Intra-Operative Assessment of Hemodynamics during Retrograde Pedal Access Revascularization
Michael Rouse, Qingwen Kawaji, Darshan Randhawa, Jason Howard, David Blitzer, Suzanne Kool, Jason Chin, Raghuveer Vallabhaneni, Jason Crowner
MedStar Baltimore, Baltimore, MD
INTRODUCTION: Lower extremity angiography is one of the most prevalent vascular procedures performed, generally accessed from the contralateral common femoral artery. The use of retrograde pedal artery access to perform angiography has long been reserved as a “bail-out” technique to help cross chronic total occlusions that were not amenable from an antegrade approach. There is increased utilization of pedal access for primary revascularization. The purpose of this study is to describe the outcomes of pedal access as a primary approach and to propose a novel evaluation of distal perfusion changes associated with intervention by the use of direct pressure measurements.
METHODS: This was a retrospective observational study evaluating all patients who underwent lower extremity angiography via retrograde pedal access between December 1st 2020 and June 30th 2021 within a single healthcare system spanning 3 hospitals. Demographics, comorbidities, procedural indications and details were all recorded. Hemodynamic measurements were obtained and recorded upon initial pedal access and post intervention with a pressure transducer connected directly to the access sheath. Outcomes were analyzed with a paired t-test.
RESULTS: Twenty-eight angiograms using primary pedal access for endovascular intervention were performed during the study period. Most patients were African American (75%) females (57%) with hypertension (89%), hyperlipidemia (79%), diabetes (90%), coronary artery disease (64%), and current tobacco use (86%). The most prevalent indication for angiography was tissue loss (71%). Pedal access was most commonly achieved via the anterior tibial artery (79%). Sixty-three vessels were treated during the 28 angiograms (2.3 vessels per angiogram), most commonly the superficial femoral (27%), anterior tibial (25%), and popliteal (22%) arteries. Balloon angioplasty (64%) was predominately performed with an overall technical success rate of 94%. The median initial and post-intervention pressures were 37 (IQR 22-52.75) and 79 (IQR 73-95.5) mmHg, respectively. The median change in pressure after intervention was 47.5 (IQR 29.8-59.8) mmHg (Fig. 1). There was a statistically significant difference detected between pre-procedural and post-procedural pressure (p<0.00). There were no major amputations nor adverse cardiovascular events at a mean follow-up duration of 89 ± 11 days. Six of the total 28 patients (21.4%) underwent repeat endovascular intervention on the ipsilateral extremity within a median of 45 (IQR 22.5-62.3) days.
CONCLUSIONS: Primary pedal access is a viable option for performing lower extremity angiographic interventions. A significant increase in pedal artery pressure can be observed after angiographic intervention from retrograde pedal artery access. Further studies are necessary to define the clinical prognostic importance of these findings in relation to wound healing rates. 
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