The spread of Coronavirus Disease 2019 (COVID-19) pandemic across the globe and the United States presented unprecedented challenges with dawn of new policies to reserve resources and protect the public. One of the major policies adopted by hospitals across the nations were postponement of non-emergent procedures such as transaortic valve replacement (TAVR), left atrial appendage closure device (LAAC), MitraClip and CardioMEMS. Guidelines were based mainly on the avoidable clinical outcomes occurring during COVID-19 era. As our understanding of the SARS-CoV-2 evolved, advanced cardiac procedures may safely continue through careful advanced coordination. We aim to highlight the new guidelines published by different major cardiovascular societies, and discuss solutions to safely perform procedures to improve outcomes in a patient population with high acuity of illness during the COVID-19 pandemic era.

Background: With the rising prevalence of critical limb ischemia (CLI), the pedal-plantar loop technique and retrograde access may be needed to increase interventional success. Case Report: A 63-year-old female with severe peripheral artery disease presented with a 2-month nonhealing wound on the dorsum of her left foot despite wound care. We inserted a 65-cm Destination Guiding Sheath and crossed the right superficial femoral artery (SFA) chronic total occlusion (CTO) that we initially treated with a 4.0-mm Ultraverse balloon. We attempted unsuccessfully to cross the distal anterior tibial artery into the dorsalis pedis artery. We obtained antegrade access of the posterior tibial artery at the level of the ankle with a 2.9-French Cook pedal access kit. We inserted a 90-cm CXI catheter with a 0.014 Fielder XT wire and used the lateral plantar artery as a conduit to cross the dorsalis pedis artery and distal anterior tibial artery CTO with retrograde wire manipulation via lateral plantar artery. Finally, we performed distal anterior tibial and dorsalis pedis CTO balloon angioplasty with a 2.5 × 220-mm Ultraverse balloon and performed SFA percutaneous transluminal angioplasty and stenting with a 7.0 × 120-mm Zilver PTX stent, postdilated with a 6.0-mm Ultraverse balloon. We successfully established in-line flow to the foot with 3-vessel runoff. The patient's wound healed in a month. Conclusion: Retrograde pedal access can improve the success rate of recanalization of below-the-knee disease in patients with CLI.

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Patients with posterior circulation ischemia due to vertebral artery stenosis account for 20 to 25% of ischemic strokes and have an increased risk of recurrent stroke. In patients treated with medical therapy alone, the risk of recurrence is particularly increased in the first few weeks after symptoms occur with an annual stroke rate of 10 to 15%. Additionally, obstructive disease of the vertebrobasilar system carries a worse prognosis, with a 30% mortality at 2-years if managed medically without additional surgical or endovascular intervention. Percutaneous transluminal angioplasty and stenting of symptomatic vertebral artery stenosis is a promising option that is widely used in clinical practice with good technical results; however, improved clinical outcome has been examined in various clinical trials without sufficient sample size to conclusively determine whether stenting is better than medical therapy. Surgical revascularization is an alternative approach for the treatment of symptomatic vertebral artery stenosis that carries a 10-20% mortality rate. Despite the advances in medical therapy and endovascular and surgical options, symptomatic vertebral artery stenosis continues to impose a high risk of stroke recurrence with associated high morbidity and mortality. The aim of this review is to provide a focused update on percutaneous treatment of vertebral artery stenosis, its appropriate diagnostic approach and advances in medical therapies.