Evaluation of the Validity of Anatomical Merkmal Method for Anterolateral Popliteal Puncture Technique

Treatment of chronic total occlusion (CTO) in the femoropopliteal segment remains technically challenging, and some CTO lesions may require distal puncture. The anterolateral popliteal puncture technique was reported in 2017 and has many advantages, including the ability to continue the procedure in the supine position. We investigated the anatomical Merkmal of anterolateral popliteal artery puncture and verified the efficacy of the Merkmal method by contrast-enhanced lower limb computed tomography (CT) at our hospital. We assumed that the popliteal artery would run along the medial margin of the fibular head when the medial margin of the fibular head and the tibia were in the most separated oblique position. On bone 3D CT images, we set a region of interest (ROI) over the expected course of the popliteal artery according to the Merkmal method. The primary endpoint was the hit rate, defined as the ratio of the area of the popliteal artery in the ROI on 3D CT divided by the area of the popliteal artery at the same level on contrast-enhanced CT. The secondary endpoints were the diameter of the popliteal artery, its distance from the skin, and the angle of obliquity. We retrospectively validated the Merkmal method in 108 limbs of 56 patients who underwent contrast-enhanced lower limb CT at our hospital. The hit rate was 66.5% (range, 39.8%-87.0%), the mean diameter of the popliteal artery was 4.6 ± 0.7 mm, the mean distance from the skin to the popliteal artery was 48.6 ± 4.8 mm, and the mean angle of lateral obliquity was 57.3 ± 12.0°. These findings indicate the potential of the Merkmal method to facilitate anterolateral popliteal puncture.Clinical ImpactThis anatomical Merkmal method may facilitate anterolateral popliteal puncture.