Below-the-Ankle Antegrade Teleferic Technique: New Approach for Below-the-Ankle Revascularization in Challenging Cases of Chronic Limb-Threatening Ischemia

Abstract

Purpose:

To describe a novel bailout technique to approach below-the-ankle (BTA) chronic total occlusions or plantar-arch severe disease where the balloon/catheter is unable to follow the crossing guidewire and no other described recanalization approach is feasible.

Technique:

When facing a complex BTA revascularization, if the guidewire crosses but the balloon cannot progress due to a lack of pushability, an antegrade puncture of the infrapopliteal vessel where the tip of the guidewire lays is performed. The guidewire is then carefully navigated through this distal BTA vessel into the needle to achieve its rendezvous and externalization. A low-profile balloon is inserted through the femoral access and advanced till the non-crossable point of the BTA vessels. A torque device is then attached to the proximal hub of the balloon, and the through-and-through guidewire is subsequently pulled from the new distal access, allowing the balloon to be dragged across the lesion together with the wire.

Conclusion:

The below-the-ankle antegrade teleferic (BAT) technique may be considered for highly complex BTA revascularization procedures where the wire crosses the lesion, but no other device can be tracked over it.

Clinical Impact

The clinical impact of this article lies in the description of a bailout technique for BTA revascularization where the guidewire crosses, but no device can be advanced. This technique can be helpful in scenarios where failure to achieve success could result in limb loss. The BAT technique provides a solution in extremely challenging cases, enhancing technical success, improving outcomes and potentially preserving the limbs of patients who would otherwise face amputation, if not revascularized.

The video shows the BAT technique performed with a support catheter under fluoroscopy: antegrate puncture of the DP, advancement of the support catheter over the wire, rendezvous of the guidewire in the catheter and subsequent externalization of the wire.

Keywords

antegrade approach below-the-ankle vessels chronic total occlusion chronic limb-threatening ischemia recanalization plantar arch limb salvage

Chronic limb-threatening ischemia (CLTI) is defined as the last stage of peripheral artery disease (PAD) with symptoms that include rest pain, gangrene, or a lower-limb ulceration lasting more than 2 weeks.¹

There has been a shift in the approach to distal arterial revascularization for CLTI patients in recent years, with a greater emphasis on below-the-ankle (BTA) interventions to improve clinical success.^2,3 Studies have shown that targeting specific infrapopliteal vessels that directly supply the wound territory, known as the “angiosome concept,” and to establish in-line arterial flow to the wound can significantly optimize tissue perfusion, leading to improved limb salvage and healing rates.⁴

In cases where standard BTA revascularization methods have failed, bidirectional bailout techniques like retrograde puncture⁵ or transcollateral approach can be employed to achieve successful revascularization. If no distal vessel can be punctured retrogradely, the plantar-loop recanalization technique can allow the operator to create a connection between the dorsal and plantar circulation of the foot, significantly improving the perfusion of the forefoot, even if only one infrapopliteal artery is patent.⁶

Despite advancements in guidewire technology, devices, and crossing techniques, there are still cases where what can be considered “standard advanced maneuvers” do not allow achieving success. One of the most challenging issues is represented by the situation when the guidewire crosses but no balloon does. In these cases, PIERCE technique⁷ and the BAlloon Deployment using FORcible Manner technique (BADFORM technique), also known as the teleferic maneuver,⁸ have been described. In particular, the latter is used when a bidirectional access and rendezvous of the guidewire are achieved but no device can cross; a torque-control device is then fixed over the guidewire just proximally to the lumen port of the balloon/microcatheter which is intended to progress through the lesion. Finally, the externalized guidewire is pulled from one of the two accesses, forcefully dragging the balloon/catheter past the lesion.

However, the success of the technique relies on the guidewire externalization from the already in place retrograde access. Patients with lesions who have no distal retrograde puncture sites available for guidewire externalizations are not considered as candidates.

We describe a new technique for endovascular treatment of distal BTA or plantar-arch occlusions/severe diffuse stenotic disease where the balloon/catheter is unable to follow the guidewire and the standard BADFORM technique cannot be applied.

