IP219. When Antegrade Access Fails: Utilization of Retrograde Arterial Access in the Management of Infrainguinal Occlusive Disease Is a Safe and Feasible Strategy

Abstract

The objective of this review is to describe technical success and short-term outcomes after a retrograde approach for infrainguinal therapeutic revascularization. Retrograde access techniques allow entry into the distal target vessel to aid in recanalization of occlusions when endovascular antegrade access fails. A lower extremity intervention vascular registry was queried to identify patients in whom a retrograde access was performed when a tibial, popliteal, or superficial femoral artery (SFA) occlusion could not be managed through an antegrade approach. Demographics, surgical indication, comorbidities, rates of procedural success, limb salvage rates, periprocedural complications, and mortality were collected. Access of the tibial, peroneal, pedal, or popliteal artery was obtained after anesthetizing the skin with a micropuncture sheath under ultrasound. Lesions successfully crossed were then treated either directly via the retrograde access or via subintimal arterial flossing with antegrade-retrograde intervention. From February 2012 to August 2015, 51 cases were identified (19 office and 32 hospital) in which a retrograde access was performed. Preoperative indications included Rutherford 3 (6), Rutherford 4 (12), and Rutherford 5 (33). Technical success rate was 86% (44 of 51). Technical failures were due to inability to cross the lesion or to connect with the antegrade access. Of these failures, two required below-knee amputation (BKA), four remained chronic Rutherford 5, but with healing wounds, and one died. A variety of tibial (23) and SFA/popliteal (56) lesions were treated via percutaneous angioplasty (PTA) alone (29), atherectomy (27), or with PTA/stent (26). At follow-up, there was a 73% overall improvement rate in clinical status as measured by Rutherford score. Three intraoperative crossing complications occurred. All complications were repaired successfully with stents, except one posterior tibial perforation that did not lead to limb compromise. At 60 days postprocedure, five major amputations (three below- and two above-knee amputations) had occurred. One BKA was the result of wet gangrene. The patient later developed a stump infection, underwent a knee disarticulation, and ultimately died secondary to sepsis for a 2% mortality rate. Retrograde approach for extensive infrainguinal occlusive disease in high-risk patients for limb salvage is a safe and feasible strategy with excellent limb-salvage and complication rates at follow-up. This technique can be expanded to both office and hospital locations offering an endovascular option for revascularization to patients who are not otherwise bypass candidates for limb salvage.