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

REVIEW /Cardiovascular imaging

Infrapopliteal arterial recanalization: A trueadvance 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

KEYWORDSDiabetes mellitus;Critical limb;Ischemia;Angioplasty

Abstract The world is facing an epidemic of diabetes; consequently in the next years, crit-ical limb ischemia (CLI) due to diabetic arterial disease, characterized by multiple and longocclusions of below-the-knee (BTK) vessels, will become a major issue for vascular operators.Revascularization is a key therapy in these patients as restoring adequate blood supply to thewound is essential for healing, thus avoiding major amputations. Endoluminal therapy for BTKarteries is now a key part of the vascular specialist armamentarium. Tibial artery endovascularapproaches 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 themajority of CLI patients, especially in those with associated medical comorbidities. To do so, thevascular 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 anterogradeipsilateral 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 tothe correct portion of the foot is the paramount for ulcer healing. As such, a good understandingof the current angiosome model should enhance clinical results. The devices used should becarefully selected and optimal choice of guide wire is also extremely important and should bebased on the characteristics of the lesion (location, length, and stenosis/occlusion) togetherwith the characteristics of the guide wire itself (tip load, stiffness, hydrophilic/hydrophobiccoating, flexibility, torque transmission, trackability, and pushability). Passing through chronictotal 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 theparallel technique; subintimal arterial flossing with anterograde-retrograde procedures (Safari);the pedal-plantar loop technique and revascularization through collateral fibular artery vessels.

© 2015 Éditions francaises de rad

∗ Corresponding author.E-mail address: j.marc.pernes@wanadoo.fr (J.-M. Pernès).

http://dx.doi.org/10.1016/j.diii.2014.09.0022211-5684/© 2015 Éditions francaises de radiologie. Published by Elsevie

iologie. Published by Elsevier Masson SAS. All rights reserved.

r Masson SAS. All rights reserved.

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ritical ischemia and diabetes: theurrent situation

hronic lower limb critical ischemia (CI) causes pain inatients when they are lying down, trophic problems andangrene following a major deterioration in foot perfusion.t differs from acute ischemia because it is longstanding,resent for more than 15 days and represents stages 4 to

of the Rutherford classification which has been acceptedince the production of the TASC2 consensus document in007 [1]. Distal perfusion often becomes suddenly disruptedfter many years of progression of unrecognized or evenndiagnosed chronic disease. The natural history of thisype of resting ischemia without ‘‘aggressive’’ treatments extremely poor, as 1 year after nocturnal pain or ulcer-tion have developed, 50% of patients are either dead orave been amputated [2—4]. It is estimated that one millionmputations are carried out annually throughout the world,.e., one every 30 seconds, half of which are performed firstine with no prior diagnostic assessment [5]. Diabetes andts comorbidities, primarily neuropathy, are the predomi-ant risk factor for developing CI [6,7]. The disease is partf a genuine pandemic with a prevalence of 4% in France,.e., a figure consistent with the 4 million diabetic patientsecognized; 7% of these suffer or have suffered from a footound once in their life (between 75,000 and 150,000 annu-lly). More than 70% of healed diabetic wounds recur within

years, explaining the high frequency of amputations due tohis disease or between 10 and 15,000/year, half of whichre estimated to be avoidable as they have been precededy unrecognized ulceration [8,9]. Not all diabetic woundsre ischemic but compared to neuropathic or mixed ulcers,hey are the ones which carry the worst prognosis with a-year survival of 40% (65% for neuropathic ulcers) and anmputation rate of 28% (10% in the neuropathy group) [10].

Looking for obstructive arterial lesions is therefore aundamental stage in the optimal management of a dia-etic wound, guided by clinical examination and Dopplerltrasound. One of the fundamental features of diabeticI is the predominance of diffuse and extensive diseaselong the subpopliteal tibial arteries either in isolationr concomitantly with proximal femoro-popliteal obstruc-ive lesions [11—13]. Graziani et al. [14] showed throughngiography that 417 diabetic patients with ischemic trophicisorders had 2893 lesions, 55% of which were obstructive.hese involved the iliac arterial system in 1% of patientsut were present in 74% of patients at the asubpoplitealevel, 66% of leg lesions were obstructive and 50% were over0 cm in length. All three arterial systems were involvedn 28% of patients whereas in 55%, at least one distalrtery remained patent. The authors found a morphologicalncrease in severity classification and noted that category 42 obstructed arteries associated with multiple tibial-fibularnd/or femoro-popliteal stenosis) was the most often rec-gnized (36% of patients).

