Tibio-pedal arterial minimally invasive retrograde revascularization in patients with advanced peripheral vascular disease: the TAMI technique, original case series.

BACKGROUND: A tibial-pedal access method is needed for patients with advanced peripheral artery disease (PAD) unable to tolerate common femoral artery (CFA) access and intervention due to body habitus or comorbidities. This is the first case series reporting an alternative technique to revascularize such patients. Using ultrasound (US) and the tibio-pedal arterial minimally invasive retrograde revascularization (TAMI) technique, operators accessed, and revascularized the lower extremity completely via tibial-pedal arterial access. METHODS: This retrospective, single-center, case series recorded on 23 patients who underwent TAMI revascularization during a seven-month period in 2012, demonstrating the feasibility and safety of the TAMI technique. Eighty-three percent had Rutherford Classification IV-VI. Ultrasound guidance aided all tibial access. Demographics, vascular symptoms, disease characteristics, success, procedure length, time to discharge, immediate and 30-day complications were collected. Comparison was sought with 201 unmatched patients treated via traditional CFA access over a similar period. RESULTS: Arterial access was successful in all patients. Thirty-six lesions were treated. Lesion success (ability to cross lesion and achieve post treatment stenosis <30%) was achieved in 95% of patients. 25% of lesions were above the knee. Average prestenosis was 92.5%; average poststenosis 12%. No major complications were noted. Two patients presented within 30 days with access site pain. Access site peroneal artery pseudo-aneurysms were diagnosed and treated percutaneously with covered stents. Both recovered with no sequelae. CONCLUSION: Retrograde tibio-pedal intervention appears to be safe and effective. The TAMI technique offers an alternate revascularization method for critically ill advanced PAD patients.

Comparison between angiographic and arterial duplex ultrasound assessment of tibial arteries in patients with peripheral arterial disease: on behalf of the Joint Endovascular and Non-Invasive Assessment of LImb Perfusion (JENALI) Group.

BACKGROUND: Endovascular treatment of peripheral arterial disease (PAD) involving the tibial arteries is becoming an increasingly important part of revascularization. The current anatomical description of vessel patency in tibial arteries does not contribute effectively to therapeutic strategies. The Joint Endovascular and Non-Invasive Assessment of Limb Perfusion (JENALI) score, is a novel scoring system developed to further assess patency of tibial arteries, via both angiography and arterial duplex ultrasonography. A comparison was made between the JENALI score obtained by ultrasound and by angiography. Angiography is currently considered the gold standard of tibial artery imaging. METHODS: This prospective single-center study involved 49 patients undergoing peripheral angiography for evaluation of PAD, between November 2011 and November 2012. All patients underwent a detailed ultrasound assessment of the tibial arteries ± 7 days from diagnostic angiography. Eligible patients had a Rutherford score ≥ III or abnormal ankle-brachial index values. Angiography and ultrasound were evaluated in a blinded fashion. RESULTS: Average age of patients was 69.8 years. A total of 846 segments were assessed by both angiography and ultrasound. We found that 648 segments (76.6%) were deemed to be patent by angiography compared to 723 (85.5%) by ultrasound. Critical limb ischemia (CLI; Rutherford score ≥ 4) was described in 26 patients (53%). Average JENALI score for the right lower extremity was 7.0 by angiogram vs 7.7 by ultrasound. The average JENALI score of the left leg was 6.7 by angiogram vs 7.7 by ultrasound. A total of 94 lower extremities were assigned a JENALI score. Ultrasound was accurate in detecting tibial artery patency or occlusion in 80% of segments. The overall sensitivity/specificity of ultrasound detecting tibial artery patency was calculated at 93% and 40% (P<.05), respectively. Detection of patency via ultrasound was highest for the anterior tibial artery and the lowest for the peroneal artery. The angiographic and ultrasound JENALI scores better correlated with vessel patency (higher scores) than the lower angiographic and ultrasound JENALI scores. CONCLUSION: Using the novel JENALI scoring system allowed for direct comparison between two imaging modalities. In theory, the comparison can be extended to other imaging modalities. Ultrasound imaging had a high sensitivity in detecting patent vessels confirmed by angiography. Detecting occluded segments via ultrasound was less accurate. The highest accuracy was in the more superficial arteries (ie, anterior tibial, posterior tibial), compared to the deeper peroneal arteries. Risk stratification, treatment, and patient outcomes may be future applications of the JENALI scoring system.

Utility and feasibility of ultrasound-guided access in patients with critical limb ischemia.

BACKGROUND: Patients with advanced peripheral vascular disease (PVD) and critical limb ischemia (CLI) require immediate revascularization to improve blood flow and prevent amputation. Vascular, and especially tibial, access is arguably a very important part of the procedure. Utilization of ultrasound (US) guidance to access the peripheral vessels will maximize success and decrease the risk of complications. METHODS: This is a retrospective analysis of patients admitted to our institution between 2010 and 2011. Eighty-six patients with 191 lesions underwent revascularization for advanced PVD and CLI. US guidance was utilized to access the vascular bed in an antegrade or retrograde fashion in 100% of these patients. Data collected included success rate and time to access using US. Immediate in hospital and 30 day outcomes were also documented. RESULTS: The average age of patients was 69.8 years, with 69.7% male patients. All tibial access (33.7%) was obtained under US guidance. Obtaining vascular access using US was achieved in 95.3% of patients. At discharge, access site complications were limited to one patient (1.1%) with a pseudoaneurysm; no access complications related to the tibial vessels. At 30 days, there was one major amputation (1.1%) and one vascular access complication (1.1%). CONCLUSION: US guided access is a feasible and safe procedure that can aid in accessing vascular conduits in patients with CLI. Applying this technique across the board in CLI patients decreases the risk of immediate complications and facilitates accessing tibial arteries.