Retrograde Popliteal Access and Balloon Dilatation of Chronic Total Occlusion of Superficial Femoral Arteries

Abstract

The objective of the study was to evaluate the effectiveness of retrograde popliteal access in subjects with chronic total occlusion of the superficial femoral artery. A retrospective review of subjects who underwent balloon dilatation via retrograde popliteal access (RPA) is included. Age, gender, tobacco use, comorbid diseases, body mass index, ejection fraction, claudication distance (0 to 50meters, 50 to 100meters and 100 to 150meters), preoperative Rutherford scale, and Ankle-brachial index (ABI) are noted for each subject. A duplex ultrasound (DUS) was performed preoperatively. The localization side of the lesion (right-left), the length of the atherosclerotic segment, and the localization of the diseased segment (proximal superficial femoral artery [SFA], mid-SFA, distal SFA, popliteal-above the knee) were noted. Subjects were followed for at least one year after the procedure. Subjects were reevaluated in the first, 6th, and 12th months after the procedure. In control subjects, Rutherford class and ABI were noted. A DUS was performed to detect restenosis. The subjects' preoperative Rutherford class and ABI and restenosis degree were compared with their postoperative values. A total of 93 subjects (75.3% male, 24.7% female; mean age 68.57±8.70years old) were evaluated. In all 93 (100%) subjects, successful RPA was achieved. Overall, balloon dilatation via RPA was successful in 86 (92.47%) of the 93 subjects. The procedural success rate was 92.47%. The occluded segment was on the right side in 49.5% of the subjects (n=46) and on the left side in 50.5% (n=47) of the subjects. The mean length of the lesion was 10.77±2.21cm, and the average stenosis degree was 95.9±5.05%. The localization of the occluded segment was in the proximal SFA, mid SFA, distal SFA and popliteal above the knee in 45.2%, 50.5%, 25.8% and 10.8% of the patients, respectively.When comparing the successful and unsuccessful groups, target lesion length (10.48±2.01 vs. 14.43±0.79, P<0.001), mid-SFA localization (n=40 vs. n=7, P=0,012) and claudication distance in the first 50meters (P=0,003) were significantly higher in subjects with failed balloon dilatation via RPA. When the Rutherford scale was examined, the mild, moderate, and severe claudication ratios were 23.7%, 29%, and 47.3%, respectively. After the procedure, 61.3% of the cases were asymptomatic, and 38.7% had mild claudication. The change in the Rutherford scale was statistically significant (P<0,001). When the ABI measurements were examined before procedure, it increased from 0.63±0.08 before to 0.90±0.06 after the procedure, indicating a statistically significant difference (P<0,001). When Doppler findings were examined, in the successful RPA group, the no-stenosis percentages were 82.6%, 72.1%, and 65.1 at the first, 6th, and 12th month follow-up, respectively. The mean disease-free survival time was 9.80±0.39months. In the first year, subjects were divided according to stenosis degree. Subjects with less than 50% stenosis were compared with subjects with more than 50% stenosis to detect the preprocedural characteristics that affect the restenosis degree. Tobacco use, chronic obstructive pulmonary disease, hyperlipidemia, chronical renal insufficiency, and popliteal above the knee localization were significantly higher in subjects who had more than 50% stenosis 1year after the procedure (P=0.009, P=0.015, P=0.044, P=0.001, and P=0.017, respectively). RPA under DUS guidance is an effective method. RPA has high procedural success rate with low morbidity. Longer target lesion length, mid-SFA localization, and claudication distance in first 50meters found to be related factors with RPA balloon dilatation failure. Restenosis rates after 12months of follow-up is low and comparable with literature.