Calcifications are very common [15]; and are a combina-ion of those which are relatively specific for diabetes (andhronic renal impairment), due to calcium deposition in the

nterstitium of media (Mönckeberg medial calcific sclerosis),hich have long been the predominant lesion and spares

he lumen of the artery and intimal classification which is

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J.-M. Pernès et al.

haracteristic of progression of atherosclerosis, graduallyeducing the lumen of the artery. The assessment of cal-ifications, their severity and distribution is an importanttage of the underlying thinking to decide on the method ofndovascular recanalization, whether transluminal or extra-uminal, as described below.

Revascularization is the only solution which reperfuseshe territory of the wound and allows it to heal. Until the endf the 1990s, the only revascularization technique for distalrteries was bypass surgery [16]. The endovascular optionshich developed for other anatomical areas were hinderedt the time by materials which were inappropriate for theorphological features of subpopliteal obstructions. From

he start of the millennium, however, the technical feasibil-ty of endovascular methods with non-specific devices haseen demonstrated clearly by the pioneers Dorros et al. andöder et al. [17,18]. In later years, technological researchirected towards creating dedicated angioplasty materialsas logically been accompanied by an improvement in theechnical success rate and this treatment method is beingsed for increasingly complex lesions [19—21]. As a result,ndovascular revascularization has now become the first linehoice to treat tibial obstruction in diabetic patients withI [22—25]. This strategy is based on the superior periop-rative safety of results compared to surgery. Results aret least equivalent in terms of efficacy, with a limb salvageate at 1 year similar to that of surgery [26—28]. In 2008,omiti et al. [29] made a meta-analysis including 30 studiesn infrapopliteal vessel angioplasty (2557 cases) and found arimary patency rate of 48% at 3 years, secondary patency of2%, limb salvage of 82% and a survival rate of 63%. No signif-cant difference was found between the subgroups in whichngioplasty was only used for the distal vessels and thoseombined with proximal treatment and no difference waslso found between endo- and subintimal intentional angio-lasty. Ferraresi et al. [30], in 2009, described 101 diabeticatients with CI treated by angioplasty for exclusively sub-opliteal disease and found a limb salvage rate of 91% at

years, 9% of patients having died at 1 year, and a restenosisate of 42% with only 3 patients undergoing a further angio-lasty because of recurrence of the CI. In 2013, Park et al.31] described a technical success rate of 93%, a limb sal-age rate of 91% at 1 year and a primary patency rate of5% in 63 patients in a clinical population similar to that oferraresi.

Healing is a phenomenon which is directly related torterial flow and the basic approach as the ideal revas-ularization strategy therefore aims to maximize perfusionf the foot. Until recent years, the preferred endovascularpproach was to seek direct anterograde blood flow in onef the three leg arterial systems (according to the princi-le that one patent vessel is better than nothing), generallyefined as the artery which was most technically accessibleo recanalization. A second chronological stage designed toptimize limb salvage aimed to achieve as complete revas-ularization as possible on the basis that 3 open vessels wereetter than 2, which were better than one! In 2010, Peregrint al. [32] therefore showed that complete revascularization

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

year limb salvage rate of 56% if direct patency was notbtained in at least one vessel (0 vessels open) and 73%,0% and 83% if one, 2 or 3 vessels became patent again

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Infrapopliteal arterial recanalization: A true advance for lim

respectively. In 2005, Faglia et al. [33] carried out firstline angioplasty in 993 diabetic patients with CI and found amajor amputation rate of 2% at 2 years, with a 5-year limbsalvage rate of 88%. He also found that angioplasty of tib-ial arteries (anterior and posterior) produced better resultsthan when angioplasty was limited to the fibular artery.

A new relatively recent principle which has emerged isdirect reperfusion of the artery supplying the wound terri-tory (‘‘wound-related artery’’ for English speaking authors)is based on the concept of the angiosome which is ancomposite, multi-tissue, anatomical unit (skin, subcuta-neous tissue, fascia, muscles and bone) which is vascularizedby a major vessel and represents a single skin territory (thereare 40 of these in the human body). Taylor et al. [34,35]confirmed that 5 were located on the feet and ankle and cor-responded to the three leg arteries: anterior tibial, posteriortibial and fibular (Fig. 1).

