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When to Use Popliteal Access and Other Alternative Access Sites

Rahul S. Patel MD FSIRDivision of Interventional Radiology

Icahn School of Medicine at Mount SinaiNew York, NY

Faculty DisclosuresRahul Patel: Consultant –Blackswan, Medtronic, Scientia, SirtexMedical; Speakers’ Bureau – Penumbra Inc.

Dr. Rahul Patel has disclosed that the off-label use of nBCA and Onyx will be discussed.

Brand names are included in this presentation for participant clarification purposes only. No product promotion should be inferred.

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Alternative Access

� Alternative antegrade access® Radial® Brachial® Axillary

� Retrograde access® Popliteal® Pedal

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Radial Access

� Lots of new tools (longer)® Sheaths® Wires® Stents® Balloons® Atherectomy

� Helpful in patients with simpler lesions ® No re-entry devices

� Helpful in obese patients and patients with hostile groins

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Radial Access Limitations

� Difficult for long CTOs® No re-entry devices currently long enough

� No DCB or DES� No covered stents� Infrapopliteal disease is tough and not always possible

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Aortoiliac Disease

� Tools already exist that will reach� Large studies published on TRA

® Ruzsa et al (n=156)¡ Used sheathless guide cath system ¡ Cross over rate of 3.8%

� 1 failed access in to RA� 3 failed re-entry of CTO� 2 due to length issues

¡ CTO in 28 patients with 96.5% success rate� Dual access was needed in 10.7%

@MountSinaiIR Catheterization and Cardiovascular Interventions, Volume: 88, Issue: 6, Pages: 923-931, First published: 03 June 2016, DOI: (10.1002/ccd.26592)

(A) High-grade right and left common iliac stenosis (white arrow) and left iliac external occlusion (black arrow). (B) Selective cannulation of the left common iliac artery, with a long 125 cm multipurpose catheter and recanalization with a hydrophilic Terumo wire. (C) Balloon angioplasty in the left iliac artery. (D) Simultaneous kissing stent implantation (white arrows) and the result after dual stent implantation. (E) The final post-dilatation result.

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Fem-Fem bypass with CIA stenoses and decreased ABIs

• 100cm 6Fr Shuttle (Cook Medical)• Epic Stent (Boston Scientific)

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Where we are for infrainguinal?

� Currently longest balloon available for SFA is on a 180cm shaft OTW .018 balloon® Terumo will have RX .035 balloons for SFA (200cm shaft)

� Longest sheath is 110cm (6 or 7Fr)® R2P Destination sheaths 119cm

� No re-entry catheter, crossing catheter or atherectomy device ® Diamondback CSI now available in 200cm length

� Longest stent delivery system 145cm (coronary DES)

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Device Types Name / Characteristics Length Limitations / CommentsSheaths and Guiding Catheters 5Fr Shuttle sheath (Cook) 110cm

6Fr guiding catheter (Boston Scientific) 110cm, 125cm5Fr, 6Fr guiding catheter (Cordis) 125cm4Fr Glidecath (Terumo) 150cm6Fr R2P Destination Slender sheath (Terumo) 119cm, 149cm7Fr (6Fr ID) R2P Slenguide catheter (Terumo) 120cm, 150cm hydrophilic tip only6.5Fr – 7.5Fr (4 – 5Fr ID) Sheathless Eucath (Asahi) 100cm8.5Fr (6Fr ID) Sheathless Eucath (Asahi) 120cm NA

Guidewires Nitrix .035” (Medtronic) 400cmViper .014” ((CVS) 335cm - 475cmGlidewire .035” (Terumo) 350cm - 450cmNovagold .018” (Boston Sci) 480cm Off-label for vascular intervention

Support catheters Various 135cm, 150cm 4Fr-6FrPTA Balloons Advance 14LP (Cook) 170cm 4Fr

Pacific Plus (Medtronic) 180cm 4Fr Ultraverse Rx .014” (Bard) 200cm 4Fr, 5Fr, RExMetacross (Terumo) 200cm 6Fr, Rex

Drug Coated Balloons & Stents -------- NARe-entry Devices -------- NASelf-Expanding Stents Everflex Entrust (Medtronic) 150cm 5Fr; longest shaft available in USA

Sinus SuperFlex 518 (Optimed) 180cm 5Fr ; NAMisago (Terumo) 200cm 6Fr; FDA approved but NA, REx

Atherectomy Diamondback (Cardiovascular Systems) 200cm 5Fr

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Obese patient with CFA stenosis and claudication

Medtronic Pacific-Plus018 OTW 180cm Shaft

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Obese HIV patient (70inches tall) on AC for recurrent PE. Lifestyle limiting claudication (1/2 block)

Treated over a 480cm 0.018” guidewire- PTA with 4mm 180cm shaft

Ultraverse RX balloon- 6mmx15cm Everflex stent

placed

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Infrapopliteal Disease

� No studies to date� Current devices are not long enough in most patients� No FDA approved stents for infrapopliteal disease� Longest shaft coronary DES stents are 150cm

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Brachial Access

� Multiple studies/series showing feasibility for PAD intervention� Helps compensate for length issues (gain about 20-30cm of working length)� Allows for larger sheath insertion � Higher access complication rates (~10%)� Closure devices are off label but have been described

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Popliteal Access

� Allows for retrograde access for crossing SFA CTO� Intervention can be completed for popliteal access� Typically done after failed antegrade approach� Would recommend a catheter from above for imaging� Patient typically done in prone position

® Can be done from a medial/surgical approach® Frog legged (this can be very cumbersome)

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Popliteal Access

� Closure can be an issue� Closure devices have been used (off label)� Can not treat infrapopliteal disease from the same access

� Most of us now use pedal access

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Pedal Access (TAMI)

� Intervention can be done from a pedal access® Hostile groins® Patient cant lay flat

� Good pre-op imaging is key� Can place a 4fr sheath or a 4/5Fr slender radial sheath

® Allows for atherectomy, stenting and angioplasty� Make sure to give a ”cocktail” into access artery

® 200µg NTG, 2.5mg verapamil, 3000u heparin� Use ultrasound or IVUS to help guide the intervention� Can use radial catheter to image from above

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Conclusion

� Most of our interventions are still done via CFA� Radial and pedal access is useful in patients with hostile groins but limited in

what we can do� Pedal access also useful to help cross long CTOs