Technique

The technique is demonstrated in a case of a 73-year-old male patient, former smoker with a history of hypertension, dyslipidemia, diabetes, coronary artery disease, and sarcoidosis. The patient presented with a 3-month history of an ulcer on the lateral aspect of the heel with associated rest pain wound, ischemia, and foot infection (WIfI)⁹ 2,3,2. Despite dedicated wound care, the ulcer did not heal. The Duplex ultrasound (US) showed a femoropopliteal segment patent with a triphasic waveform and no significant stenosis, occlusion of the posterior tibial (PT) artery with the common plantar artery patent with monophasic waveform, a patent peroneal artery with biphasic waveform, and occlusion of the distal segment of the anterior tibial (AT) artery with monophasic waveform at the level of the dorsalis pedis (DP). Plantar acceleration time (PAT)¹⁰ at the level of the lateral plantar artery was 245 millisecond (Class 3).

An US-guided ipsilateral antegrade common femoral access was gained. An initial dose of 1 mg/kg of unfractionated heparin was given and subsequently topped up, with the goal of maintaining the activated clotting time between 250 and 300 seconds during the overall procedure.¹¹

The diagnostic angio showed femoropopliteal segment patent without significant lesions, patency of the peroneal artery without significant branches to the anterior and posterior circulation, flush chronic total occlusion (CTO) of the PT artery, reconstitution at the level of the common plantar artery, and subsequent further occlusion of the proximal lateral plantar artery. The proximal two-thirds of the AT artery were patent, where the last third was instead occluded with reperfusion at the level of the DP, feeding a patent small-caliber plantar arch.

Given the non-healing ulcer location at the level of a severely ischemic heel, by following the woundosome concept,⁴ decision was taken to attempt recanalization of the occluded PT. This unfortunately failed because of the lack of a proximal stump. At this point, to recanalize the distal AT artery was decided, in order to approach the lateral plantar occlusion via the pedal-plantar-loop technique. After a 0.014″ guidewire (Command; Abbott Vascular, Redwood City, CA) was successfully passed through the plantar arch and the occluded lateral plantar artery and its tip was positioned at the level of the patent common plantar artery, no device, low-profile balloon, or microcatheter could be progressed through the occluded lateral plantar artery.

At that point, a fluoroscopically guided antegrade puncture of the patent common plantar artery by 18G/9 cm Gauge needle (Cook Medical, Bloomington, IN) was performed, until clear arterial back bleeding from the needle was noticed.

Once the antegrade puncture was completed, the antegrade guidewire coming from the plantar arch was carefully pulled back into the BTA vessels until reaching the level of the needle. By torquing the tip of the wire, rendezvous within the 18G needle itself was achieved. Once the guidewire was externalized, a low-profile 2-mm balloon (Armada XT; Abbott Vascular) was progressed through the femoral access up to the BTA non-crossable point. A standard torque device was attached at the end of the angioplasty balloon (just next to the guidewire lumen port of the balloon or microcatheter). Finally, the distal end of the externalized wire was pulled retrogradely dragging the balloon past the lateral plantar CTO (Figures 1 –4).

Following pre-dilation by this 2-mm low-profile balloon, a 2.5 × 120-mm (Armada 0.014; Abbott Vascular) angioplasty balloon was successfully advanced and inflated at the level of the foot arch/occluded. Thereafter, a full recanalization of the PT artery was performed. The procedure was completed by dilating both the AT and PT arteries with a 3 × 200-mm balloon (Armada 0.014; Abbott Vascular), including the common plantar artery, with hemostasis of the distal antegrade access obtained by 2.5-mm balloon “endoclamping.”

The patient was discharged 48 hours after the index procedure with palpable pedal pulses and PAT of 145 millisecond, Class 1. Intravenous antibiotic therapy was prescribed, and home-based wound care assistance was arranged. The patient achieved complete wound healing in 47 days. At 6-month follow-up, control transcutaneous oxygen pressure (TCPO2) at the level of the previous wound was 59 mm Hg, and the patient presented palpable DP and PT pulses.

This maneuver has been performed in 6 cases so far. All the patients presented with a high WIfI classification grade, moderate to long lesion lengths, and a severe PACSS (Peripheral Artery Calcification Scoring System Classification) score¹² (Table 1).

Table 1.

Baseline characteristics.

