This page describes practice advice for infrainguinal endovascular interventions done for limb salvage. For open revascularization, see surgical bypass.

Pre-operative considerations

In planning the case, consider:

  1. indication/wound location & relevant angiosome(s);
  2. antiplatelets/anticoagulants;
  3. baseline eGFR;
  4. pulse exam (both for initial access and for level of disease);
  5. presence of adequate caliber and length ipsilateral great saphenous vein;
  6. any previous imaging;
  7. clinical that needs management prior to the angiogram (incl. orthopnea, contrast allergy).

The CPT code for OR scheduling should generally use the 36247 code, NOT any procedural code beginning with a 7.

Special situations

Pre-hydration for chronic kidney disease:

For advanced chronic kidney disease, especially eGFR<30mL/min, pre-admission that will include:

  1. normal saline at 0.5mL/kg/hr; and
  2. vitamin C 500mg PO BID.

Contrast allergy:

For iodinated contrast allergy (compiled by Maria R. – thank you!). This is an order set in CPRS: Surgery Orders –> Imaging Contrast Sensitivity/ Allergy –> “Click here — to order Prednisone and Benadryl”.

  1. Prednisone 50 mg PO 13 hours before contrast dose.
  2. Prednisone 50 mg at 6 hours before contrast dose.
  3. Prednisone 50 mg 1 hour before contrast dose.
  4. Benadryl 50 mg PO (outpatients) or IV (inpatients) one hour before contrast dose.

Procedural steps

Basic steps of my preferred approach: Bentson to get 5Fr sheath in; Contra/Omni to the aorta. Up-and-over with floppy angled Glidewire. Try to get floppy Glidewire to popliteal. If successful, place a 135cm Quickcross catether for the angiograms starting in distal leg. Visualize more proximal segments later. See here for preferences of other staff surgeons.

Ultimately, these seven digital subtraction angiography runs with the following power injector settings for the affected extremity:

  1. popliteal at 20° oblique, 5x5
  2. upper calf w tibia-fibula separated, 5x5-10
  3. calf w tibia-fibula separated, 5x5-10
  4. craniocaudal foot shot magnifiedx1, 4x12
  5. lateral foot shot magnified x1, 4x12 Then, after withdrawing the catheter more proximally:
  6. AP thigh, 5x5
  7. femoral at 15° oblique, 5mL/sec for 5mL.

If severely impaired eGFR, consider carbon dioxide angiography with this setup.

If intervention: long Amplatz wire through Quickcross + 45cm 6Fr (if SFA/pop) or 55/70cm 5Fr (if tibial). Cross (0.014” or 0.018” system for tibials, 0.035” system for SFA), confirm location with DSA, PTA, consider stent.

Post-operative management

After the case: bedrest for six hours. Generally an outpatient procedure. Inpatient observation again only if needed for hydration, renal protection. Discharge without outpatient narcotics (Tylenol only), Plavix bolus if intervention. Discuss cilostazol otherwise.