that neurologists billed more for interpreting the EEG the day after the operation while drinking coffee than I did for doing the surgery (I cannot confirm or deny this claim, but the thought of it annoys me). The reader needs to pay close attention to any publication reporting SP thresholds and whether the authors measure mean or peak systolic pressures. The authors in the current paper made the mistake of not mentioning if threshold criteria reported in other papers were one or the other and lumped the results together. A systolic SP > 40 or 50 mm Hg has been reported by several groups as being a safe threshold for performing CEAs under GA. For vascular surgeons who continue to prefer performing CEA using GA, measuring SP appears to be a reasonable alternative to EEG monitoring as a method to determine the need for shunting.

ultrasound-guided access, a 0.014-or 0.018-inch guidewire should be advanced under fluoroscopic guidance through a pedal or tibial artery. The authors even advocate using plantar arteries if the more proximal tibial or pedal vessels are occluded. A 4 French micropuncture sheath should be used for pedal access (various Pedal Access Kits are available). Straight or angled 0.014-or 0.018-inch support catheters are useful, such as the Quick-cross support catheter (Spectranetics, Colorado Springs, Colo). Once the retrograde guidewire crosses the lesion, it can be snared from a proximal antegrade sheath and externalized from the antegrade access site. Full through-and-through guidewire access is then obtained and the intervention can be performed from the antegrade approach.Conclusion: The advent of pedal access revolutionized endovascular treatment of critical limb ischemia, making any CTO amenable to percutaneous recanalization. Patients that were once facing certain amputation are now experiencing higher rates of limb salvage.Commentary: The authors are interventional radiologists, not vascular surgeons. They state that pedal access has become an indispensable technique for endovascular therapy of lower extremity peripheral arterial disease and is particularly useful for CTOs. I wonder how many vascular surgeons agree with this opinion and how many use this approach on a regular basis. I have fair experience with retrograde popliteal artery access with a high success rate crossing superficial femoral artery CTOs, but I have very limited experience with retrograde pedal access because I question the indications and long-term results of using this strategy. It is interesting that the authors address only the technical aspects of pedal access and do not even make a passing reference regarding the merits of arterial bypass. Most vascular surgeons agree that if a suitable distal outflow artery and suitable vein conduit exist, a surgical bypass yields good long-term patency rates. I don't want to close my eyes to a potentially new, useful technique, but there is an old saying: just because a procedure can be done does not necessarily mean it should be done. If any reader finds an article documenting valid, good long-term arterial patency (documented by duplex ultrasound) and limbsalvage rates using pedal access for tibial artery occlusions, please forward the article to me.Dhillon AS, Li S, Lewinger JP, Shavelle DM, Matthews RV, Clavijo LC, et al.