An educational video: Choosing PAD access sites and strategies

Selecting the right access site is a critical step in planning peripheral arterial disease (PAD) interventions. In this video, Drs. Peña and McMackin share how they approach access site selection across a range of clinical scenarios, emphasizing the importance of thoughtful preparation and individualized decision-making.

Their discussion begins with the importance of patient-specific considerations, including prior procedures, target anatomy, disease location, and the presence of scar tissue. Dr. McMackin highlights how careful planning helps anticipate technical challenges and align the access approach with procedural goals.

Dr. Peña adds perspective on the value of flexibility, underscoring the need to remain agile and prepared to adjust strategies as anatomy or procedural conditions change. Together, these experts review commonly used access sites as well as alternative access options, offering practical insights, tips, and considerations for navigating complex PAD cases.

By combining planning principles with real-world experience, this video demonstrates a deeper understanding of how access site selection influences procedural success and patient outcomes in PAD care.

Jeremy Andrews (00:11):
Welcome everyone. Thanks for joining. We’re going to be talking about access and PAD today. So, with that, thank you for joining us. To get started, you know, access is very broad when we talk about treating PAD, and I think first off, I’d like to hear from each of you, right? And Dr. McMackin, we’ll start with you first, is how important is access and when access— we’re not talking about just the initial site, but everything that gets you to that intervention or treatment that changes patients’ lives. Right? So, in your own words and then of course, Dr. Peña, if you would follow up.

Katherine McMackin (00:45):
Absolutely. Planning access is a huge part of cases. So, thinking about what has the person had done before? Have they had any other surgeries? Is there any scarring? Where am I trying to get to? What’s the easiest way to get there? That gives you an idea of where you should start, what’s your backup plan, and what’s plan C in some cases.

Constantino Peña (01:03):
Yeah, I would agree with that. I think you want to have a plan, and each plan is going to be tailored to your patient. Having an idea of what you think you’re going to do because you’re never 100% sure. And have an access that you think is the safest, best access to start with. And again, be ready to pivot. Sometimes you need to pivot to other types of accesses.

Jeremy Andrews (01:21):
Great. And so now, Dr. Peña, I’ll go ahead and start with you since you’re still speaking there. What is the most common site you access for PAD?

Constantino Peña (01:32):
So, I would say our most common access would be a common femoral access. So, whether it’s going to be retrograde, which is going up towards the aorta, or antegrade, means going down towards the foot in that particular common femoral artery. I would say that would be our most common approach. Depending on what we’re going to treat is the way we’re going to be, whether it’s anterograde or retrograde. And in certain situations, we go on the other extremity. So, we will go retrograde, let’s say on the right leg to treat a left PAD, depending on where we think we need to treat and what the clinical situation is.

Jeremy Andrews (02:05):
Dr. McMackin, your most common site for—

Katherine McMackin (02:08):
So common femoral is the same. You know, we talked about safety before, and I think safety is the biggest point of it. There’s complications that can have— that happen. And common femoral is a large artery. One of the great things about the vascular space is there’s a lot of different thought leaders working in it, and that gives you different perspectives. So, we have vascular and interventional radiology here, but cardiology also works in this space and they’re using a lot of radial access, which I’ve recently started using in my practice. And it just gives you a lot of different ways to treat disease and to look at it from different avenues.

Jeremy Andrews (02:39):
Yeah, it’s funny you mentioned that because that’s going to lead me right into my next question for you both is— You know, the common fem is one of the most highly— like that’s the majority of it. But what about— what are some other access sites? Right? And Dr. McMackin, since you— we’ll start with you, like, that you utilize or that you’ve experienced.

Katherine McMackin (02:55):
Yeah. So, depending on what you’re doing and where you need to go, you can think upper extremity, radial, brachial, subclavian. Usually, I do either radial or subclavian. Brachial has some issues with post-procedural hematoma. It makes it a little bit more difficult. And then you can work your way down and everywhere you can feel a pulse, theoretically, is a good access site. So, femoral. You could do popliteal. Most people don’t. But dorsalis pedis or posterior tibial all give you ways to access this highway system to treat disease.

Jeremy Andrews (03:26):
Dr. Peña.

Constantino Peña (03:27):
Yeah, I would say exactly what she said. In terms of what the alternative access is, I think radial is probably one of the most common as an alternative access. I would say for my practice, I do a radial access when I have to. I mean, I think it’s— You know, if the groins are hostile and I want to go radial, then I’ll go ahead and do radial. If I’m doing something in the upper extremity, if I’m doing something in the celiac or renal arteries, I may go radial just from the angles. I think there’s a lot of alternative accesses, like have been said. Popliteal access, something we used to do a lot of, we still do. And there’s two ways you can do that, you know, frog leg, so you don’t have to move the patient, or you actually have the patient prone. You can do tibial access, pedal access. Again, I stay away from brachial access as well. We do it when we have to. And a lot of times in those, to me, the biggest issue though is controlling that brachial artery. So, a lot of times I’ll get my surgical colleagues that work with me and deal with a cut down, being able to manage that, working together, to kind of minimize those kinds of complications.

Jeremy Andrews (04:27):
Yeah, no, that’s a lot. So, thanks. When we’re talking about treating an SFA for PAD or the popliteal, what are some of the biggest challenges, do you think, when it comes to access or reaching that lesion? Dr. McMackin?

