Challenges and Evolutions in Limb Salvage

[Jihad Mustapha]
I got to my cardiology fellowship at Louisiana State University, and I did peripheral intervention and coronary intervention in vascular medicine. One thing I found to be extremely interesting is the tibial-pedal anatomy and how afraid everyone was to come near it or even advance a wire into the tibial artery. So, I fell in love with the tibials because nobody else wanted to mess with them. I decided, well, I'll mess with them. In 2003, I finally finished training and started in the summer of 2003. The first week of work, I got in trouble and had to go to the office because I saw a patient with rest pain and I opened the SFA and the posterior tibial artery. That was probably the fourth day being at my practice. The problem was not that I opened the SFA, it was that I opened the posterior tibial artery.

[Sabeen Dhand]
In any kind of field, you've got to find something that needs work on or needs to develop a niche. You've definitely advanced tibial-pedal anatomy and interventions to a great degree. So congratulations on all of that.

[Jihad Mustapha]
Thank you.

[Sabeen Dhand]
I wanted to touch on two technical aspects that I think you and your group have really advanced. Everyone knows that pedal access now has changed the game of crossing lesions from an endovascular approach. How has pedal access evolved in the last five years in your group?

[Jihad Mustapha]
This will be the ninth year right now we've been doing pedal access. Initially, we went through the normal thing that everyone goes through and we did get the letters of reprimand of why we stuck a tibial artery or a pedal artery. We were defending ourselves. Then with trials after trials, we showed safety. We went through this and then we started to see what else we could do with pedal access. When you fail to cross from above, you can go from below and the success rate is significantly higher and quicker. This goes back to our point earlier that the success rate is only 40% in some centers to cross a CTO. With the pedal access in evolution, it's not just an access to cross. It also allows shortened time of the patient on the table, radiation reduction, and contrast reduction. And, now, we can deliver the entire therapy from below and the patient can go home within 45 minutes, depending on which size sheath and what you did. Eight years ago we were being reprimanded for doing pedal access and today, our patients actually come in and ask we don't go through their groin. They say, “Dr. Mustapha went through my foot last time and that was much easier.” We’re starting to hear that more. Right now, most of the time when I have a limb salvage, I start with the pedal access, then with the groin access. I'm not sure if I'm right or wrong, but we're evaluating it in our institution and I'll let you know in about six months.

[Sabeen Dhand]
I can't wait to hear about that. A lot of people have questions about #primarypedal and that's really going to be an interesting insight. I think most of our listeners know intravascular ultrasound when we can look at vessels, but extravascular ultrasound is an entirely different beast. What is that?

[Jihad Mustapha]
We call it EVUS, extravascular ultrasound. It's basically an ultrasound that is historically used for diagnostic imaging where you do an arterial Doppler or venous evaluation for DVT or venous insufficiency. What we decided to do is actually use EVUS as a tool for intervention during the procedure. We get access under it, put the sheath under it, cross the CTO, do the exchange, do everything that we need without using any radiation or contrast. Today, it's very hard for me to watch someone gain access under fluoroscopy or blindly by palpation. I feel bad for somebody struggling to cross a CTO, especially during a live case and they're just looping the wire and the wire is not going somewhere. In our center, we just put in an EVUS or an ultrasound probe and within two minutes, you can see where you're stuck. You go around it, and then you cross. And literally, it's just two to three minutes and you can go through what you're struggling with. EVUS is an extraordinary tool to use during complex revascularization and it makes your life so much easier. But the best part of it is that it has significant value to the patient in terms of safety, possibly efficacy too someday.

[Sabeen Dhand]
Totally great. I think the biggest challenge for people to get EVUS started is it does require a second pair of hands.

[Jihad Mustapha]
Absolutely.

[Sabeen Dhand]
You have to have a vascular tech or someone else who's very familiar in that setting. You did note something, too, when you see someone else trying to get access with fluoroscopy, you chuckle to yourself, saying, "Oh no. Just use ultrasound. It's so much better."

[Jihad Mustapha]
Yeah. I do, but it will eventually become the norm.