	Patient characteristics	Wound characteristics	Punctured vessel	Lesion characteristics
Case 1	73yo, ♂ , former smoker, DM, HBP, DL, CAD, sarcoidosis	WIft 2,3,2 Heel ulcer	Common plantar	KC type 2A LL 120 mm PACSS grade 3
Case 2	84yo, ♀, DM, HBP, ESRD	WIfi 2,3,1 2nd-3rd-4th toes necrosis	Dorsalis pedis	KC type 2B LL 225 mm PACSS grade 4
Case 3	79yo, ♂ , current smoker, DM, HBP, COPD, RA	WIft 2,3,1 Forefoot necrosis	Distal posterior tibial	KC type 3 LL 250 mm PACSS grade 4
Case 4	63yo, ♂ , former smoker, DM, HBP, DL, ESRD	WIft 2,3,3 Wet gangrene in 2nd toe and plantar abscess	Distal posterior tibial	KC type 3 LL 220 mm PACSS grade 4
Case 5	82yo, ♂ , DM, HBP, CAD, COPD, stroke	WIfI 2,3,2 1st and 2nd toes necrosis and heel ulcer	Lateral plantar	KC type 3 LL 100 mm PACSS grade 4
Case 6	76yo, ♂ , DM, HBP, DL, CAD, ESRD, liver cirrhosis	WIfi 2,3,1 3rd-4th toes necrosis	Common plantar	KC type 2A LL 180 mm PACSS grade 4

Abbreviations: ♂ = male; ♀ = female; CAD = coronary artery disease; COPD = chronic obstructive pulmonary disease; DL = dyslipidemia; DM = diabetes mellitus; ESRD = end-stage renal disease; HBP = high blood pressure; KC = Kawarada plantar arch Classification; LL = lesion length; PACSS = Peripheral Artery Calcification Scoring System Classification; RA = rheumatoid arthritis; yo = years old.

The antegrade puncture was achieved at the level of the distal PT artery in 2 cases, at the level of the common plantar artery in 2 cases (in 1 case, the vessel was occluded), and at the level of the lateral plantar and DP arteries in 1 case each. All the punctures were performed under plain x-ray guidance using the plantar-loop guidewire as a landmark. Mean time to achieve the antegrade puncture was 5 minutes, and mean time to complete the rest of the maneuver (rendezvous within the needle and dragging the balloon catheter past the lesion) was between 4 and 5 minutes.

In the 6 cases, the antegrade access and the target vessel recanalization were achieved without complications. Distal puncture site complications (dissection, bleeding, or thrombosis) were neither observed.

Discussion

It is well known that retrograde recanalization of a tibial vessel through the plantar arch is limited by lack of pushability due to the presence of arch disease, vessel spasm, and/or tortuosity. This becomes even more evident in case where calcification is present at the level of the occluded target vessels, increasing the likelihood of procedural failure.¹³

The antegrade puncture of BTA vessels to achieve forefoot artery recanalization was first described by Palena and Manzi¹⁴ as a bailout crossing strategy. DP and distal PT/common plantar artery were the preferred puncture sites. The technique to achieve the access was similar to the standard retrograde one, with a sheath-less approach as the extra access was only used to cross the lesion, with the therapy provided then from the femoral access once the rendezvous of the guidewire has been achieved.

The previously described BADFORM technique was instead described by Nakabayashi et al⁸ to overcome the impossibility to advance any device through a lesion already crossed by locking the balloon/microcatheter to through-and-through guidewire.

It is important to emphasize that the most differentiating aspects of the technique hereby described compared to the BADFORM one is the need for an antegrade puncture either in the distal below-the-knee ( BTK) vessels or in the BTA segment where no retrograde access is proved to be useful for the device crossing due to the ultra-distal location of the extremely diseased segment.

The rendezvous of the guidewire is recommended to be performed directly inside a standard 18G needle. Alternatively, a 21G needle could be used to advance a 0.018″ guidewire over a 2.6F microcatheter; this can be advanced in a sheath-less fashion, and the guidewire can be externalized after having advanced it into the microcatheter (Figures 4 and 5). The rationale for using a low-profile needle is that, by reducing the size of the needle, the chances of successful puncture of these diseased and small-caliber vessels can increase. However, the rendezvous into a standard 18G needle has to be considered far easier due to its larger diameter, which can more easily accommodate the tip of the 0.014″ guidewire used for the distal CTO recanalization, very often slightly deformed after the arch navigation, and which presents limited torqueability. To basculate the x-ray tube between lateral and antero-posterior projection is utterly important in order to better understand the spacial relationship between the needle and guidewire tip, especially in case of antegrade puncture of an occluded artery.

