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Procedural and Safety Outcomes of a Tibiopedal Approach to CLI Treatment

George Pliagas, MD, Advanced Cardiac and Vascular Centers for Amputation Prevention, Las Vegas, Nevada

Dr Pliagas discusses his retrospective study, recently published in JCLI, in which he and his co-investigators sought to demonstrate safety and performance of the Terumo Glidesheath Slender for tibiopedal access. Initially, tibiopedal access was considered a very experimental technique, but over the past few years, Dr Pliagas and his colleagues have learned to routinely gain access to vessels from below, using this technique.


*This transcript has been lightly edited for clarity*

Hello, everyone. My name is Dr. George Pliagas, and I'm here today to discuss a recent article that we published in the Journal of Critical Limb Ischemia. This is a very interesting article that I think everyone will find very helpful because it does discuss the efficacy and the safety of a tibiopedal approach to treating critical limb ischemia.

As we all know, critical limb ischemia has many different access points that you can entertain, and we do discuss this at all of our conventions and all our symposiums, and different sites that we travel to. But the main thing to understand is that fact is that you have to pick the right access point to facilitate the increased perfusion to the lower extremities.

Now, with tibiopedal anatomy, you have to think about many things, and one thing that you have to understand is exactly what vessel you're trying to improve the flow through.

What is an angiosome concept? Are we looking at anterior tibial, posterior tibial, perineal? I think these are all things you have to consider.

In the Journal of Critical Limb Ischemia article that we published, we showed that of the 440 patients that we entered into the trial, 95% of these patients within 30 days returned complication free and with increased perfusion of the lower extremity. I think that's an amazing result because it shows you both efficacy and safety of this tibiopedal approach.

Of course, as any new technique, it does require a certain amount of training, experience, and the ability to understand exactly what you can do through these sheaths.

I've been using these Terumo's Slender sheaths for years now, and they have done a very excellent job of allowing us to get access easily, to be able to entertain different approaches of treating everything from the iliac vessels all the way through the SFA popliteal, and of course, even the tibial vessels, and even a transarterial, minimally invasive technique where we can treat more than one tibial vessel at one time.

It allows us also to be able to maintain the slender shape of the outside of the Terumo sheath because number one, it is smaller, but allows us the capacity to entertain larger modalities that require slightly one French size larger, so we can introduce sheath through there and we can introduce different types of balloons, and I think that's very, very important. The object of this and the results were to show that the Terumo Glidesheath does produce good results, and the answer is, as you will see in the article, that it certainly does serve its purpose.

In the old days, we used to do bareback. And I think air bareback, unfortunately, and you'll see again written in the article, did injure the vessel quite significantly because it required several passes, and every time you entertain a pass through a vessel, the wall gets injured. And initially, in the first few years of tibio-pedal access with bareback potential, there were a lot of complications including pseudoaneurysms, bleeding, hematomas, and in fact, there were thromboses that people couldn't account for.

So, initially, it was considered a very experimental technique, but over the past 13 years and 14 years, we've discovered that tibiopedal anatomy and the approach through tibiopedal sheath, such as the Terumo Slender Glidesheath have done an amazing job at allowing us to gain access to vessels from below.

As we all know, it increases your crossing potential significantly. A lot of people think that perhaps crossing from above is in the 90 percentile. I differ completely. I think that basically, crossing from above is somewhere realistically between 60% and 70% of very difficult anatomy, especially, difficult tibial vessels. But if you add what we've learned over the years from the CTOPP trial and what we've been able to discuss in understanding that you can facilitate easy crossing from below. 67% of the time you actually can cross in a much more efficient fashion from below and use other technique such as either the rendezvous technique or the synapse technique and get the desired effect that you need.

And in this situation, you're able to increase the flow to the tibial vessels through the proximal inflow because both inflow and outflow matter in patients with critical limb ischemia. And as we discovered, when it was when critical limb ischemia was first entertained in 1982 in the British Journal of Surgery, at that point, we're understanding the concept even better now that critical limb ischemia needs improved techniques, and it also needs equipment that can facilitate usage of different modalities and different support catheters and balloons and stents and atherectomy devices, that will allow us to complete our task.

So, again, I want to thank everybody for listening. Look us up in the Journal of Critical Limb Ischemia. You'll find our article there, and the tibiopedal approach is an excellent way to treat critical limb ischemia.

Thank you for your attention.

Read full study here.

J CRIT LIMB ISCHEM 2023;3(1):E12-E17. doi: 10.25270/jcli/CLIG22-00006