Attinger et al. [36] highlighted the importance of thisconcept in the initial work on plastic reconstruction surgeryin the leg and Neville et al. [37] confirmed higher heal-ing and limb salvage rates after distal bypass surgery tothe artery supplying the ischemic angiosome. Alexandrescuet al. [38] used this model in 2008 to guide endovascularprocedures at the different supra- and subinguinal levelsin diabetic patients suffering from CI and achieved excel-lent results on a retrospective analysis in 98 patients (73% ofpatients were alive without amputation at 3 years). In 2011,the same group reported 3-year results in 213 patients withCI from a historic comparison, before (89 patients) and after(134 patients) introduction of the concept of ‘‘angiosome-guided’’ endovascular revascularization [39]. This appearedto be superior in the group in which revascularization was

based on the concept of the angiosome (salvage rates:89%/79%). In 2010, Iida et al. [40] confirmed better resultsin 177 patients, (4-year limb salvage rate of 86%) when theangioplasty of blood vessels supplying the ischemic area

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Figure 1. The 5 angiosomes of the feet and ankle correspond to the 3common terminal branches (2: color orange) and lateral (3: color yellofibular (5: color black).

lvage in diabetics 425

‘‘direct’’ revascularization) had been achieved technicallynd to those in which this did not apply and when ‘‘indirect’’evascularization involved one or more other vessels (sal-age rate 69%).

This attractive concept should nevertheless be used withaution in ‘‘real life’’ as it has a number of absoluteimitations: the published studies on the subject are alletrospective, invariably contain methodological bias andevere deep infected losses of tissue are rarely confined to aingle angiosome, interruption of the connections betweenifferent arterial systems is often found in situations whereorefoot amputation is justified, hence the need for the mostomplete possible revascularization carrying a hope of post-mputation healing [41]. Finally, direct revascularization isore or less useful depending on the quality of the col-

ateral supply. Varela et al. [42] showed equivalent resultsn terms of healing and limb salvage for revascularizationf the wound territory through the large collaterals whichere still present and functional (plantar and fibular) and

hose which developed as a result of restoring flow in theorresponding angiosome artery.

In summary, the quest for complete and/or direct revas-ularization, whilst desirable, cannot be dogmatic and thendovascular procedure considered must be adapted forach patient in the light of ‘‘realistic’’ technical optionsnd the patient’s overall clinical situation (Fig. 3).

onventional leg blood vesselecanalization techniques in 2014

he initial crucial stage of endovascular revascularization

s passing an angioplasty guide through the occluded area.he first line technique remains the anterograde translumi-al crossing method, (through the lumen of the true arteryhich is now obstructed) which is recommended particularly

leg arteries: posterior tibial (1: color orange), its collaterals andw), anterior tibial arteries and its branches (4: color green), and

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 oft recat ith re

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he tibiofibular trunk before and after angioplasty; b: intraluminalhe anterior tibial stenosis; c: near complete healing at 4 months w

f extensive calcification is present in the vessel. Ipsilat-ral femoral arterial puncture, possibly ultrasound-guided,s the preferred approach for most operators as it optimizesuide-catheter couple manipulations [43]. A long 4F Desiletntroducer (45 cm) is advanced to the lower popliteal artery,

roviding satisfactory support from the outset. The limita-ions of the approach are morbid obesity and the presencef proximal iliac or common or superficial femoral disease,n which case a retrograde contralateral femoral approach

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igure 3. Endoluminal recanalization of the anterior tibial artery byost-angioplasty.

nalization of the posterior tibial artery followed by angioplasty ofstored patency of the anterior and posterior tibial arteries.

s performed using the ‘‘crossover’’ technique across theortic bifurcation. Puncture is then more straightforward,arries less risk of iatrogenic bleeding but requires these of long angioplasty devices which are certainly avail-ble (4F, 90 cm), although are slightly more difficult for

he user. This trans- (or intra-) luminal recanalization viahe guide are facilitated by concomitant use of a miniatur-zed ‘‘support’’ catheter (2.6 F), which is reinforced (with

stainless steel mesh), may be angulated and is a genuine

a 0.014 guide using the ‘‘drilling’’ technique before, during and

b salvage in diabetics 427

Figure 4. Technical principles of the ‘‘drilling’’ (guide rotation)and ‘‘penetration’’ technique (the operator applies a degree ofp

