Retrograde Tibio-Pedal Access for Revascularization of Lower-Extremity Peripheral Artery Disease Using a 6 Fr Slender Sheath: The "Pedal-First" Pilot Project

We studied the safety and efficacy of tibio-pedal access (TPA) as the sole primary access (ie, the "pedal-first" strategy) for revascularization of peripheral artery disease (PAD). We reviewed a prospectively maintained database of patients where TPA was used as a primary access for retrograde diagnostic angiography and intervention. Patients suffering from symptomatic PAD and abnormal non-invasive testing were treated with the intention of using only ipsilateral TPA if there was antegrade flow in one of the three run-off vessels on ultrasound (US). Additional radial or femoral access (FA) was used only if needed for successful revascularization. TPA was achieved with US guidance using a 6 Fr thin-walled hydrophilic sheath. Patency of the accessed tibio-pedal artery was evaluated with US at 30 days. The pedal-first approach was attempted for 41 limbs in 36 patients. The overall rate of successful revascularization was 95% (39 limbs). TPA was successfully used in all 39 limbs and "pedal-only" success occurred in 30 limbs (77%). Two procedures were unsuccessful in revascularizing target-vessel occlusion despite dual access. Patients without FA were able to ambulate at an average of 3 hours post procedure. No acute vascular access-related complications were noted. Each accessed tibio-pedal artery was patent on US evaluation at 30 days. The pedal-first approach of using TPA with a 6 Fr thin-walled sheath as a primary access and as the only access for diagnosis and intervention of PAD is safe and highly successful in carefully selected patients.