Color flow is used to identify flow in the target artery; then, using gray scale, the needle is used to access the anterior wall of the vessel under duplex guidance.

There are a couple of technical points worth mentioning when using this technique. Use of the smallest available ultrasound probe is recommended as the large ones are quite bulky and will interfere with the access process. Also, heavily calcified vessels can cause extensive shadowing that will make the technique difficult. In these situations, straight fluoroscopy or roadmapping may offer a better chance for successful access. Also, use of micropuncture needles that are purported to be echogenic is recommended as it is difficult to see Inhibitors,research,lifescience,medical the tip of the regular needles using the duplex ultrasound probe. Figure 2. Duplex ultrasound-guided access into the dorsalis pedis artery. (A) Duplex ultrasound probe and 21-gauge needle in place. (B) Color duplex identifies the patent anterior tibial artery lumen. (C) Tip of the needle inside the vessel on ultrasound (red arrow). Inhibitors,research,lifescience,medical … The position of the foot during the access procedure is important. We recommend placing the foot in plantar flexion when accessing the dorsalis pedis and anterior tibial artery and inverting the foot when accessing the distal peroneal

artery in the leg, which is not a vessel that Inhibitors,research,lifescience,medical is typically accessed. We also prefer eversion and dorsiflexion when accessing the posterior tibial artery in the distal leg. Choosing the site of Inhibitors,research,lifescience,medical vessel access is important to achieve success,

and it is usually an area that is patent and as healthy as possible. A micropuncture needle is used for access. Sometimes Ganetespib purchase bending the needle tip rather than keeping the needle straight can make easier it to access the vessel. This is particularly helpful if the point of access is in the anterior tibial artery, Inhibitors,research,lifescience,medical just above the ankle, or in the posterior tibial artery. After accessing the artery (as evidenced by back bleeding), the micropuncture access wire (0.018 in) is passed through the needle into the vessel under fluoroscopic guidance (Figure 3). The needle is removed, and a micropuncture 4-Fr sheath is passed over the wire, securing access. Sometimes we use only the dilator of the sheath without the sheath itself to secure access (Figure 4). Cook Medical Inc. (Bloomington, IN) has a commercially available dedicated pedal access kit. The kit includes a 21-gauge, 4-cm echogenic needle; a 7-cm long micropuncture 4-Fr introducer with a 2.9-Fr found inner diameter; and a Check-Flo® hemostasis valve that attaches directly to the introducer to inject fluids and contrast (Figure 5). Once the retrograde introducer is in place, the patient is fully heparinized in the usual fashion to avoid any thrombosis in the tibial vessels during the intervention. Some operators elect to use the 0.018-in wire in a sheathless manner to reduce the risk of disrupting the access vessel—the dorsalis pedis or distal tibial arteries.