Cardiovasc lntervent Radiol (1992) 15:123-125
CardioVascular andInterventional Radiology 9 Springer-Verlag New York Inc. 1992
Technical Notes
Antegrade Popliteal Puncture: Technical Note Mark H. Wholey, Nell Solomon, and Chester R. Jarmolowski Pittsburgh Vascular Institute. Department of Radiological Sciences and Diagnostic Imaging. Shadyside Hospital, Pittsburgh, and the University of Pittsburgh. School of Medicine. Pittsburgh, Pennsylvania. USA
Abstract. P e r c u t a n e o u s transluminal angioplasty was performed via an antegrade popliteal puncture. This technique was utilized because the patient had a superficial femoral artery occlusion and coexistent popliteal stenoses, with the occlusion unable to be traversed in the usual c o m m o n femoral artery antegrade approach. To our knowledge, this technique has not been described in the literature. The clinical utility of this a p p r o a c h and important anatomical considerations will be discussed.
Key words: Antegrade popliteal p u n c t u r e - - A n g i o plasty
The antegrade popliteal puncture is a technique used to treat stenoses that are otherwise not amenable to percutaneous angioplasty due to occlusion of the superficial femoral artery. To our knowledge there has been no prior description in the literature utilizing this a p p r o a c h . This condition would occur in two categories of patients in whom a superficial femoral artery occlusion exists: a nonsurgical candidate with superficial femoral artery occlusion not amenable to antegrade or retrograde recanalization; and those patients in which a femoral-to-distal popliteal or tibial bypass procedure could be converted into a femoral-to-proximal popliteal bypass graft [ I ].
being evaluated ["or bilateral I to 2 block chmdication. The right ankle brachial index (ABI) was {).66. The patient was not considered to be a surgical candidate at this time due to his heart disease. A diagnostic arteriogram demonstrated a segmental 10-cm occlusion of the right superficial femoral artery and three stenoses in the reconstituted popliteal artery [Fig. I]. The right superficial femoral artery occlusion could not be traversed in the usual antegrade fashion from the common femoral artery. Although several recanalization devices were attempted, passage beyond the occlusion could not be accomplished. Successful recanalization from a retrograde popliteal approach was considered unlikely due to the length of the lesion and extent of calcification, and was not attempted. It was elected to perform an antegrade puncture of the proximal popliteal artery. Access was obtained with the assistance of ultrasound, doppler guidance, and the use of fluoroscopic observation as arterial calcification was present at the puncture site. The proximal popliteal artery was punctured with an I8-gauge needle. Subsequently, passage of a 0.035 inch steerable wire through the three stenotic sites (Wholey Wire: Peripheral Systems Groups, Mountain View, CA USA) was achieved. A 5 French dilator was then positioned over the wire within the popliteal artery (Fig. 2). This was then followed with exchange for a 5 mm-2 cm 5 French angioplasty balloon catheter, and the three sites were then dilated (Stellar 535 Balloon Catheter, Peripheral Systems Group). A postprocedural arteriogram demonstrated marked improvement in overall dimensions at the stenotic sites [Fig. 3]. The postprocedure resting ABI was unchanged at 0.66. The patient was maintained on aspirin and persantine. Originally not considered a satisfactory surgical candidate for a distal bypass. following successful dilatation of the popliteal lesions, the patient was subsequently bypassed with an above-the-knee femoral popliteal Dacron prosthetic graft. The distal anastomosis of the bypass graft was proximal to the three angioplasty sites. The patient continued to do well for approximately 3 months. when he returned with claudication. Repeat arteriography demonstrated 40%, restenosis at the proximal angioplasty site. The two distal sites remained well patent and consequently the patient was being managed medically.
Materials and Methods A 63-year-old male with insulin-dependent diabetes mellitus, atherosclerotic heart disease, and peripheral vascular disease was
Mark H. Wholey, M.D., Chairman, Pittsburgh Vascular Institute, Department of Radiotogical Sciences and Diagnostic Imaging, Shadyside Hospital, 5230 Centre Avenue, Pittsburgh, Pennsylvania 15232, USA
Address reprint requests to:
Discussion The antegrade popliteal puncture could be a valuable technique for treating patients with superficial femoral artery occlusion and coexistent popliteal stenoses. An understanding of the a n a t o m y of the popliteal fossa is helpful. The popliteal artery origi-
124
Fig. 1. Diagnostic arteriogr~m, in the supine position demonstritlen three lk~caI popliteal stenoncs (arrows). Fig. 2. Antegrade poplileal artery puncture in Ihe prone ponition. Arrow indicates the 5 French diagnostic catheter. Fig. 3. PosI-PTA arteriogram in the prone position. Number,, I, 2, and 3 indicate location of stenosis prior to angioplanty.