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Infrapopliteal arterial recanalization: A true advance for lim

new arrival into the modern armamentarium, together witha dedicated guide of diameter of 0.014 or 0.018 inches, themanufacturing technology for which has been derived froman adaptation of the technology for recanalization of chroniccoronary artery occlusions [44—47]. Each model of guide isbased on a compromise between support from the catheter(the bore) and capacity to cross the occlusion, which isrelated to the rigidity of its distal tip. There is now a widerange of increasing rigidity guides available with polymercoatings which offer good capacity to cross the occlusion,some of which have a very high penetration potential usingthe principle of crossing the obstruction through the old trueformer lumen which is now occluded and reaching the truelumen immediately beyond the obstruction (Fig. 2). Usu-ally, the procedure is started with the ‘‘drilling’’ techniqueusing 0.014 intermediate rigidity hydrophilic guides aim-ing to rotate fairly quickly with alternating clockwise andanticlockwise movements ‘‘pushing’’ gently: the directionof recanalization is dictated by the artery itself, probablybecause of the presence of areas of lower resistance in theocclusion which ‘‘attract’’ the sliding of the guide (Fig. 3).

If this method does not cross the occlusion and if theobstruction is not too long, the next step involves takinga second more rigid 0.014 guide (the first guide can beleft in parallel in the subintimal space) or a 0.018 guideto attempt deliberate perforation maneuvers which involvemore ‘‘forcing’’ of the guide. In this case, the path of theguide is dictated by the operator and no longer by the artery(Fig. 4).

Failure of these methods, (failures usually occur if theocclusion is very long), are due to massive calcificationwhich deflect the guide from its intraluminal path, anattempt can then be made to cross the occlusion using a

subintimal approach [48—50]. This can be carried out eitherusing the same guide which spontaneously or intentionallyhas a characteristic loop at the entrance to the subinti-mal space or after changing materials and using a small

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Figure 5. Intentional subintimal angioplasty of the lower femoral pop

ushing force on the guide).

0.035 guide dedicated for this purpose. This technique isnown as subintimal angioplasty and was designed by Boliat al. [51]. It can also be considered first line when it isaid to be ‘‘intentional’’. This was for many years the onlyption before the development of miniaturized guides. Ifhe obstruction is not calcified (Fig. 5), the estimated suc-ess rate is equivalent to that of intraluminal recanalization52]. The technical failure rate due to the guide failing toe-enter to the true lumen beyond the occlusion is around0% when the artery contains little calcium or is uncalcified.he failure rate is increased in massive calcification and as aesult, this method should be used by default in this anatom-

cal situation. The small diameter of the lower leg vesselso not enable the ‘‘re-entry’’ commercial mechanical sys-ems (such as ‘‘Outback-Cordis’’, ‘‘Pioneer’’, ‘‘Medtronic

liteal and posterior tibial arteries with a dedicated 0.035 J guide.

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atheter’’ or ‘‘Off-road-Boston’’) to be used. Inflation of balloon next to the assumed re-entry area or ‘‘home-ade’’ fashioning of a diathermy cutting tip for a diagnostic

atheter can be used to traumatically cross the dissectionembrane and return subsequently into the true lumen

Fig. 6). The current technical success rate of intentionalr unintentional intra- or extraluminal anterograde crossingf the occlusion is around 80% [53] (Fig. 7).

The next stage involves inflating an angioplasty catheteralloon, the profiles of which have also improved consider-bly.

Coaxial balloons which are compatible with 0.014 and.018 guides offer greater capacity to cross the occlusion

han those belonging to the monorail systems and shoulde used in preference. They are available in a wide rangef lengths (from 20 to 220 mm), with diameters of 1.5 to

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igure 6. A tip if re-entry fails after an attempt at subintimal angiopatheter and inflating an undersized balloon.

igure 7. a: high occlusion of the anterior tibial artery and at several

he posterior tibial artery; c: endoluminal recanalization of the anteriormmediate result.

J.-M. Pernès et al.

mm; conical balloons whose diameter differs by 0.5 mmetween the proximal and distal ends have been producedpecifically for distal arteries; ‘‘active’’ balloons impreg-ated with paclitaxel are available in a wide range of lengthsnd diameters and appear to offer a better late patencyate than is obtained with uncoated balloons [54,55]; thisechnology in principle offers better future prospects thantents (auto-expanding Nitinol stents or expandable balloonn a steel or cobalt chrome stent) which are only justifiedn this site when suboptimal simple angioplasty results arecceptable (residual stenosis or dissection). Liistro et al.ecently published a randomized study [55] which comparedhe effect of an active coated balloon with an uncoated

alloon (Debate-BTK study) in 132 diabetic patients with CInd a long occlusion (14 cm) of the subpopliteal vessels andound a 1-year angiographic restenosis rate of 27% in the

lasty to create an intimal breach: using the ‘‘sharpened’’ end of a

levels in the posterior tibial artery; b: subintimal recanalization of tibial artery with a 0.018 guide, introduction of a long balloon and