The below-the-ankle antegrade teleferic (BAT) technique provides an effective solution for navigating the tortuosity and the small caliber of a severely diseased plantar arch increasing pushability for standard crossing of these distal lesions (Figure 6). In addition, if a retrograde puncture of the opposite vessel cannot be performed due to an occlusion, this technique can also be useful for advancing a balloon that would allow performing a balloon-assisted retrograde puncture to convert an indirect retrograde access via the plantar arch into a direct retrograde approach and thus increasing our pushability, torqueability, and trackability.¹⁵

The main limitation of the BAT maneuver lies in the fact that the operator must be familiar with the arterial puncture technique in the BTA segment, where the vessel caliber is small and calcification is frequent. However, this technique has been extensively adopted by the endovascular community over the last decade with high success and low complication rates.¹⁶

Similar to the complications of any conventional retrograde access, the potential risks of the antegrade approach of the BTA vessels are related to spasm and/or dissection during puncture or guidewire navigation, which can eventually lead to acute arterial occlusion.¹⁴

Moreover, although using an 18G needle to achieve the access could hypothetically increase the bleeding complications on the access point compared with a lower-profile platform, the standard endo-clamp maneuver (5 minutes inflation of an appropriately sized balloon at the site of the distal puncture) proved to be completely effective in all our cases. And as mentioned earlier, no access-site complications were observed.

The US-guided approach is, whenever possible, generally recommended to access the BTK/BTA arteries, as it is feasible, safe, and reduces significantly the operator’s radiation exposure. However, the absence of an appropriate equipment/probe, skills, or experience makes the US-guided approach in the midfoot/forefoot more challenging.

If the x-ray/roadmapping-guided access is used for the antegrade puncture, the operator can sometimes find it difficult to align the needle or to follow the configuration of the artery as when the disposition we are familiar with is altered, the automated operator movements for puncturing or 3D orientation are dissociated. In this scenario, as previously reported by Ysa et al,⁵ we find it helpful to flip the monitor screen orientation so that the longitudinal axis of the target vessel and the tip of the needle point to the 12 o’clock position. In such position, the alignment of the needle follows the standard disposition we are used to for the majority of retrograde punctures.

Prior alternative techniques (ultra-low-profile balloon, telescopic sheath maneuver, BADFORM technique, PIERCE technique) have been described to overcome “the wire crosses but nothing else does” scenario and should be considered before attempting any more complex bailout maneuver. Therefore, the described technique should not be systematically used in conventional procedures but kept as an extreme bailout in patients at high risk of amputation and failure of the other described recanalization approaches.

It is recommended to perform the maneuver using a balloon or catheter advanced (over the guidewire from the standard inguinal access) as distal as possible to prevent cheesewiring or dissection of the foot arch when pulling from the BTA antegrade access.

An alternative to the BAT technique when it is impossible to cross the plantar arch with any balloon/catheter could be using extreme retrograde punctures at the digital vessel and plantar arch levels,¹⁷ but this presents obvious technical difficulties due to the small caliber of the vessels, lack of bone support, and the risk of arch thrombosis in case of a failed puncture or dissection of the accessed vessel. On the other hand, the PIERCE technique⁷ may also be risky in small-caliber vessels that dive deeply into the forefoot, as it could lead to vessel rupture and difficult-to-control bleeding or nerve injury.

A slight increase in radiation dose to the operator’s hands has to be taken into account due to the manipulation of the needle/wire under x-ray. The operators should take care to avoid as much radiation as possible by using short exposure times and appropriate shielding or, alternatively, performing the access under US, which, on the other hand, can be extremely difficult to achieve due to the depth and small caliber of the target vessels.

Conclusion

The BAT technique expands the possibilities for successful BTA revascularization. By overcoming the challenges presented by a lack of pushability while treating ultra-distal complex lesions, it can be considered for highly complex BTA revascularization procedures where the wire has crossed the lesion, but no other device is able follow it.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Marta Lobato

August Ysa

Lorenzo Patrone

Supplemental Material

Supplemental material for this article is available online.

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