nares at the adductor canal which is formed by an opening in the attachment of the adductor magnus muscle to the medial supracondylar ridge of the lemur. Anterior to the poplitcal artery is the popliteal surt:ace of the lemur. Directly posterior and lateral to the artery is the popliteal vein, and posterior and lateral to the vein is the tibial nerve [21. At the level of the knee joint the nerve is directly posterior, and below the joint the nerve is medial to the artery 13l. Theretk~re, to avoid the tibial nerve, the approach to the popliteal artery proximal to the level of the knee
M.It. Wholcy ct aI.: Antcgrnde Poplitclil Puncture
joint should be medial to a line drawn in thc midline of the femur. As the popliteal fossa is a smaller potential space than the femoral triangle, c o m p r e s s i v e symptoms from a h e m a t o m a could be an expected potential problem. In addition, the proximal position of the needle puncture and subsequent catheter positions could be traversing a portion of the overlying s e m i m e m b r a n o s u s muscle, and an intramuscular h e m a t o m a may also be possible. T h r o m b o s i s of the popliteal artery due to c o m p r e s s i o n or excessive dissection secondary to the percutaneous tnmsluminal angioplasty (PTA), in combination with the low flow state, would be difficult to treat. There is no easy direct access and a femoral tibial bypass graft might be needed. Performing the puncture with ancillary imaging such as ultrasound and doppler are helpful as is direct visualization of a calcified artery. An additional method of localization prior to puncture is to
M.H. Wholey et al.: Antegrade Popliteal Punctt,re position a catheter in the iliac artery and localizing the popliteal artery in the prone position by digital roadmapping just prior to antegrade puncture. If difficulty is encountered during the puncture, a 22gauge needle can be positioned in the popliteal artery and subsequently used as a marker prior to puncture with the 18-gauge needle. The method is presented as a technical note and is applicable in a limited group of patients who are either nonsurgical candidates or in whom conversion from a femoral tibial graft to a femoral popliteal graft is d e e m e d feasible. Alternately, surgical bypass with intraoperative PTA of lesions distill to the
125 bypass anastomosis c o u l d also be p e r f o r m e d , o b v i ating the need for the a n t e g r a d e p o p l i t e a l a p p r o a c h .
References I. McCann R (1986) Femoropopliteal and femoroinfrapopliteal bypass. In: Sabislon, D (ed) Textbook of surgery, 13th ed. WB Saunders Co. Philadelphia, pp ] 886-1870 2. Rohen J, Yolsochi C (1983) Color atlas of anatomy. New York, Igasu-Shoin, pp 393-394 3. Pansky Ben (1979) Review of gross anatomy, 4th ed. MacMillan Publishing Co, pp 428-451
CardioVascular andInterventional Radiology 9 Springer-Verlag New York Inc. 1992
Technical Notes
Antegrade Popliteal Puncture: Technical Note Mark H. Wholey, Nell Solomon, and Chester R. Jarmolowski Pittsburgh Vascular Institute. Department of Radiological Sciences and Diagnostic Imaging. Shadyside Hospital, Pittsburgh, and the University of Pittsburgh. School of Medicine. Pittsburgh, Pennsylvania. USA
Abstract. P e r c u t a n e o u s transluminal angioplasty was performed via an antegrade popliteal puncture. This technique was utilized because the patient had a superficial femoral artery occlusion and coexistent popliteal stenoses, with the occlusion unable to be traversed in the usual c o m m o n femoral artery antegrade approach. To our knowledge, this technique has not been described in the literature. The clinical utility of this a p p r o a c h and important anatomical considerations will be discussed.
Key words: Antegrade popliteal p u n c t u r e - - A n g i o plasty
The antegrade popliteal puncture is a technique used to treat stenoses that are otherwise not amenable to percutaneous angioplasty due to occlusion of the superficial femoral artery. To our knowledge there has been no prior description in the literature utilizing this a p p r o a c h . This condition would occur in two categories of patients in whom a superficial femoral artery occlusion exists: a nonsurgical candidate with superficial femoral artery occlusion not amenable to antegrade or retrograde recanalization; and those patients in which a femoral-to-distal popliteal or tibial bypass procedure could be converted into a femoral-to-proximal popliteal bypass graft [ I ].
