene BK CTO - Tip and Tricks-

Thank youThank youfor your attentionfor your attention

Thank youThank youfor your attentionfor your attention