1. Popliteal access ,How important is it ?
Mr. Mohamed Omar El-FarokM.Sc, FRCS

2. Topics to be covered
How important is popliteal access ?
Indication of Popliteal access
How to do it ?
Steps of CTO recanalization
Different scenarios of passing SFA CTO frombelow up
One Case
3. (1) How important is Popliteal access :
It can convert a failed procedure to a successful one
It is easier to cross SFA lesion from below (clinical experience)
Used infrequently (< 5%)
Complex proximal anatomy
Failed ante-grade recanalization
4. (2) Indications of Popliteal access
Failure of SFA recanalization from above
Difficult contralateral access
Flush occlusion of SFA
Tandem lesion in SFA ad iliac both sides
5. (3)How to do popliteal access
Percutaneous difficult
Ultrasound guided ( safest)
Open surgery (least preferred )
6. Percutaneous Pop Access :
Direct Fluoroscopy looking for calcifications
Do a Roadmap from the upper end
Push the wire sub-intimal from the upper end and use it as a marker for popliteal access .
Use micro-puncture needle
Do not use more the 6 F sheath
Continuous heparininfusion
7. Steps of Ultrasound guided pop. Access
Patient Conscent
Prone or lateral
Duplex grey scale
Light pressure
Advance needle in LS. Or TS
Avoid SM
Avoid collapsed vein
8. (4) Steps of CTO recanalization
All in relation to popliteal artery :
Penetrating proximal occlusion
Negotiating length of occlusion
Distal re-entry
9. (5) Different scenarios of Popliteal CTOs
A
B
C
D
E
10. Type A
flush blunt occlusion
No angiographic clue regarding optimal point of entry
Usually easier than upper end .
Options:
Probe proximal occlusion with wire tip supported by catheter
Prolapse through (.035 wire)
Try different catheters (glide catheter, IMA, ARI, MP, SOS, AL1)
Break cap with stiff wire
You can use 0.014 plateform
11. SFA-Popliteal CTOs
Attempt to prolapse wire through occlusion
May penetrate cap
If successful, track low profile catheter through occlusion over wire
Catheter provides support and direction
Redirect wire tip as approximate distal point of reconstitution
12. Trick to be used in type A
centering balloon for back-up support
.035 wire (curved or straight)
Useful alternative technique to break fibrous cap
Exchange for hydrophilic guide wire and support catheter for conventional subintimal recanalization
13. Calcification in type A
Flush occlusion with associated calcium
Use stiff end of the wire for 1-2 mm
Catheter directed wire through non-calcified portion
Inject saline as your go
Incremental advancement of wire and catheter
14. TypeB
Favorable morphology
Tapered, centered beak
Advance wire gently into tip of occlusion
Slowly advance catheter over wire to support wire
Confirm position of wire and tip with angio ( small amount and aspirate)
15. Type B
Prolapse wire through occluded segment
Incremental advancement of wire followed by catheter
Confirm position of system
Visual course of vessel, calcium, road map
tactile if excessive binding - redirect
16. Type B
Reorient catheter tip towards point of reconstitution
Attempt to cross distal segment with straight tip of wire
Track catheter across distal segment
Assess pressure, waveform and perform end-hole injection
17. Type C
Eccentric, narrow proximal occlusion
Identify point of recanalization
Select catheter with corresponding conformation
Glide catheter
IMA
JR4
Vertebral , or MPA
18. Type C
Consider .014 wire/catheter system
Track catheter over wire into remnant of vessel lumen
Attempt to cross occlusion with wire tip
Advance to .035 wire (hydrophilic) as needed
19. Type D
Challenging morphology
Adjacent side branch
Bare wire will tend to prolapse into side branch
Solution: orient and support wire with catheter directed away from side branch
20. Type E
Most challenging anatomy
Bridging collaterals
No clearly defined lumen or hint at true lumen
If perforation happen go back and try again
21. Technical Aspects of Recanalizing
If wire fails to track
or if tracks into false channel,
redirect wire by changing orientation of catheter
Re-advance wire
repeat sequence as needed
Consider re-entry device
Avoid extending dissection into mid-distal popliteal a. or infra-popliteal
22. Recanalizing SFA-Popliteal A. CTOs

Long occlusion (entire SFA to distal popliteal)

23. ostial SFA, excessive calcium 24. bridging collaterals, > 20 mm Lesion
Complexity

10-15 cms, mid-distal SFA

25. proximal mid popliteal 26. moderate calcium 27. 5-10 cms 28. Non ostial 29. ISRPredicted Success
High
Low
30. Reanalyzing SFA-Popliteal CTOsPredicted Procedural Time
Focal occlusion Long, complex
15-20 mins
20-30 mins
10-15 mins
.014-.035 wire
4 Fr catheter
Re-entry device
FrontRunner
Excimer laser
Different catheters
Wire redirection
31. Case 1
32. Case
33. 34. 35. 36. 37. 38. 39. 40. 41. Lesson I have learned in life
Good experience comes from bad judgment
And
Good judgment comes from bad experience
42. Thank you