being evaluated ["or bilateral I to 2 block chmdication. The right ankle brachial index (ABI) was {).66. The patient was not considered to be a surgical candidate at this time due to his heart disease. A diagnostic arteriogram demonstrated a segmental 10-cm occlusion of the right superficial femoral artery and three stenoses in the reconstituted popliteal artery [Fig. I]. The right superficial femoral artery occlusion could not be traversed in the usual antegrade fashion from the common femoral artery. Although several recanalization devices were attempted, passage beyond the occlusion could not be accomplished. Successful recanalization from a retrograde popliteal approach was considered unlikely due to the length of the lesion and extent of calcification, and was not attempted. It was elected to perform an antegrade puncture of the proximal popliteal artery. Access was obtained with the assistance of ultrasound, doppler guidance, and the use of fluoroscopic observation as arterial calcification was present at the puncture site. The proximal popliteal artery was punctured with an I8-gauge needle. Subsequently, passage of a 0.035 inch steerable wire through the three stenotic sites (Wholey Wire: Peripheral Systems Groups, Mountain View, CA USA) was achieved. A 5 French dilator was then positioned over the wire within the popliteal artery (Fig. 2). This was then followed with exchange for a 5 mm-2 cm 5 French angioplasty balloon catheter, and the three sites were then dilated (Stellar 535 Balloon Catheter, Peripheral Systems Group). A postprocedural arteriogram demonstrated marked improvement in overall dimensions at the stenotic sites [Fig. 3]. The postprocedure resting ABI was unchanged at 0.66. The patient was maintained on aspirin and persantine. Originally not considered a satisfactory surgical candidate for a distal bypass. following successful dilatation of the popliteal lesions, the patient was subsequently bypassed with an above-the-knee femoral popliteal Dacron prosthetic graft. The distal anastomosis of the bypass graft was proximal to the three angioplasty sites. The patient continued to do well for approximately 3 months. when he returned with claudication. Repeat arteriography demonstrated 40%, restenosis at the proximal angioplasty site. The two distal sites remained well patent and consequently the patient was being managed medically.
Materials and Methods A 63-year-old male with insulin-dependent diabetes mellitus, atherosclerotic heart disease, and peripheral vascular disease was
Mark H. Wholey, M.D., Chairman, Pittsburgh Vascular Institute, Department of Radiotogical Sciences and Diagnostic Imaging, Shadyside Hospital, 5230 Centre Avenue, Pittsburgh, Pennsylvania 15232, USA
Address reprint requests to:
Discussion The antegrade popliteal puncture could be a valuable technique for treating patients with superficial femoral artery occlusion and coexistent popliteal stenoses. An understanding of the a n a t o m y of the popliteal fossa is helpful. The popliteal artery origi-
124
Fig. 1. Diagnostic arteriogr~m, in the supine position demonstritlen three lk~caI popliteal stenoncs (arrows). Fig. 2. Antegrade poplileal artery puncture in Ihe prone ponition. Arrow indicates the 5 French diagnostic catheter. Fig. 3. PosI-PTA arteriogram in the prone position. Number,, I, 2, and 3 indicate location of stenosis prior to angioplanty.
nares at the adductor canal which is formed by an opening in the attachment of the adductor magnus muscle to the medial supracondylar ridge of the lemur. Anterior to the poplitcal artery is the popliteal surt:ace of the lemur. Directly posterior and lateral to the artery is the popliteal vein, and posterior and lateral to the vein is the tibial nerve [21. At the level of the knee joint the nerve is directly posterior, and below the joint the nerve is medial to the artery 13l. Theretk~re, to avoid the tibial nerve, the approach to the popliteal artery proximal to the level of the knee
M.It. Wholcy ct aI.: Antcgrnde Poplitclil Puncture
joint should be medial to a line drawn in thc midline of the femur. As the popliteal fossa is a smaller potential space than the femoral triangle, c o m p r e s s i v e symptoms from a h e m a t o m a could be an expected potential problem. In addition, the proximal position of the needle puncture and subsequent catheter positions could be traversing a portion of the overlying s e m i m e m b r a n o s u s muscle, and an intramuscular h e m a t o m a may also be possible. T h r o m b o s i s of the popliteal artery due to c o m p r e s s i o n or excessive dissection secondary to the percutaneous tnmsluminal angioplasty (PTA), in combination with the low flow state, would be difficult to treat. There is no easy direct access and a femoral tibial bypass graft might be needed. Performing the puncture with ancillary imaging such as ultrasound and doppler are helpful as is direct visualization of a calcified artery. An additional method of localization prior to puncture is to
M.H. Wholey et al.: Antegrade Popliteal Punctt,re position a catheter in the iliac artery and localizing the popliteal artery in the prone position by digital roadmapping just prior to antegrade puncture. If difficulty is encountered during the puncture, a 22gauge needle can be positioned in the popliteal artery and subsequently used as a marker prior to puncture with the 18-gauge needle. The method is presented as a technical note and is applicable in a limited group of patients who are either nonsurgical candidates or in whom conversion from a femoral tibial graft to a femoral popliteal graft is d e e m e d feasible. Alternately, surgical bypass with intraoperative PTA of lesions distill to the
125 bypass anastomosis c o u l d also be p e r f o r m e d , o b v i ating the need for the a n t e g r a d e p o p l i t e a l a p p r o a c h .
References I. McCann R (1986) Femoropopliteal and femoroinfrapopliteal bypass. In: Sabislon, D (ed) Textbook of surgery, 13th ed. WB Saunders Co. Philadelphia, pp ] 886-1870 2. Rohen J, Yolsochi C (1983) Color atlas of anatomy. New York, Igasu-Shoin, pp 393-394 3. Pansky Ben (1979) Review of gross anatomy, 4th ed. MacMillan Publishing Co, pp 428-451