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Infrapopliteal arterial recanalization: A true advance for lim

coated active balloon group and 74% for the balloon, a 17%reocclusion value compared to 55% and a revascularizationrate of the target lesion of 18% compared to 29%. Theseencouraging results have not, however, been confirmed ina more recent multicenter, randomized study (the as yetunpublished results of the In-Pact Deep study) which wasstopped prematurely because of failure to meet the safetyrequirement and a considerably higher amputation rate wasfound in the active balloon group. It is not therefore possi-ble at present to propose the first line use of this technology(or at least the type of active balloon used in the study inquestion) for subpopliteal angioplasty. There are no coatedstents as yet dedicated to the lower limb vessels and thegood results from their use compared to the uncoated stentsseen in the occasional published studies in the literaturehave been obtained using coated coronary stents [56—58].

How to push back the boundaries andincrease the feasibility of crossing theocclusion: the merits of retrogradearterial approaches

We have seen the technical failure rate using the tradi-tional anterograde approach to be around 20% with moderndevices although if the patient population is not carefullyselected, this figure rises significantly (in a number of situa-tions, these anterograde approaches which are attempted

cannot recanalize the artery when chronic obstruction ispresent without a visible proximal stump). In order to min-imize the risk of failure of endovascular revascularization,new solutions have become possible, mostly as a result of

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Figure 8. a: failed anterograde recanalization of a fibular occlusion (thretrograde puncture of the fibular artery; b: retrograde catheterizationresult after anterograde inflation of a long balloon.

lvage in diabetics 429

echnological refinements of the materials in the form ofetrograde access to the occluded vessel using differentethods.

he dual or interventional ‘‘femoro-distalelepheric approach’’

his procedure requires combining a conventional ipsilat-ral femoral approach with direct puncture of the leg vesselistal to the obstruction where it is still patent from rich col-ateral supply and which could not be reached anterogradelyn order to cross the occlusion backwards. This is now pro-osed immediately after proximal approaches have failed,he introducer and guide being left in place [59—62]. Thearget artery is punctured under radioscopy control with a1 G needle (4 to 7 cm), assisted by possible landmarking ofalcifications and the use of radiological ‘‘road-mapping’’ode, less commonly under ultrasound guidance. The punc-

ure is usually made at the ankle and is relatively simple forhe pedal artery, slightly more difficult for the retromalle-lar portion of the posterior tibial artery, or higher on thebular artery or even the anterior tibial [63—67] (Fig. 8).

0.018 guide is then used to cross the upstream occlusionountercurrent, facilitated by the routine use of a relativelyigid 2.6 F support catheter (several commercial systems arevailable), and avoiding the use of an introducer, which arendeed contained in a 3F version but which can cause aegree of trauma. There are then two possibilities: either

he 0.018 guide crosses the whole length of the tibial occlu-ion throughout the lumen and therefore reaches the trueroximal popliteal lumen, or it passes through the subintimalpace at some time during the navigation and does not end

e only artery visible) with subintimal navigation of the 0.018 guide; of the 0.018 guide recovered in the 5 F anterograde catheter; c:

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p in the true proximal lumen. In the first scenario, the solu-ion is relatively simple and involves recovering the guidehrough the femoral introducer. A 6F angulated catheter oremovable valve introducer can be used in order to allowatheterization of the lumen and removal with the ret-ograde guide. A home-made or commercial lasso systems another option to remove the guide from the patientn ‘‘telepheric’’ mode. Once the guide has been recov-red, the balloon angioplasty is performed from a superiorpproach: dilatation material cannot be introduced fromistally because of potential procedural problems avoidingamaging a tortuous fragile artery by inserting an introducerf inappropriate size or removing the balloon after inflationhence the justification of the dual approach).

In the second scenario in which the retrograde guidend its support catheter pass into the subintimal space, theafari technique (acronym for Subintimal arterial flossingith anterograde retrograde intervention — Flossing being

he English term used to pass dental floss between the teetho remove tartar!) is used. This was described in 2003 bypinoza et al. [68] and involves recovering the 0.018 guidehich is blocked in the sub-intimal space into the catheteroming from superiorly, also in this space. A microlasso sys-em can be used to assist this and once this maneuver is

uccessful, the complete unit is then removed in the femoralntroducer and then angioplasty is then performed frombove, using the ‘‘telepheric’’ technique. Failures are dueo navigating both guides into the planes of the subintimal

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igure 9. a: proximal occlusion of the anterior tibial artery, the only a superior approach; b: retrograde puncture of the anterior tibial artehe guide into the 6F femoral Désilet catheter left in situ; c: meeting onterograde balloon angioplasty.