Katherine McMackin (04:42):
So, anytime you’re starting to work your way down the leg, you’re talking about longer devices. You’re talking about having— if you’re going contralateral, go up and around the aortic bifurcation. So, you need something that can make a turn, but then also has that stack stiffness to provide that pushability as you’re getting through disease. Sometimes that’s nice, when you can do the integrated access, it gives you sort of that straight shot down the leg and same thing with the pedal access, the straight shot up the leg. So, it all depends on your angles, your pushability, what the lesion looks like, that helps you decide which one of those you’re going to use.

Jeremy Andrews (05:11):
Okay. Dr. Peña?

Constantino Peña (05:13):
Yeah, I think exactly that. And that is, it’s— You know, do you have as direct as possible into the lesion that you’re treating? I think we’ve talked about which access site to choose, but also you have to think about the caliber or the size of the access site. Is it going to require a 7 Fr sheath, a 6 Fr sheath, or is it something you will be able to do with a 4 Fr sheath if you’re looking for tibial work? And I think also that goes into the decision-making process. As we know, the bigger the sheath, the more risk of bleeding in terms of access closure. So, all those things come through, but trying to create kind of a straight line to what we’re trying to treat as ideal. Sometimes we have to go up and over, add some more angles, but we kind of, you know, basically try to overcome those by using stiffer— stronger devices, stiffer wires and what have you to help us get that and still get the pushability.

Jeremy Andrews (06:01):
Good. So, I’ll stick with you. Okay. And so, when you’re accessing— And we know like all these vessels are different, right? Not everyone’s the same. It’s not cut and dried, and some of them can be pretty torturous, as you said, hostile. How do you address those when you’re doing these interventions in PAD?

Constantino Peña (06:17):
Yeah, I think we can’t lose sight that when you’re treating a patient with PAD, it’s a systemic process. So, all the arteries are going to be to some extent diseased. They may not look macroscopically diseased when we see them, let’s say on angiography. But we know that they’re going to be diseased. So, I think it’s important as you start looking and planning that you want to kind of pick the best vessel, the healthiest vessel in area that you can control. It’s going to be somewhere that you can then deliver the therapy that you’re going to deliver. So, I think you’re exactly right. Choosing the right vessel, but also choosing the safest vessel for that particular procedure is sometimes really important. And maybe even starting off sometime with a micro access system, seeing what you see, and then you may make a decision. You know what? I’m not going to go here. I’m going to go somewhere else. And, you know, being able to kind of pivot, I think is important.

Jeremy Andrews (07:09):
Dr. McMackin?

Katherine McMackin (07:10):
No, I think the pivoting point is very well taken. And you really need to have some flexibility because, you know, your preoperative, noninvasive imaging can only tell you so much. And it’s not until you start the case you see what that tortuosity is. Does it straighten out when you put a wire or sheath across? Does it not? Some of those things you’re not going to be able to tell preoperatively. So, it’s that interoperative, being able to pivot, being able to say, this is what I thought I was going to do, but the patient’s telling me that they need something else, the way their arteries are reacting. So really listening to the patient, even when they’re asleep and not talking and listening to what that patient’s anatomy is telling you and letting that guide your case.

Jeremy Andrews (07:46):
Good. All right, so we’ve talked a lot about accessing, so I’m going to kind of flip it real quick, and we’re going to talk about at the end, closing it. And I’ll go ahead and stick with you, Dr. McMackin. Do we do closure device or do you hold manual pressure or some other type of thing?

Katherine McMackin (08:02):
So, everyone who’s accessing the vascular space needs to know how to hold good manual pressure. You’re going to have times when an access or closure device works really well and times when it doesn’t. So, you always need to be able to know that you can hold pressure and pick an access site that you know you can hold manual pressure if you’re going to have a closure failure. I personally like closure devices. I think that, you know, they can get the patient ambulatory much faster. They have low complication rates. So, you know, depending on the access, how big the sheath is, how big the vessel is, you know, how clean was my stick, all of those will decide which access device or, excuse me, which closure device I’ll use at the end. But, yeah, ideally, closure device is plan A, and then manual pressure is usually plan B.

Jeremy Andrews (08:47):
Okay, Dr. Peña.

Constantino Peña (08:48):
Yeah, I would agree with that. I think you have to have a variety of skill for manual closure, as well as multiple closure devices, right? Because there are multiple different types of closure devices that function differently, and you kind of have to need to understand the differences of when you may use one over another. I think the quality of your puncture, how well that patient is responding is also important as you start choosing what you’re going to use. If you have a very small artery, you may say, you know what, maybe not ideal for a closure, but maybe you have someone who’s anticoagulated, high risk for bleeding. You say, you know, going to— In this particular case, my risk benefit is I’m going to go ahead and close. And I think that’s exactly what you have to go through in your mind and kind of be able to have a decision of when you’re going to close, when you’re not. But for the most part, we close most of our arterial punctures.

Jeremy Andrews (09:35):
Well, it’s been great. I really appreciate you both, lots of great information. I thank you for your time, and I’m sure the viewers will enjoy it as well.

Drs. Peña and McMackin are paid consultants of Cook Medical.