J.-M. Pernès et al.

pace too far away and incompatible with returning the ret-ograde guide into the proximal catheter. At the end of therocedure, hemostasis can be facilitated at the distal punc-ure site by low inflation pressure of a balloon against theuncture site although the manual pressure after removinghe materials is usually sufficient and effective and localomplications such as thrombosis are very rare.

The technical success of this approach using retro-rade puncture after anterograde failure is estimated to beround 80%, [69,70] (Fig. 9). Even in 124 patients (12% of035 people treated with infrapopliteal angioplasty for CIetween 2007 and 2010), in which anterograde recanaliza-ion failed, Gandini et al. [71] reported a technical successate of 96% using this dual approach with a limb salvage ratef 83% at 6 months and a 10% mortality rate during clinicalollow-up, with 26% repeat procedure and 16% amputationates.

he ‘‘LOOP’’ technique

his technique can be used to recanalize a target artery viahe plantar arcade or a sufficiently well-developed collat-ral supply:

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

osed when anterograde recanalization has failed and whent is possible to carry out a direct distal retrograde punc-ure. This involves navigating the guide-catheter couplehrough the plantar arcade between the plantar and dorsal

rtery visible, returning at the ankle: failure of recanalization fromry at the junction of the pedal artery and attempted recovery off the 2 guides and effective Safari technique; d: final result after

Infrapopliteal arterial recanalization: A true advance for limb sa

circulation across the anastomosis which connects thesephysiologically in the first metatarsal space, creating a loopand then advancing it retrogradely to come out into thetrue lumen: if successful, this approach is then followed byangioplasty (Fig. 10). If there are difficulties progressing thecatheter, a further anterograde attempt is made, borrow-ing the new channel created by the retrograde guide, bothguides, usually size 0.014, travelling in the same ipsilateralfemoral introducer. The main indication for this approachother than failure of an anterograde approach is its firstline use when very distal interdigital disease is present, withthe hope of improving perfusion of the forefoot by restoringmissing connections in the toes and heels. In this specific sit-uation, recanalization of the foot arteries, Manzi and Palena[73] described a technical success rate of 85% in 135 patients(10% of a population of patients treated via an endovascularapproach for CI over a period of 2 years).

Transcollateral angioplasty: the recanalization is per-formed through a highly developed collateral artery which

Figure 10. Distal occlusion of the two anterior and posterior tibialarteries, recanalization through the plantar arcade using the ‘‘LoopTechnique’’ principle.

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

lvage in diabetics 431

rovides access to the occluded target vessel (Fig. 11).his is similar to the technique used during recanalizationf a coronary occlusion and allows better targeting of thentrance to the occlusion and therefore shortens attemptso penetrate using specific guides [74].

‘Extreme below-the-knee interventions’’

f all of the techniques described above are unsuccessful orot possible, it is now technically possible to directly punc-ure the first metatarsal artery or even the plantar arcadend to undertake retrograde recanalization of the foot andower leg arteries through this approach [75]. Palena andanzi [76] reported a technical and clinical success ratef 85% at 6 months in 28 patients. Following local anesthe-ia and local administration of antispastic verapamil, theuncture is performed under radioscopy using a 21G needle,enerally in the first metatarsal artery (25/28), and in thistudy, was associated with an increase in tcPo2 (12 mmHgreprocedure, compared to 49 mmHg at 6 months) with 71%f patients alive and not amputated at 6 months.

onclusion

he range of technical endovascular revascularization pos-ibilities for long tibial artery occlusions has recentlyncreased considerably enabling anterograde endoluminalr even sub-intimal recanalization of occluded segmentsn 80% of cases by miniaturized 0.014 or 0.018 guides. Ifhis approach fails, retrograde recanalization appears to beffective in almost 80% of situations, mostly using distaletrograde puncture and a dual femoro-distal ‘‘telepheric’’pproach, and less commonly by access through a collateral

r by the principle of the ‘‘pedal-plantar loop’’ technique.inally, even more distal punctures (of the first metatarsalrtery!) are proposed by some as the ultimate fallback andppear to produce good results.

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isclosure of interest

he authors declare that they have no conflicts of interestith this article.

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